*exEPA
United Stales
Environmental Protector
Healthcare Environmental Assistance Resources
Pollution Prevention and Compliance Assistance
for Healthcare Facilities
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Profile of the
Healthcare Industry
Office of Compliance Sector Notebook Project
NOTEBOOKS
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Healthcare Industry Sector Notebook Project
EPA/310-R-05-002
EPA Office of Compliance Sector Notebook Project
Profile of the Healthcare Industry
February 2005
Office of Compliance
Office of Enforcement and Compliance Assurance
U.S. Environmental Protection Agency
1200 Pennsylvania Avenue, NW (MC 2224-A)
Washington, D.C. 20460
Cover photo courtesy of Dartmouth-Hitchcock Medical Center
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Healthcare Industry Sector Notebook Project
This report is one in a series of volumes published by the U.S. Environmental Protection Agency
(EPA) to provide information of general interest regarding environmental issues associated with
specific industrial sectors. The documents were developed under contract by Eastern Research
Group, Inc. (ERG) (Lexington, MA), Abt Associates (Cambridge, MA), GeoLogics Corporation
(Alexandria, VA), Science Applications International Corporation (McLean, VA), and Booz-
Allen & Hamilton, Inc. (McLean, VA). A listing of available Sector Notebooks is included on
the following page.
The Notebook will orient readers from a wide audience to the environmental responsibilities and
challenges facing health service providers including major medical centers, ambulatory
healthcare clinics, dental offices, doctors offices and veterinary clinics. The Notebook will be
especially useful in educating those in industry as well as government and the general public
who are unfamiliar with the complex environmental regulations that apply to the healthcare
industry. With references for more detailed information, the Notebook will nicely complement
new resources on compliance, environmental management systems, pollution prevention, and the
nascent on-line healthcare environmental resource center.
Obtaining copies:
Electronic versions of all Sector Notebooks are available on EPA's web site at
www. epa.gov/compliance/sectornotebooks. html.
A limited number of complimentary volumes are available to certain groups or subscribers,
including public and academic libraries; federal, state, tribal, and local governments; and the
media. You can order from EPA's National Service Center for Environmental Publications at
(800) 490-9198 or www.epa.gov/ncepihom. When ordering, use the applicable EPA publication
number from those listed on the following page.
The Sector Notebooks were developed by the EPA's Office of Compliance. Direct general
questions about the Sector Notebook Project to:
Coordinator, Sector Notebook Project
U.S. EPA Office of Compliance
1200 Pennsylvania Ave., NW (2224-A)
Washington, D.C. 20460
(202)564-2310
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Healthcare Industry
Sector Notebook Project
AVAILABLE SECTOR NOTEBOOKS
Questions and comments regarding the individual documents should be directed to Compliance
Assistance and Sector Programs Division at (202) 564-2310 unless otherwise noted below. See
the Notebook web page at: www.epa.gov/compliance/sectornotebooks.html for the most
recent titles and links to refreshed data.
EPA Publication
Number
EPA/310-R-95-001.
EPA/310-R-95-002.
EPA/310-R-95-003.
EPA/310-R-95-004.
EPA/310-R-95-005.
EPA/310-R-95-006.
EPA/310-R-95-007.
EPA/310-R-95-008.
EPA/310-R-95-009.
EPA/310-R-95-010.
EPA/310-R-95-011.
EPA/310-R-02-001.
EPA/310-R-95-013.
EPA/310-R-95-014.
EPA/310-R-02-002.
EPA/310-R-95-017.
EPA/310-R-95-018.
EPA/310-R-97-001.
EPA/310-R-97-002.
EPA/310-R-97-003.
EPA/310-R-97-004.
EPA/310-R-97-005.
EPA/310-R-97-006.
EPA/310-R-97-007.
EPA/310-R-97-008.
EPA/310-R-97-009.
EPA/310-R-98-001.
EPA/310-R-OO-OOl.
EPA/310-R-00-002.
EPA/310-R-00-003.
EPA/310-R-00-004.
EPA/310-R-05-002.
EPA/310-R-05-003.
EPA/310-R-99-001.
EPA/300-B-96-003.
EPA/310-R-05-001.
Industry
Profile of the Dry Cleaning Industry
Profile of the Electronics and Computer Industry*
Profile of the Wood Furniture and Fixtures Industry
Profile of the Inorganic Chemical Industry*
Profile of the Iron and Steel Industry
Profile of the Lumber and Wood Products Industry
Profile of the Fabricated Metal Products Industry*
Profile of the Metal Mining Industry
Profile of the Motor Vehicle Assembly Industry
Profile of the Nonferrous Metals Industry
Profile of the Non-Fuel, Non-Metal Mining Industry
Profile of the Organic Chemical Industry, 2nd Edition*
Profile of the Petroleum Refining Industry
Profile of the Printing Industry
Profile of the Pulp and Paper Industry, 2nd Edition
Profile of the Stone, Clay, Glass, and Concrete Industry
Profile of the Transportation Equipment Cleaning Industry
Profile of the Air Transportation Industry
Profile of the Ground Transportation Industry
Profile of the Water Transportation Industry
Profile of the Metal Casting Industry
Profile of the Pharmaceuticals Industry
Profile of the Plastic Resin and Man-made Fiber Industry
Profile of the Fossil Fuel Electric Power Generation Industry
Profile of the Shipbuilding and Repair Industry
Profile of the Textile Industry
Profile of the Aerospace Industry
Profile of the Agricultural Crop Production Industry
Contact: Ag Center, (888) 663-2155
Profile of the Agricultural Livestock Production Industry
Contact: Ag Center, (888) 663-2155
Profile of the Agricultural Chemical, Pesticide and Fertilizer Industry
Contact: Agriculture Division, (202) 564-2320
Profile of the Oil and Gas Extraction Industry
Profile of the Healthcare Industry
Profile of the Rubber and Plastic Industry, 2nd Edition
Government Series
Profile of Local Government Operations
Profile of Federal Facilities
Profile of Tribal Government Operations
Spanish translations of 1st Editions available in electronic format only.
www. her center, ors/links
11
February 2005
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Healthcare Industry Sector Notebook Project
DISCLAIMER
This Sector Notebook was created for employees of the U.S. Environmental Protection Agency
(EPA) and the general public for informational purposes only. This document has been
extensively reviewed by experts from both inside and outside the EPA, but its contents do not
necessarily reflect the views or policies of EPA or any other organization mentioned within.
Mention of trade names or commercial products or events does not constitute endorsement or
recommendation for use. In addition, these documents are not intended and cannot be relied
upon to create any rights, substantive or procedural, enforceable by any party in litigation with
the United States.
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Healthcare Industry Sector Notebook Project
Healthcare Industry - Including Hospitals, Physicians Offices, Dental Offices,
Nursing Homes, etc.
(NAICS 62)
TABLE OF CONTENTS
Page
LIST OF ACRONYMS viii
I. INTRODUCTION TO THE SECTOR NOTEBOOK PROJECT 1
LA. Summary of the Sector Notebook Project 1
IB. Additional Information 2
II. INTRODUCTION TO THE HEALTHCARE INDUSTRY 3
II. A. Introduction, Background, and Scope of the Notebook 3
II.B. Characterization of the Healthcare Industry 5
II.B.l. Service Characterization 5
II.B.2. Industry Size and Geographic Distribution 5
II.B.3. Economic Trends 10
III. ACTIVITY DESCRIPTIONS 14
III. A. Healthcare Activities 14
III.B. Waste Streams Generated by the Healthcare Industry 26
III.B.l.Municipal Solid Waste 27
III.B.2.Biohazardous Waste (Regulated Medical Waste) 28
III.B.3.Hazardous Waste 29
III.B.4. Wastes by Media Category 41
III.C. Assessment of Wastes Generated by Functional Activity 42
HID. Management of Waste Streams 48
IV. WASTE AND EMISSIONS PROFILE 52
IV. A. Solid, Biohazardous, and Hazardous Waste Production Data for the
Healthcare Industry 52
IV.A.l. Municipal Solid Waste 52
IV.A.2. Biohazardous Waste 53
IV.A.3. Hazardous Chemical Waste 54
IV.B. Wastewater Discharge Data for the Healthcare Industry 54
IV.C. Air Emissions from the Healthcare Industry 56
V. POLLUTION PREVENTION OPPORTUNITIES 59
V. A. General Pollution Prevention Opportunities 59
V.A.I. Environmental Management Systems (EMS) 59
V. A.2. Purchasing/Product Substitution/Source Reduction 59
V.A.3. Process Change 60
V.A.4. Recycling 62
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Healthcare Industry Sector Notebook Project
V.B. Pollution Prevention Opportunities by Waste Type 63
VI. SUMMARY OF FEDERAL STATUTES AND REGULATIONS 72
VIA. Industry-Specific Requirements 72
VLB. Regulations by Waste Category 98
VI.C. Pending and Proposed Regulatory Requirements 99
VI.D. Additional Applicable Regulations (Non-EPA Administered) 100
VII. COMPLIANCE AND ENFORCEMENT HISTORY 103
VILA. Background 103
VII.B. Compliance and Enforcement Description 104
VII.C. Compliance and Enforcement Data Definitions 105
VII.D. Healthcare Industry Compliance History 106
VILE. Comparison of Enforcement Activity Among Selected Industries .... 112
VII.F. Review of Major Legal Actions 117
VIII. COMPLIANCE ACTIVITIES AND INITIATIVES 125
VIII. A.Healthcare Related Programs and Activities 125
VIII.B. Summary of Trade Organizations and Industry Organizations 132
IX. CONTACTS/ACKNOWLEDGMENTS/RESOURCE MATERIALS/
BIBLIOGRAPHY 136
IX.A. Contacts/Document Reviewers 136
IX.B. Bibliography 138
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Healthcare Industry Sector Notebook Project
LIST OF TABLES
Page
II-1 Number of Healthcare Establishments, Number of Healthcare Employees,
and Total Healthcare Receipts, by State 9
III-l Examples of RCRA Listed Hazardous Waste Found in Healthcare Facilities ..31
III-2 Healthcare Facility Wastes 43
IV-1 Direct Dischargers Included in PCS 55
IV-2 Pollutant Discharge from Direct Discharging Healthcare Facilities 55
IV-3 Total Emissions for VOC, NOx, and HAPs (Tons/Year) 57
V-l Pollution Prevention and Waste Management Strategies by Waste Category . . 64
VI-1 Summary of Potentially Applicable EPA Regulations 73
VI-2 EPA Regulations by Waste Category 98
VII-1 5-Year Enforcement and Compliance Summary for the Healthcare
Industry (SIC 8000), By Region 108
VII-2 5-Year Enforcement and Compliance Summary for the Healthcare
Industry (SIC 8000), by Region and Statute 109
VII-3 5-Year Enforcement and Compliance Summary for Selected Industries 113
VII-4 5-Year Enforcement and Compliance Summary by Statute for
Selected Industries 115
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Healthcare Industry Sector Notebook Project
LIST OF FIGURES
Page
II-1 Number of Establishments in the Healthcare Industry 6
II-2 Number of Paid Employees (millions) by Type of Healthcare Facility 7
II-3 Value of Revenue in the Healthcare Industry (millions) 8
II-4 National Healthcare Expenditures as a Share of the GPD 11
II-5 The Nation's Health Dollar, CY 2000 12
II-6 Community Hospital Expenditures: Inpatient and Outpatient
Shares for All Payers 13
IV-1 Hospital Solid Waste Composition 53
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Healthcare Industry
Sector Notebook Project
ADA
AFS
AHA
AHCA
AHERA
AIRS
AMA
ANA
ANSI
ASHE
ASHES
AST
AVMA
BBP
BIF
BOD
BRS
C&D
CAA
CAM
CAP
Cd
CDC
CERCLA
CERCLIS
CESQG
CFC
CFR
CMS
CSRD
CWA
DMR
DOT
e-CFR
ECHO
ECOS
EEG
EMS
EPA
EPCRA
EPP
EtO
FDA
FIFRA
LIST OF ACRONYMS
American Dental Association
Air Facility Subsystem
American Hospital Association
American Health Care Association
Asbestos Hazard Emergency Response Act
Air Facility Indexing and Retrieval System
American Medical Association
American Nurses Association
American National Standards Institute
American Society for Healthcare Engineers
American Society for Healthcare Environmental Services
Aboveground Storage Tanks
American Veterinary Medical Association
Blood Borne Pathogens
Boilers and Industrial Furnaces
Biochemical Oxygen Demand
Biennial Reporting System
Construction and Demolition
Clean Air Act
Compliance Assurance Monitoring
College of American Pathologists
Cadmium
Centers for Disease Control
Comprehensive Environmental Response, Compensation, & Liability Act
Comprehensive Environmental and Liability Information System
Conditionally Exempt Small Quantity Generator
Chi orofluorocarb on
Code of Federal Register
Centers for Medicare and Medicaid Services
Central Sterile Reprocessing and Distribution
Clean Water Act
Discharge Monitoring Reports
Department of Transportation
Electronic Code of Federal Regulations
Enforcement and Compliance History Online
Environmental Council of the States
El ectroencephal ograph
Environmental Management System
Environmental Protection Agency
Emergency Planning and Community Right-to-Know Act
Environmentally Preferable Purchasing
Ethylene Oxide
Food and Drug Administration
Federal Insecticide, Fungicide, and Rodenticide Act
www. her center, ors/links
Vlll
February 2005
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Healthcare Industry
Sector Notebook Project
FQPA
FRN
FRS
GDP
H2E
Hal
HAP
HAZWOPER
HBN
HCWH
Hg
HHS
HMIWI
HVAC
ICIS
IDEA
IS
ISO
JCAHO
LDR
LEPC
LQG
MACT
MCL
MCLG
MMS
MOU
MRI
MS4
MSDS
MSW
MWTA
NAAQS
NAICS
NCDB
NEETF
NESHAP
NET
NIHE
NLIC
NOVs
NOX
NPDES
NPIC
NRC
NSPS
Food Quality Protection Act
Federal Register Notice
Facility Registry Systems
Gross Domestic Product
Hospitals for a Healthy Environment
Hydrochloric Acid
Hazardous Air Pollutants
Hazardous Waste Operations and Emergency Response
Healthy Building Network
Health Care Without Harm
Mercury
Health and Human Services
Hospital/Medical/Infectious Waste Incinerators
Heating Ventilation and Air Conditioning
Integrated Compliance Information System
Integrated Data for Enforcement Analysis
Information Services
International Organization for Standardization
Joint Commission on Accreditation of Healthcare Organizations
Land Disposal Restrictions
Local Emergency Planning Committees
Large Quantity Generators
Maximum Achievable Control Technology
Maximum Containment Levels
Maximum Containment Level Goals
Minerals Management Service
Memorandum of Understanding
Magnetic Resonance Imaging
Municipal Separate Storm Sewer Systems
Material Safety Data Sheet
Municipal Solid Waste
Medical Waste Tracking Act
National Ambient Air Quality Standards
North American Industry Classification System
National Compliance Database
National Environmental Education & Training Foundation
National Emission Standards for Hazardous Air Pollutants
National Emission Trends
National Institute for Health and the Environment
National Lead Information Center
Notices of Violation
Nitrogen Oxides
National Pollutant Discharge Elimination System
National Pesticide Information Center
Nuclear Regulatory Commission
New Source Performance Standards
www. her center, ors/links
IX
February 2005
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Healthcare Industry
Sector Notebook Project
NSR
NTI
OAR
OB/GYN
OECA
OSHA
OSWER
P2
P2OSH
Pb
PCB
PCS
PEER
POTW
PSD
PVC
RCC
RCRA
RCRAInfo
RMW
SARA
SDWA
SERC
SHP
SIC
SIP
SO2
SPCC
SQG
SWDA
TCLP
TIP
TRI
TRIS
TSCA
TSS
UIC
USDW
USPS
UST
VOC
New Source Review
National Toxics Inventory
Office of Air and Radiation
Obstetrics and Gynecology
Office of Enforcement and Compliance Assurance
Occupational Health and Safety Administration
Office of Solid Waste and Emergency Response
Pollution Prevention
Pollution Prevention and Occupational Safety and Health
Lead
Polychlorinated Biphenyls
Permit Compliance System
Public Entity Environmental Resource Center
Publicly Owned Treatment Works
Prevention of Significant Deterioration
Polyvinyl Chloride
Resource Conservation Challenge
Resource Conservation and Recovery Act
Resource Conservation and Recovery Act Information System
Regulated Medical Waste
Superfund Amendments and Reauthorization Act
Safe Drinking Water Act
State Emergency Response Commissions
Sustainable Hospitals Project
Standard Industrial Classification
State Implementation Plan
Sulfur Dioxide
Spill Prevention Control & Countermeasure
Small Quantity Generators
Solid Waste Disposal Act
Toxicity Characteristic Leaching Procedure
Tribal Implementation Plans
Toxic Release Inventory
Toxic Release Inventory System
Toxic Substances Control Act
Total Suspended Solids
Underground Injection Control
Underground Sources of Drinking Water
United States Postal Service
Underground Storage Tanks
Volatile Organic Compounds
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February 2005
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Healthcare Industry Sector Notebook Project
I. INTRODUCTION TO THE SECTOR NOTEBOOK PROJECT
LA. Summary of the Sector Notebook Project
Environmental policies based upon comprehensive analysis of air, water, and land
pollution (such as economic factors and community-based approaches) are becoming an
important supplement to traditional single-media approaches to environmental protection.
Environmental regulatory agencies are beginning to embrace comprehensive, multistatute
solutions to facility permitting, compliance assurance, education/outreach, research, and
regulatory development issues. The central concepts driving this policy are that pollutant
releases to each environmental medium (air, water, and land) affect each other, and that
environmental strategies must actively identify and address these interrelationships by designing
policies for the "whole" facility. One way to achieve a whole-facility focus is to design
environmental policies for similar industrial facilities. By doing so, environmental concerns that
are common to the manufacturing of similar products can be addressed in a comprehensive
manner. Recognition of the need to develop the industrial "sector-based" approach within EPA's
Office of Compliance led to the creation of this document.
The Sector Notebook Project was initiated by the Office of Compliance within the
Office of Enforcement and Compliance Assurance (OECA) to provide its staff and managers
with summary information for specific industrial sectors. As other EPA offices, states, the
regulated community, environmental groups, and the public became interested in this project, the
scope of the original project was expanded. The ability to design comprehensive, common-sense
environmental protection measures for specific industries is dependent on knowledge of several
interrelated topics. The key topics examined for this project are: general industry information
(economic and geographic); a description of activities; pollution outputs; pollution prevention
opportunities; federal statutory and regulatory framework; compliance history; and a description
of partnerships that have been formed between regulatory agencies, the regulated community,
and the public.
For any given industry, each topic listed above could alone be the subject of a
lengthy volume. However, in order to produce a manageable document, this project focuses on
providing summary information for each topic. This format provides the reader with a synopsis
of each issue, and references where more in-depth information is available. Text within each
profile was researched from a variety of sources, and was usually condensed from more detailed
sources pertaining to specific topics. This approach allows for a wide coverage of activities that
you can further explore using references listed at the end of this profile. As a check on the
information included, each Notebook went through an external document review process. The
Office of Compliance appreciates the efforts of all those who participated in this process and
enabled us to develop more complete, accurate, and up-to-date summaries. Many of those who
reviewed this Notebook are listed as contacts in Section IX and may be sources of additional
information. The individuals and groups on this list do not necessarily concur with all
statements within this Notebook.
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Healthcare Industry Sector Notebook Project
LB. Additional Information
Providing Comments
OECA's Office of Compliance plans to periodically review and update the
Notebooks and will make these updates available both in hard copy and electronically. If you
have any comments on the existing Notebook, or if you would like to provide additional
information, please send a hard copy and computer disk to EPA Office of Compliance, Sector
Notebook Project (2224-A), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Comments
can also be sent via the Sector Notebooks web page at:
www. epa.gov/compliance/sectornotebooks. html. If you are interested in assisting in the
development of new Notebooks, or if you have recommendations on which sectors should have a
Notebook, please contact the Office of Compliance at (202) 564-2310.
Adapting Notebooks to Particular Needs
This Sector Notebook is meant to generally describe the healthcare industry on a
national basis. In many instances, facilities within specific geographic regions or states may
have unique characteristics that are not fully captured in these profiles. The Office of
Compliance encourages state, tribal, and local environmental agencies and other groups to
supplement or repackage the information included in this Notebook to include more specific
industrial and regulatory information that may be available. Additionally, interested states and
tribal governments may want to supplement the "Summary of Applicable Federal Statutes and
Regulations" section with state, tribal, and local requirements. Compliance or technical
assistance providers may also want to develop the "Pollution Prevention" section in more detail.
Updated Web Site Links
An updated list of all of the web links contained in this Notebook can be found at
www. her center, ors/links.
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Healthcare Industry Introduction, Background, and Scope
II. INTRODUCTION TO THE HEALTHCARE INDUSTRY
This section provides background information on the size, geographic
distribution, employment, and economic condition of the healthcare industry. Facilities
described within the document are also described in terms of their North American Industry
Classification System (NAICS) codes. The NAICS, which was developed jointly by the United
States, Canada, and Mexico to provide new comparability in statistics about business activity
across North America, has replaced the U.S. Standard Industrial Classification (SIC) system,
under which Health Services is designated 80. Facilities in the healthcare industry are identified
under NAICS code 62.
Note that, while there are benefits to the NAICS codes for organizing categories
of business, there are disadvantages in the case of the healthcare sector. For the most part,
healthcare organizations, whether large or small, in-patient or outpatient, have some level of
complexity to their operations and functions. Even small multiservice hospitals have complex
service offerings, and generate a large variety of waste. Therefore, the NAICS code information
presented below is supplemented with a more robust picture of the rapidly changing healthcare
universe.
II.A. Introduction, Background, and Scope of the Notebook
The healthcare and social assistance industry (NAICS code 62) comprises many
subsectors including ambulatory healthcare services, hospitals, nursing and residential care
facilities, and social assistance. This Notebook focuses primarily on the activities performed at
hospitals. However, many of these activities can be performed by others in the healthcare
industry, and as such, this notebook applies to those providers as well.
The specific subsectors covered in this industry document are:
• NAICS 621. Ambulatory Healthcare Services. The following types of
facilities are covered under this NAICS code:
— Physicians' offices,
— Dentists' offices,
— Other health practitioners' offices,
— Outpatient care centers,
— Medical and diagnostic laboratories,
— Home healthcare services, and
— Other ambulatory healthcare services.
These entities may be free standing and perhaps privately owned or may
be part of a hospital or health system. Currently, most hospitals (NAICS
622) also offer ambulatory healthcare services. For some facilities, these
services represent as much as 60-70 percent of hospital business. Much of
this change has been driven by adjustments in healthcare finance and
reimbursement, advances in technology, and new and effective
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Healthcare Industry Introduction, Background, and Scope
Pharmaceuticals, which eliminate the need for inpatient and invasive care
services.
Also of note is the growing emergence of complementary healthcare
services that are also ambulatory in nature. These include chiropractic
care, massage, acupuncture, and acupressure.
• NAICS 622. Hospitals. The following types of facilities are covered
under this NAICS code:
— General medical and surgical hospitals,
— Psychiatric and substance abuse hospitals, and
— Specialty (except psychiatric and substance abuse) hospitals.
This category potentially includes many types of hospitals such as
academic medical center/university-based/teaching hospitals, community
hospitals, speciality hospitals (i.e., orthopedic or pediatric), and tertiary
care facilities that are qualified to handle major trauma cases (i.e., burns
and catastrophic accidents). There are also distinctions between public
and private hospitals, hospitals that are part of a healthcare system (i.e.,
organizations such as Kaiser Permanente), Veterans Administration
hospitals, and other types of facilities.
Hospitals and healthcare systems are continually changing their service
offerings, and responding to various internal and external forces including
reimbursement issues, advances in technology, and shifts in the
populations they serve.
• NAICS 623. Nursing and Residential Care Facilities. The following
types of facilities are covered under this NAICS code:
— Nursing care and assisted living facilities,
— Residential mental retardation/health and substance abuse
facilities,
— Community care facilities for the elderly, and
— Other residential care facilities.
Nursing care and residential care facilities offer nonacute care to
individuals, either those suffering from a chronic condition (e.g.,
dementia, developmental delay, multiple sclerosis, Parkinson's disease,
autism), aging, or mental health problems.
As population demographics in the United States shift and demand for
care services and facilities increases, more and more facilities offering
some component of the above services will arise.
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Healthcare Industry Introduction, Background, and Scope
The veterinary services industry (NAICS 541940) also performs many activities
similar to the healthcare industry. Veterinary facilities may find some of the information in this
Notebook relevant and useful.
• NAICS 541940. Veterinary Services. This industry includes
establishments of licensed veterinary practitioners primarily in the practice
of veterinary medicine, dentistry, or surgery for animals, and
establishments providing testing services for licensed veterinary
practitioners.
II.B. Characterization of the Healthcare Industry
II.B.l. Service Characterization
The healthcare industry provides a variety of services to support the healthcare
needs of a community or individuals. Many of the activities in healthcare result in waste outputs
and air or water pollution. In order to understand which activities generate polluting waste
outputs, it is necessary to look at various functions within healthcare, and understand the
products and supplies used and the resulting wastes. Much of the waste in healthcare is solid
waste consisting of paper, cardboard, glass, plastic, and metals. A subcomponent of healthcare
waste is biohazardous, or infectious waste. Another component is Resource Conservation and
Recovery Act (RCRA) hazardous waste.
Healthcare is vastly different from the many industries that have a defined
'product line,' a finite number of input materials and defined and consistent 'waste outputs.'
There are thousands of procedures, tests, processes, and activities, which encompass as many
materials. The hazardous component in healthcare waste tends to be made up of small amounts
of many different wastes, emanating from many different departments. Due to the decentralized
nature of service delivery in healthcare, there can be various departments with different functions
all generating various amounts of hazardous waste.
Hospitals are most often described by speciality or service areas. Some of these
areas include, but are not limited to: cardiology, critical care, emergency services, family
practice, facility engineering, general surgery, gynecology, infectious disease, internal medicine,
laboratory and analysis, medical monitoring/computer services, morgue, neurology,
neurosurgery, obstetrics, oncology, pathology, pharmacy, radiology, residential care, and
urology.
II.B.2. Industry Size and Geographic Distribution
The healthcare industry impacts the lives of nearly every person in the United
States. According to the 1997 Census of the Healthcare Industry (NAICS codes 621, 622, and
623), there are more than 500,000 healthcare facilities throughout the country, employing almost
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Healthcare Industry
Introduction, Background, and Scope
12 million people, with an annual payroll of more than $353 billion. In 2002, the 5,794
registered1 hospitals included 975,962 staffed beds and admitted 36,325,693 patients.
Hospitals alone contribute more than $1.3 trillion to the nation's economy,
according to a TrendWatch report by the Lewin Group released at the 2004 AHA Annual
Meeting in Washington. Hospitals employ nearly five million people, rank second as a source of
private sector jobs, and directly or indirectly support one of every nine jobs in the United States.
Figure II-l demonstrates how the healthcare industry is divided among
ambulatory healthcare facilities, hospitals, and nursing and residential care facilities. The
majority of the facilities, 88 percent, are ambulatory healthcare facilities. The remainder of the
industry is divided between nursing and residential care facilities (11 percent) and hospitals (1
percent).
Figure II-l: Number of Establishments in the Healthcare Industry
455,381
D Ambulatory health care services
• Hospitals
D Nursing & residential care facilities
Source: The 1997 Economic Census of the Healthcare and Social Assistance Industry.
Although ambulatory healthcare facilities make up 88 percent of the healthcare
facilities, hospitals have the most employees, totaling more than 42 percent of the industry.
Ambulatory healthcare facilities have 37 percent of the healthcare staff, while nursing and
residential care facilities have only 21 percent. Figure II-2 shows the number of employees by
type of healthcare facility.
1 Registered hospitals are those hospitals that meet the American Hospital Association's (AHA) criteria for
registration as a hospital facility. Registered hospitals include AHA member hospitals as well as nonmember
hospitals. For a complete list of the criteria used for registration, please see
http.V/www.hospitalconnect. com/aha/resource center/
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Healthcare Industry
Introduction, Background, and Scope
Figure II-2: Number of Paid Employees (millions) by Type of Healthcare Facility
2.47
4.41
4.93
D Ambulatory health care services
• Hospitals
D Nursing & residential care facilities
Source: The 1997 Economic Census of the Healthcare and Social Assistance Industry.
The revenue for healthcare facilities is divided unevenly across the number of
ambulatory healthcare, hospitals, and nursing and residential care facilities. As shown in Figure
II-3, the majority of the revenues, 46 percent, are from hospitals. It is important to once again
note, however, that a large part of a hospital's service offerings are ambulatory healthcare
offerings. There are also many hospitals/health systems that have affiliated nursing homes,
residential care facilities and other healthcare sector entities that deliver service, which may not
be reflected in the value of claims and revenues. The remainder is divided between ambulatory
healthcare facilities (43 percent) and nursing and residential care facilities (11 percent). In the
healthcare industry, these revenues come from:
• Patient care services (which includes laboratory services, diagnostic
testing, and direct patient care);
• Home healthcare services, including sales of blood, blood products,
organs and tissues, and ambulance services;
• Rental and leasing of goods and equipment, including both medical and
"other"; and
• Other services and medical equipment related to prescription and
nonprescription drugs, vision care services, orthopedic services, and other
related needs.
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Healthcare Industry
Introduction, Background, and Scope
Figure II-3: Value of Revenue in the Healthcare Industry (millions)
93,080
379,178
355,441
D Ambulatory health care services
• Hospitals
D Nursing & residential care facilities
Source: The 1997 Economic Census of the Healthcare and Social Assistance Industry.
Healthcare establishments are concentrated in areas with high population density.
California has the highest number of facilities, followed by New York, Texas, Florida, and
Pennsylvania. California has more than 67,000 ambulatory healthcare, hospital, and nursing and
residential facilities, which employ over one million people per year. Table II-1 presents the
number of healthcare establishments, the number of healthcare employees, and the total
healthcare receipts in each of the 50 states and the District of Columbia. The information is
ordered by number of establishments.
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Introduction, Background, and Scope
Table II-1: Number of Healthcare Establishments, Number of Healthcare Employees, and
Total Healthcare Receipts, by State
State
California
New York
Texas
Florida
Pennsylvania
Illinois
Ohio
Michigan
New Jersey
Georgia
Massachusetts
North Carolina
Virginia
Washington
Maryland
Indiana
Missouri
Tennessee
Wisconsin
Arizona
Colorado
Minnesota
Louisiana
Connecticut
Oregon
Alabama
Kentucky
Oklahoma
South Carolina
Iowa
Kansas
Arkansas
Mississippi
Utah
Establishments
67,049
37,640
35,543
33,863
25,826
21,107
20,872
19,135
18,508
12,802
12,799
11,669
11,273
11,157
10,709
10,076
9,813
9,756
9,173
8,800
8,334
8,081
8,026
7,444
7,212
6,706
6,647
6,601
5,783
5,355
4,868
4,471
3,828
3,658
Paid Employees
1,084,719
968,004
790,629
664,362
626,842
519,598
535,457
431,813
354,546
290,674
389,529
319,631
247,869
222,782
225,103
263,591
274,628
257,050
245,975
159,723
151,265
157,894
214,367
93,899
127,530
180,407
171,005
147,287
136,320
98,979
66,756
108,101
112,359
71,790
Receipts
($1,000)
93,742,883
68,576,184
53,894,354
49,513,538
42,445,050
36,820,144
34,537,846
29,168,412
27,056,992
22,242,191
25,146,242
21,908,538
17,692,485
15,460,294
15,968,224
16,950,896
17,365,887
18,489,619
15,368,388
11,947,321
10,772,791
9,864,404
13,843,010
6,241,205
8,518,910
12,688,762
11,345,390
8,832,649
9,597,946
5,129,312
3,667,767
6,870,149
7,577,714
4,795,081
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Healthcare Industry
Introduction, Background, and Scope
Table II-l: Number of Healthcare Establishments, Number of Healthcare Employees,
and Total Healthcare Receipts, by State (Continued)
State
West Virginia
Nevada
New Mexico
Nebraska
Maine
Hawaii
Idaho
New Hampshire
Rhode Island
Montana
District of
Columbia
South Dakota
Delaware
Vermont
Alaska
North Dakota
Wyoming
Establishments
3,461
3,010
2,933
2,847
2,777
2,430
2,351
2,256
2,143
1,967
1,496
1,363
1,356
1,274
1,141
1,064
972
Paid Employees
83,485
49,295
64,709
48,392
37,388
22,932
43,029
55,401
31,298
23,902
47,742
41,507
19,353
27,330
20,740
27,686
17,728
Receipts
($1,000)
5,526,231
4,434,559
4,134,335
2,865,939
2,272,419
2,090,765
2,678,189
3,618,105
2,197,746
1,294,100
4,194,304
2,371,023
1,367,588
1,589,182
1,787,722
1,339,141
1,076,409
Source: The 1997 Economic Census of the Healthcare and Social Assistance Industry.
The 1997 Census information did not separate Veterinary Services (NAICS
541940) from the other industries within the 5419 code category. However, according to the
American Veterinary Medical Association, as of September 2002, there are 61,477 veterinarians
employed in approximately 21,044 veterinary practices located across the United States. These
practices have a mean gross practice revenue of $677,823 per practice per year. This
information includes both private clinical practices and public and corporate employment.
II.B.3. Economic Trends
Healthcare Expenditures as a Share of the Gross Domestic Product
According to the Centers for Medicare and Medicaid Services (CMS), the
healthcare industry currently accounts for approximately 13 percent of the Gross Domestic
Product (GDP) of the United States. By the year 2010, healthcare expenditures are expected to
increase to 17 percent of the GDP. As shown in Figure II-4, the growth of spending has
stabilized since 1993 because medical prices averaged only a 2.9 percent annual growth between
1993 and 1999. This growth is relatively minimal compared to the 11.2-percent average annual
growth between 1980 and 1982, and the 6-percent average annual growth between 1982 and
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Healthcare Industry
Introduction, Background, and Scope
1993. Another factor to consider in this stabilization is the growth in the complementary care
industry (i.e., nonallopathic healthcare services), which was reported to be approximately 42
billion dollars in the mid-1990s.
Figure II-4: National Healthcare Expenditures as a Share of the GPD
Period of
16 -
o. 14 -
Q
O
'o
8 12-
0)
0.
10 -
8 -
19
accelerated growth
Period of
stabilization
80 1984 1988 1992 1996 2000
Calendar Years
Source: CMS, Office of the Actuary, National Health Statistics Group.
Source: June 2002 Centers for Medicare and Medicaid Services Report.
Healthcare Spending
In calendar year 2000, the United States spent $1.3 trillion on healthcare (NAICS
code 62). Most of this money was split between hospital care (32 percent) and physician and
clinical services (22 percent).
As shown in Figure II-5, prescription drugs accounted for 9 percent of the total
healthcare spending in 2000. According to the CMS, between 1990 and 2000, prescription drug
spending increased by more than 3 percent while the amount of money spent at hospitals
decreased by 4.8 percent.
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Healthcare Industry
Introduction, Background, and Scope
Figure II-5: The Nation's Health Dollar, CY 2000
Other Spend ing
24%
Program
Administratbn
and
Net Cost
6%
Prescription
Drugs
9%
Hospital
Care
32%
Nursing Home
Care
7%
Physician and
Clinical Services
22%
Total Health Spending = $1.3 Trillion
Note: Other spending includes dentist services, other professional services, home health,
durable medical products, over-the-counter medicines and sundries, public health, research and
construction.
Source: CMS, Office of the Actuary, National Health Statistics Group.
Source: June 2002 Centers for Medicare and Medicaid Services Report.
Inpatient Care Versus Outpatient Care
The implementation of Medicare prospective payment systems and the increased
enrollment into various managed care programs have contributed to the decreased length of
patient hospital stays since 1980. According to the CMS, in 1980, the average length of a
hospital stay was between 7 and 8 days. In 1999, it was approximately 2 to 3 days. These
factors, along with advances in technology and pharmaceuticals available to treat diseases, have
also led to a decline in the number of inpatient hospital procedures. As shown in Figure II-6,
inpatient care accounted for 87 percent of hospital procedures in 1980. In 2000, that number was
down to 63 percent.
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Introduction, Background, and Scope
Figure II-6: Community Hospital Expenditures: Inpatient and Outpatient Shares
for All Payers
100 -i
1980
Inpatient n Outpatient
1990
2000
Note: Community hospitals are all non-federal, short-term general, and special hospitals whose activities are available to the public.
Source: CMS, Office of the Actuary, National Health Statistics Group.
Source: June 2002 Centers for Medicare and Medicaid Services Report.
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Healthcare Industry Activity Descriptions
III. ACTIVITY DESCRIPTIONS
As discussed in Section II.B.I of this Notebook, the healthcare industry is most
often described by speciality or service area. This section describes key functions within the
healthcare industry that create wastes that must be carefully managed to mitigate environmental
pollution.
Healthcare is a very dynamic field. Institutions are changing at a rapid rate,
adding new activities and shedding others. To understand what wastes might be generated in
any given facility, it is important to have a clear understanding of the activities that are housed in
the facility. This section describes selected key activities and the wastes these activities create,
and discusses issues related to proper handling and disposal. In some cases, it is the disposal
decisions that are responsible for the pollution created, as in the case of waste incineration (i.e.,
dioxins and mercury air emissions) or mislabeled red bag waste. In other cases, it is the actual
materials necessary to be used in healthcare processes that create the pollution (e.g., ethylene
oxide used in sterilizing critical healthcare devices).
IILA. Healthcare Activities
Thousands of activities take place daily within the healthcare sector. While the
desired outcome of delivering healthcare services is improved health for patients and the
community, many of the activities of the healthcare sector are not directly related to patient care.
Maintaining physical facilities, substantial amounts of diagnostic and testing activities, key
administrative services, and research activities are not direct forms of patient care. In fact, the
majority of wastes produced in a hospital (more than 50 percent of waste can be cardboard and
office paper) never comes in direct contact with patients.
In some healthcare facilities, activity areas may be separately owned and
operated, or run by contractors. It would not be unusual to find laboratory services at a hospital
owned and run by a private firm, housekeeping run by a contract cleaning service, food service
operated by another vendor or series of vendors, and dialysis run by another private service. As
a result, knowledge of and control over environmental issues and wastes can be decentralized
and scattered.
Producing an exhaustive list of every healthcare activity would be extremely
cumbersome and ultimately would not focus on those functions within healthcare that create
problem wastes and pollution. Nor would it equip the reader with information and strategies for
identifying and mitigating the waste. Instead, this Notebook identifies 17 key functions and
major activities that are the major sources of waste and pollution within health sector
institutions. These activities, and the wastes produced and environmental impacts that may be
associated with them, are described below.
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Administrative Activities and Services
All healthcare settings include administrative functions, which can include
offices, billing services, medical records, public relations/marketing, nursing care
documentation, human resources, security services, social services/care management, retail
services, shipping and receiving, and printing/copying.
From this standpoint, healthcare institutions can be viewed similarly to office
settings. From an environmental management perspective, the majority of waste from these
functional areas is paper. Specific activity locations within this category that deserve closer
scrutiny include:
• Shipping and Receiving - The majority of "product" coming into any
facility will pass through a central receiving area, where it is inventoried,
temporarily warehoused, and then distributed to various departments. A
number of hazardous materials used in any facility pass through this point,
and some are stored here. It is important to note that some individual
departments in some facilities may have direct ordering, bypassing
shipping and receiving. These may include areas such as the lab, facilities
management, food service, or housekeeping.
• Retail Services - Increasingly, hospitals are changing to respond to
patient demands and to seek alternative revenue streams. To accomplish
these goals, some facilities are bringing banking, childcare centers,
shopping, and food services onto the hospital campus through a lease or
other arrangements to provide patients with the ability to access their daily
needs without running to different locations.
• Printing and Copying Services - These services range from individual
printers and copiers found throughout the facility to centralized copy
shops or even professional print shops.
Support Services
A wide range of support services can be found under one roof whether a
healthcare facility is large or small. These support services can include information services,
food services, laundry services, pharmacy, central sterile reprocessing, and biomedical
engineering. In some cases, the support services are contracted services. Wastes from support
services vary greatly by support area.
• Information Services (IS) - The reliance on computers and electronic
technologies for all levels of function is growing at a rapid pace. IS might
be responsible for managing portable electronic devices and repairing or
disposing of dysfunctional or older equipment including computers and
monitors.
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• Purchasing - All of the products that are handled by shipping and
receiving are bought through the purchasing department. Wastes in this
department consist mostly of paper and paper products but can also
include pallets, shrink wrap, and cardboard.
• Food Services - Facilities utilize a large number and amount of products,
from meats and vegetables, to canned goods, cleansers, disinfectants, and
pesticides which generate solid and organic wastes. The food service at a
large healthcare facility can be the largest restaurant in the community,
and should be examined in that light from a compliance standpoint. These
facilities store and use numerous chemical cleaners, and if "pest" control
is not contracted out, a number of pest control devices and chemicals can
be present. Additionally, chlorofluorocarbons might be present in freezer
and refrigeration units. Special wastes, such as kitchen grease from
fryalators need separate collection and disposal to avoid drain disposal or
disposal as a "solid" waste. Drain disposal of wastewater from
dishwashing and food preparation must also be monitored to avoid excess
grease, harsh chemicals, or an excessive amount of organic substances
(increased BOD) from being discharged to the sanitary sewer.
• Laundry Services - Although many healthcare facilities have contracted
out to commercial laundries, some laundry services still exist within
hospitals. Water use, boilers for hot water, detergents and disinfectants
are all environmental areas of concern. Hospital laundries may process
large quantities of linens contaminated by blood and body fluids. This is
seldom of concern to a publicly owned treatment works (POTW) directly,
but is the reason for the use of industrial detergents and disinfectants.
• Pharmacy Services - This is an essential service that includes the
compounding and dispensing of pharmaceuticals. Pharmaceuticals are
received and prepared for administration within a pharmacy setting,
generating large quantities of paper and plastic waste from product
packaging and inserts. Administration of pharmaceuticals to patients and
the resulting residual waste can take place in any number of clinical areas
within a healthcare setting, including patient care floors, surgical suites,
and free-standing clinic settings. Pharmaceuticals can also be packaged
for administration in home-care settings. There are a number of common
pharmaceuticals that are listed as RCRA P- or U- listed waste and many
others that meet the criteria for RCRA characteristic waste. The pharmacy
function may take place in one central location, may be off site, or may
have a number of satellite sites throughout a facility. Of particular
importance is the management of the large amounts of expired, unused, or
partially used pharmaceuticals, the control of chemotherapeutic agents,
and management of contaminated materials and containers, as well as
residual or bulk amounts of chemotherapy product. Drug classes to be
concerned about include: antineoplastic (toxic, mutagenic, persistent,
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accumulative), steroids (persistent, reproductive effects), antibiotics
(persistent, bacterial resistance), antifungal (toxic, mutagenic, target
organs, endocrine effects), antiviral (toxic, mutagenic, chronic effects),
vaccines with thimerosal (contains mercury), and contrast reagents (with
barium). Of less concern are recombinant proteins, analgesics,
antihistamines, antiemetics, and electrolytes.
• Central Sterile Reprocessing and Distribution (CSRD) - This service
function provides support for surgical services and other departments
requiring sterile products. Typically a CSRD unit includes a 'dirty' or
decontamination area that receives and cleans used equipment, and a
'clean' area that manages sterilized and cleaned products for redistribution
throughout the facility. CSRD units usually work very closely with
surgical services units, endoscopy units and other care units requiring a
ready supply of key materials routinely cleaned and distributed from
within the organization. Often these areas house ethylene oxide
sterilizers, steam sterilizers (autoclaves) and chemical treatment (steris,
sterrad) units. Solid and biohazardous wastes are regularly generated in
these areas. Select hazardous chemical wastes may be generated
depending upon the types of processes used at a given site. Water
discharges from chemical processes and autoclaves should be monitored.
Air discharges should be monitored if ethylene oxide (EtO) is utilized.
• Biomedical Engineering - This service function provides support to the
many types of equipment and devices used in providing direct patient care
and support services. Biomedical engineering can be an in-house function
or a contracted service and would include calibrating blood pressure
monitoring devices (both mercury and nonmercury). Often, a mercury
sphygmomanometer and/or barometer is used to aid in calibration.
Biomedical engineering often handles the increasingly large quantity of
batteries (including NiCD, NiHydride, Lead acid, Lithium, dry cell) that
have to be tested and changed out in many different types of equipment.
Facilities Management, Maintenance, and Plant Operations
The maintenance of a hospital or healthcare facility includes housekeeping,
maintenance shops (paint, electric, plumbing), heating ventilation and air conditioning (HVAC)
systems, water treatment, waste treatment, aboveground tanks, underground tanks, fleet
management, groundskeeping, and pest management. It is similar in many ways to the
maintenance of a large commercial or light manufacturing facility. It has many of the same
functions and generates many of the same environmental concerns involving waste, air, and
water issues.
• Housekeeping or Environmental Services - Cleaning complex facilities
with many varying needs for cleanliness, ranging from "clean" to
"sterile," requires the use of chemical agents, technologies, and water.
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Maintaining surfaces (e.g., floors, walls, counters, sinks, toilets, furniture,
and equipment) requires the use of a large range of cleaners, disinfectants,
and treatments. Cleaning floors can involve the use of strippers and
waxes, as well as cleansers. Housekeepers are also often charged with
collecting, transporting, and overseeing the storage of all the wastes
generated, including solid waste, biohazardous waste, and hazardous
chemical wastes. In addition, they often operate equipment that uses
hydraulic fluids (compacters and balers).
• Engineering and Maintenance - These functions and the scope of this
service is defined differently in different settings. Often, there is overlap
between the housekeeping staff, maintenance staff, and engineering staff
duties. Maintenance functions, including painting, electrical work,
plumbing, and carpentry, are sometimes internal functions with full shop
areas in place to provide these services. Solvents, degreasers, cleaners, oil
paints, and a number of toxic and often flammable products are regularly
used, stored, and disposed of. Large amounts of chemicals are required in
maintaining the HVAC and water treatment systems, boilers, and coolers.
Monitoring systems for air emissions and water discharges must be
maintained. Staff serving in these functions also are often responsible for
changing out lighting fixtures and bulbs, generating waste fluorescent
bulbs and lighting ballasts. Mercury management is often a primary
concern in this service, as mercury is often found in devices throughout
the facility in thermostats, mercuric oxide batteries, switches and relays in
alarms and other electrical equipment, gauges and switches on boilers, as
well as in additives to paints, cleaners, and other chemicals.
• Waste Treatment - Technologies might be on site and in operation to
treat the facility wastes. These technologies could range from wastewater
pre-treatment, an incinerator (solid and biohazardous waste), to an
autoclave (biohazardous waste) to distillation units for solvents, alcohols,
and formalin (usually located in conjunction with the lab), to bulb crushers
(fluorescent bulbs). Emissions (primarily air) are of concern with all of
these, as are residual wastes. Additionally, the treatment and disposal
process may convert some materials that are nonhazardous into hazardous
waste. Incineration of PVC plastics, products, and packaging (which
comprise a portion of plastic wastes in healthcare) can create dioxins
when incinerated. Many facilities collect biohazardous waste in red bags
and red sharps containers and certain chemotherapy wastes in yellow
bags. The colors in these containers can be from cadmium-based
pigments, although the use of cadmium has been phased out in recent
years. Cadmium, a hazardous air pollutant, can be released if these
containers are combusted as part of the treatment process.
• Fleet Management - Vehicles of various kinds can be owned, leased, or
used through a contracted service. Facilities that maintain a fleet (this can
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Healthcare Industry Activity Descriptions
range from golf carts, to cars, trucks and vans, to ambulances, to
helicopters) must determine how to address maintenance and cleaning of
the vehicles, as well as fuel storage. Wastes to be addressed include waste
oil, solvents, tires, batteries, and coolants/CFCs.
• Groundskeeping - Landscaping, mowing, snow removal, and pest
management increasingly are services that are contracted out. Use of
fertilizers, herbicides, pesticides, and deicing substances needs to be
carefully monitored for releases and run-off Similarly, pest control is
often a contracted service.
Laboratory Services
Thousands of medical and diagnostic tests and services are performed on a daily
basis, even in small labs serving healthcare facilities. These services can include hematology,
microbiology, chemistry, blood bank, surgical pathology, and histology. The functions of
laboratory testing are highly varied, and involve a number of separate processes. Labs utilize
large volumes of a few chemicals (e.g., xylene, alcohol, formalin) and small quantities of a large
number of other substances. Labs tend to expend many of the chemicals used in testing through
evaporation or dilution and disposal to the sanitary sewer. Both air and water emissions are of
concern. Larger quantities of some chemicals may be collected for disposal, or in some cases
may be reprocessed for reuse within the lab. More information is available at: Environmental
Management Guide for Small Laboratories, EPA 233-B-00-001, May 2000, Office of the
Administrator (2131), http://www.epa.gov/sbo/smalllabguide 500.pdf.
Labs can be free-standing entities or part of a larger facility. If they are within a
larger facility, they still may be privately owned and operated, or operated under contract.
Consequently, responsibility for managing hazardous materials and wastes can be complicated.
Disinfecting equipment and materials is important to the accuracy of lab
functions, so a range of disinfecting solutions is often found in labs. Autoclaves are often used
to sterilize equipment that has been cleaned for reuse, and they may be available in labs to
pretreat some wastes (e.g., culture plates) prior to disposal.
Many labs have automated chemical analyzer systems. These systems contain
many reagent reservoirs and reagents with preservatives. It is often necessary to contact the
manufacturer to identify all potential chemical waste locations within the system.
A range of mercury-containing devices in labs is still not uncommon, sometimes
due to the age of equipment or interpretation of accreditation standards that require mercury
calibration equipment.
Wastes that are commingled (biological samples and chemicals) are also
common, especially in surgical pathology where tissue samples in formalin have to be processed
and in many cases stored for extended periods.
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Healthcare Industry Activity Descriptions
Diagnostic Services
An increasingly diverse and large number of diagnostic services are now
available. These can include, but are not limited to endoscopy, cardiac catheterization, radiology
(CT, MRI, digital imaging), nuclear medicine, sleep studies labs, and electroencephalograph
studies (EEG). Diagnostic services are often found in association with medical centers but in
some cases can be free-standing facilities.
• Endoscopy and Cardiac Catheterization - New techniques in these
areas have resulted in less biohazardous waste generation but an increased
use of high-level disinfectants (e.g., glutaraldehyde) or sterilants (e.g.,
ethylene oxide (EtO) gas), both of which represent significant hazards as
releases to water or air.
• Radiology - These functions have traditionally involved the use of film
and film-developing chemicals. Radiology activities can occur within a
hospital center, urgent care setting, outpatient clinic, dental offices, or
other care areas that require X-rays to help evaluate healthcare conditions.
Although many healthcare organizations are transitioning away from wet
processing and silver-containing films to digital imaging and PAX-it
brand systems, heavy metals waste is generated through a number of
activities in Radiology. In particular, lead shields are used to shield
patients from exposure. These shields wear out over time, and should be
managed as a hazardous waste or sent back to the supplier for
remanufacture into a smaller shield device. Additionally, contrast
reagents are not always fully consumed by the patient and will result in
hazardous waste if discarded unused.
• Nuclear Medicine - This branch of diagnostic testing primarily offers
diagnostic imaging and radioisotope treatment. Radionuclides are used in
various tests and procedures and require careful management, storage, and
monitoring until they are safe for disposal. Radioactive waste may also be
RCRA hazardous waste, which should be separated from the
nonhazardous waste prior to decay storage.
Surgical Services
Surgical services include anesthesia, preoperative services, ambulatory outpatient
services, surgery, and post-anesthesia care. Advances in surgery have vastly reduced the
invasive nature of different procedures and correspondingly reduced the amount of biohazardous
wastes (e.g., blood and body-fluid-contaminated wastes) generated. However, surgery functions
still represent one of the highest waste-generating areas. Many of the new surgical devices
represent environmental challenges, such as batteries with heavy metals that must be managed,
or devices that require special chemical disinfection or sterilization.
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Healthcare Industry Activity Descriptions
In most areas, the majority of surgery is performed as ambulatory, or "day"
surgery. These procedures do not require that patients stay overnight. As a result, what was
previously a highly centralized function is now very decentralized, with many of the specialized
wastes being generated outside of large institutions.
Special wastes can be found in anesthesia services and surgical pathology units.
Anesthesiologists and nurse anesthetists administer to patients during surgical procedures and
provide pain management services. Waste anesthetic gases from care delivery must be managed
to prevent releases. Careful management of compressed gas cylinders (e.g., oxygen, nitrogen,
and argon) is also a safely concern. Surgical pathology units can present a host of hazardous
chemicals to monitor, as tissue samples are taken and preserved in formaldehyde, or a dilute
version, formalin (e.g., biopsies and surgical excisions).
Inpatient Care Services
The need for inpatient care services has declined in the last decade, with an
increasing number of services being offered on an out-patient basis (e.g., stay at the facility is
less than 24 hours). Specialized treatment for many acute and chronic conditions or more
serious illness or injury still requires overnight and longer terms stays in hospitals and other
types of healthcare institutions. The primary concerns in waste are usually limited to the
management of biohazardous wastes (mostly sharps), the use of cleaners and disinfectants, and,
as in all patient care areas, the possible presence of mercury-containing devices (e.g., fever
thermometers, sphygmomanometers, and a variety of pharmaceutical products). Some services,
such as dialysis and oncology (discussed below), can be delivered in these areas. Inpatient care
services include medical surgical care, orthopedic care, neurology care, urology care, cardiac
care, psychiatric/behavioral health, geriatric care, palliative care, cancer care, maternal child care
(labor and delivery/birthing, postpartum care, nursery, pediatrics), pediatric care, and
rehabilitative care.
Critical Care Services
Critical care inpatient services such as surgical intensive care, medical intensive
care, pediatric intensive care, cardiac intensive care, burn care, and neonatal intensive care are
conducted in hospital facilities. Many critical care waste concerns are the same as in other
inpatient service areas (discussed above). In addition, specialized monitoring equipment and an
array of pharmaceuticals are used in these areas. Two common drugs used in critical care areas
that become hazardous when disposed of are epinephrine and warfarin (Coumarin).
Emergency Care Services
Emergency care services are offered in different types of settings, both in very
large and small hospitals, as well as in free-standing units. While care offered in these types of
service units is meant to be limited in time and scope, they are often designed to provide a wide
range of services, as their goal is to respond to "emergencies." These services entail a large
degree of response to unpredictable situations, including emergency response to industrial
accidents and bioterrorism incidents. Additionally, as the ranks of uninsured Americans grows,
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it is common for individuals to seek routine care in emergency department settings, rather than at
physicians' offices.
Emergency service areas are also responsible for disaster response management,
and many institutions have set up decontamination rooms in association with emergency
services. Such rooms are designed to allow individuals who have been exposed to chemicals or
biological agents to be safely decontaminated before entering the emergency service area.
Decontamination can involve using chemicals and copious amounts of water. Facilities should
have a system of trapping the wastewater so that they can test and then properly manage the
wastes.
Many emergency service waste concerns are the same as in other patient care
service areas (see above) and include biohazardous wastes, chemicals for cleaning and high-level
disinfection or sterilants, the possible presence of mercury-containing devices, and the
possibility of pharmaceutical wastes.
Other activities that may also be present as part of emergency services include
storing formalin for preserving specimens, operating X-ray technology, and managing
photographic chemicals, wastewater, silver recovery, and films. Given the range of instruments
used, there may also be disinfectant chemicals, such as glutaraldehyde, or other high-level
disinfectants present.
Respiratory Care Services
A variety of wastes are generated through respiratory care functions, which
include pulmonary function testing and oxygen therapies. Reprocessing some equipment may
involve using high-level disinfectants. As in other patient care areas, mercury devices and
batteries could be used. Special management concerns include pressurized tanks such as
oxygen.
Dialysis
Dialysis can be conducted in a wide variety of settings, from homes to specialty
clinics to large hospital facilities. There are different types of dialysis. Hemodialysis involves
external technologies that filter the blood using a mechanical dialyzer. Peritoneal dialysis
involves pumping dialyser fluids into the patient's abdominal cavity and using the peritoneum
liner as a natural filter. Areas conducting hemodialysis can generate larger amounts of
biohazardous wastes due to the nature of the process. The waste often contains large amounts of
liquid and is heavy.
Hemodialysis equipment requires water treatment and the use of high-level
disinfectants. In the past, formaldehyde was commonly used to clean machinery. Today, less
toxic disinfectants are primarily used.
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Physical Therapy/Occupational Therapy
Generally, these areas generate little waste of concern. As in other patient care
areas, mercury devices could be used. Biohazardous waste, such as sharps, forceps, blades, or
lancets may be generated, especially if wounds/burns are debrided and treated in these areas. If
prosthetic devices are made on site, chemicals related to leather working (tanning chemicals,
adhesives) and plastics molding may be used.
Outpatient Services (Nonsurgical)
Outpatient services include womens' health/gynecology, general medicine, family
practice, specialty clinics (e.g., orthopedics, urology, pulmonology, allergy), pediatrics, and
rehabilitative services.
Generally, these areas generate little waste of concern. As in other patient care
areas, mercury devices could be used. In some cases, formalin may be used to preserve tissue
samples (biopsy). Sharps management is the biohazardous waste management concern. As in
many patient care functions, a variety of pharmaceutical products may be present. For example,
trichloroacetic acid and potassium hydroxide, both characteristic (corrosive) wastes are usually
used in OB/GYN practices.
Oncology/Cancer Care Services
Oncology care includes administering chemotherapy medications to cancer
patients. In radiation oncology, treatment can involve intravenously administering radioactive
isotopes and applying radiation externally to cancer patients. These treatment activities are
sometimes grouped together but are often found separately. They may take place in either
outpatient or inpatient settings. In some cases, chemotherapy is administered through home-
based treatment programs.
Antineoplastic, or cytotoxic, agents that are used to produce chemotherapy
solutions are generally procured through a central purchasing area or directly from the pharmacy.
Chemotherapy medications may either be prepared in a special area within the hospital pharmacy
or prepared in a special area in the oncology unit (in-patient or outpatient type of unit). The
amount and type of chemotherapy found in any institution depends on the amount of care/
number of procedures provided and physician preferences for ordering pharmaceuticals. In the
preparation area, work is conducted in a safety cabinet equipped with the appropriate filters.
Facilities must maintain the filters and determine if they require special disposal, which is often
done under a maintenance contract. Residuals from preparation include any contaminated
materials including vials, bottles, IV bags, packaging, and personal protective equipment.
Proper segregation containers need to be available for materials determined to be RCRA waste,
or as nonhazardous materials (often personal protective equipment and packaging) that can be
collected separately. Chemotherapy wastes that are not classified as RCRA waste must be
properly labeled as chemotherapy-containing materials (e.g., collected in yellow bags) but they
can be sent out for incineration (or other technologies as they become available) with the
institution's biohazardous waste. Note that if an unregulated chemotherapy waste is
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contaminated with a RCRA hazardous waste, RCRA regulations apply. Radiation therapy areas
will contain radioactive materials that must be properly handled and monitored.
Dentistry
Dentistry services, including oral surgery, periodontics, and oral healthcare, are
provided in a wide range of settings from individual private practices to dental surgery centers
that are free standing or located within large teaching and research hospitals. It is estimated that
dental facilities in the United States used 40 metric tons of mercury in 1997, which may be
placed in teeth, recycled, discharged into wastewater, or disposed of as waste.2 Approximately
50 percent of dental amalgam is mercury. A study by the Association of Metropolitan Sewerage
Agencies found that dental offices are the largest source of mercury to POTWs, contributing
more than 35 percent of mercury influent to the POTWs studied.3 Other studies have estimated
the contributions to be as high as 80 percent.4
Mercury in dental amalgam can enter the environment in a variety of ways.
Dental amalgam waste that is generated (for instance, excess amalgam that is not placed in a
tooth, or amalgam that is captured by traps and filters in the dental office) can release mercury
into the environment if it is not managed properly. When amalgam restorations are placed in or
removed from teeth during dental work, amalgam can enter dental wastewater; when it reaches a
wastewater treatment plant, a small percentage of the mercury in the amalgam will be discharged
by the plant.
While amalgam has very low solubility in water, a small percentage can be
released in a bioavailable form and be converted to methylmercury, the form that accumulates in
the food chain, presenting potential health risks to humans and wildlife who consume
contaminated fish. Most of the mercury that reaches sewage treatment plants (in excess of 90
percent) is likely to be captured by the treatment plant and enter the sewage sludge, or biosolids.5
These biosolids may be land-applied, landfilled, or incinerated. Incineration will likely volatilize
mercury back into the environment.
Other wastes from dentistry include X-ray wastes (developer chemicals, silver
discharges, lead shields), high-level disinfectants, chemical sterilizers, nitrous oxide, and
biohazardous wastes, especially sharps. A simple guide to waste management specific to
dentistry practices and wastewaters can be found at the following web sites:
2 Stone, Mark E., DDS, 2004. "The Effect of Amalgam Separators on Mercury Loadings to Wastewater Treatment
Plants," CDA Journal, Vol. 32, No.7, July 2004.
3 Association of Metropolitan Sewerage Agencies (2002). Mercury Source Control & Pollution Prevention Program
Evaluation: Final Report. March 2002 (Amended July 2002).
4 Stone, 2004.
5 Options for Dental Mercury Reduction Programs: Information for State/Provincial and Local Governments, A
Report of the Binational Toxics Strategy, Mercury Workgroup Co-chairs
Alexis Cain, U.S. Environmental Protection Agency, Robert Krauel, Environment Canada,
http://www.epa.gov/region5/air/mercury/dentaloptions3.pdf, December 16, 2003, Revised August 4, 2004.
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• A Guide for Dentists: How to Manage Waste From Your Dental Practice
University of Wisconsin—Extension
http://www.tcw ex. e du/shwec/Pubs/p df/gui defordentists.pdf
• Guidelines for New Mexico Dental Facilities Waste-Management,
Education and Research Consortium
http://www. cabq.gov/p2/pdfs/dentalbooklet.pdf
• Characteristics and Treatment of the Dental Wastewater Stream
University of Illinois, Chicago http://www.wmrc.uiuc.edu/main sections/
info services/library docs/rr/RR-9 7.pdf
• Options for Dental Mercury Reduction Programs: Information for
State/Provincial and Local Governments, U.S. EPA and Environment
Canada http://www.epa.gov/region5/air/mercury/dentaloptions3.pdf
• Northeast Waste Management Officials' Association (NEWMOA) has
both a Dental Mercury Topic Hub http://www.newmoa. org/Newmoa/
htdocs/prevention/topichub/toc. cfm ?hub=103&subsec=7&nav=7 and a
list of links to articles , fact sheets, and case studies
http://www.newmoa.org/Newmoa/htdocs/prevention/topichub/bibliograph
v. cfm ?hub=103&subsec=7&nav=100
• The Environmentally Responsible Dental Office: A Guide to Proper
Waste Management http://www.delta-
institute.org/pollprev/mercuty/linkfiles/VTdentalguide.pdf
Animal Research and Testing
This testing represents a wide rage of activities that can occur at free-standing
research laboratories or in association with healthcare facilities. The research is usually
independently funded, varied, and conducted out of the usual system of procurement at the
facility. The activities and wastes of concern can encompass all of those usually encountered in
labs, with the addition of animal care and housing. Animal care facilities may have antibiotics
and pharmaceuticals in the animal's drinking water. Also, the facility may wash the animal
cages with corrosive reagents. The waste can also include chemicals and materials not usually
associated with the general delivery of healthcare services. Any facility sponsoring animal
research and testing should maintain an inventory of materials currently in use and stored at the
facility.
Clinical Research
Like animal research and testing, clinical research represents a wide rage of
activities that can take place at free-standing research laboratories or in association with
healthcare facilities. The research is usually independently funded, varied, and conducted out of
the usual system of procurement at the facility. The activities and wastes of concern can
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encompass all of those usually encountered in labs and under many patient care and treatment
activities. It can also include chemicals and materials not usually associated with the general
delivery of healthcare services. Any facility sponsoring clinical research should maintain an
inventory of materials currently in use and stored at the facility.
Construction and Renovation
Construction and renovation are constant activities in healthcare settings. The
largest portion of wastes is that common in any construction and demolition (C&D) waste
stream, mainly solid waste. However, there may be some special concerns, including stormwater
control, asbestos and lighting ballasts, as well as less obvious ones like mercury. While mercury
would be commonly associated with thermostats and other switches or gauges, a number of
healthcare facilities undergoing renovation projects have found residual mercury in drains and
traps.
IILB. Waste Streams Generated by the Healthcare Industry
There are many variables affecting healthcare waste generation, including:
• The type of products and materials purchased for use;
• The type of waste segregation systems in place;
• The degree to which problem wastes are identified and mitigation
strategies are implemented; and
• The location of care delivery (in a hospital, clinic, or home).
This subsection presents a brief overview of the major waste streams in
healthcare. Chapter IV of this Notebook will provide a broader profile of the major wastes and
waste streams. Note that states and local regulating bodies may impose more stringent
definitions of waste and more stringent waste requirements than those established by EPA and
other federal agencies.
In response to the Medical Waste Tracking Act (MWTA) of 1988, the Society for
Hospital Epidemiology produced a position paper entitled Medical Waste6. Its focus was on the
majority of wastes that are produced by healthcare activities and are generally classified as solid
waste or biohazardous wastes. It did not address the chemical or radioactive wastes from the
sector. This paper provided the most authoritative and comprehensive definition,
characterization, profiling, and analysis of risks from healthcare wastes to date.
6 (Rutala WA, Mayhall CG, "The Society for Hospital Epidemiology of American (SHEA) Position Paper: Medical
Waste." Infection Control Hospital Epidemiology. 1992; 13:38-48).
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Healthcare wastes can be categorized as follows:
• Municipal solid waste;
• Biohazardous waste (regulated medical waste);
• Hazardous waste:
— Listed and characteristic waste,
— Commingled waste,
— Pressurized containers and ignitable compressed gas, and
— Universal waste; and
• Waste by media category:
— Wastewater,
— Stormwater, and
— Air emissions.
Each of these areas is described in detail below.
IILB.l. Municipal Solid Waste
The majority of healthcare wastes are produced under circumstances identical to
restaurants and food industry facilities, hotels, and office complexes. The industry generates
large volumes of solid wastes (much of what could be subcategorized as recyclable wastes).
Studies indicate that 1 percent of all solid waste produced in the United States is generated by
healthcare facilities. There have been numerous studies of these wastes, including ways to
manage them to minimize waste and environmental impacts. In 1993, the American Hospital
Association (AHA) published a manual for its members, An Ounce of Prevention: Waste
Reduction Strategies for Health Care Facilities (Bisson, McRae and Shaner). Since then, state
hospital associations, state solid waste agencies, and a number of private organizations have
produced additional manuals. A cooperative program between the EPA and the American
Hospital Association, Hospitals for a Health Environment (H2E) is compiling recent materials;
this compilation can be found at: http://www.h2e-online.org/.
A special subcategory of municipal solid waste to be considered is construction
and demolition (C&D) debris. During remodeling, C&D debris can fall into several categories
of waste. Healthcare facilities must identify which materials are RCRA Subtitle C hazardous
waste (discussed in Section VI of this document), including lead shielding, lead paint, and
demolished equipment containing lead, mercury, silver and/or cadmium (especially batteries,
fluorescent light bulbs, and computer monitors). Facilities may identify some construction and
demolition debris that is recyclable, which can reduce disposal cost. Also, some C&D debris is
municipal solid waste, but is generated at a large enough volume to warrant separate disposal in
a construction and debris landfill.
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III.B.2. Biohazardous Waste (Regulated Medical Waste)
The concern with and need for better management of healthcare waste that
triggered the Medical Waste Tracking Act largely relates to those wastes in healthcare that can
potentially harbor and transmit infectious diseases. This includes a wide range of materials that
are considered contaminated or pose special risks (e.g., sharps). This category of wastes is
defined by regulation at the state, tribal, or local level.
There is general agreement on certain characteristics and components of this
waste as noted in the list below, but the specific definitions of this waste are defined on a state-
by-state basis, and there are sometimes significant differences in those definitions between
states. Further, what and how much waste falls into this category can vary widely depending on
the interpretation of these regulations by the generator on a facility-by-facility basis, even within
states.
Terminology used to describe this waste category is often confusing and used
interchangeably. Words such as "biohazardous waste" "infectious waste" "infectious medical
waste" "potentially infectious material" "contaminated trash" and "regulated medical waste"
are examples of the terms used in describing this segment of healthcare wastes.
Wastes usually considered in this category include7:
• Cultures and stocks of infectious agents and associated biologicals,
including: cultures from medical and pathological laboratories; cultures
and stocks of infectious agents from research and industrial laboratories;
wastes from the production of biologicals; discarded live and attenuated
vaccines; and culture dishes and devices used to transfer, inoculate, and
mix cultures.
• Human pathological waste, including tissues, organs, and body parts and
body fluids that are removed during surgery or autopsy, or other medical
procedures, and specimens of body fluids and their containers.
• Human blood and blood products including: (i) liquid waste human blood;
(ii) products of blood; (iii) items saturated and/or dripping with human
blood; or (iv) items that were saturated and/or dripping with human blood
that are now caked with dried human blood, including serum, plasma, and
other blood components, and their containers, which were used or
intended for use in either patient care, testing and laboratory analysis or
the development of pharmaceuticals. Intravenous bags are also included
in this category.
7 Definition taken from the Federal Plan Requirements for Hospital/Medical/Infectious Waste Incinerators
Constructed On or Before June 20, 1996.
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• Sharps that have been used in animal or human patient care or treatment or
in medical, research, or industrial laboratories, including hypodermic
needles, syringes (with or without the attached needle), Pasteur pipettes,
scalpel blades, blood vials, needles with attached tubing, and culture
dishes (regardless of presence of infectious agents). Also included are
other types of broken or unbroken glassware that were in contact with
infectious agents, such as used slides and cover slips.
• Animal waste including contaminated animal carcasses, body parts, and
bedding of animals that were known to have been exposed to infectious
agents during research (including research in veterinary hospitals),
production of biologicals, or testing of pharmaceuticals.
• Isolation wastes including biological waste and discarded materials
contaminated with blood, excretions, exudates, or secretions from humans
who are isolated to protect others from certain highly communicable
diseases, or isolated animals known to be infected with highly
communicable diseases.
• Unused sharps including unused, discarded hypodermic needles, suture
needles, syringes, and scalpel blades.
III.B.3. Hazardous Waste
There are some special waste streams that fall most logically under the heading of
"hazardous" but because of their unique nature and the risks inherent in each of them, they are
discussed separately below as Mixed Waste, Pharmaceutical Waste, Pressurized Containers and
Ignitable Compressed Gas, and Universal Waste. The RCRA standard is cited below. States
must at least accept these standards but have the right to impose stricter standards and list
additional wastes.
To be considered hazardous waste under RCRA, waste must either be listed or
characteristic. Listed wastes are specifically named in 40 CFR Section 261. Characteristic
wastes are either ignitable, reactive, corrosive, or toxic. This subsection gives a quick overview
of listed and characteristic hazardous wastes, and lists the most common healthcare hazardous
wastes. The following EPA web site provides a flowchart that outlines the major steps in the
hazardous waste identification process: w ww .fedcenter. gov/resources/facility tour/hazardous/
whatis/flow chart/
RCRA Listed and Characteristic Wastes
• Listed Waste - The four types of RCRA listed waste are F, K, P, or U,
with a three-digit identifier (e.g., F005, P039, U135). EPA listed these
wastes as hazardous because they are known to be harmful to human
health and the environment when not managed properly, regardless of
their concentrations. Some states may list more wastes as hazardous than
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EPA. Visit www. her center, org to locate state-listed wastes. The lists
include the following four types of waste:
— F-listed wastes. These non-specific-source wastes are
material-specific, such as solvents, generated by several different
industries. Waste codes range from F001 to F039. Examples of
healthcare facility wastes that fit this category are solvents often
used in research laboratories, pharmacies, and morgues (e.g.,
methanol, acetone, and methylene chloride).
— K-listed wastes. These source-specific wastes are from
specifically identified industries and range from K001 to K161.
Healthcare facilities typically do not produce K-listed wastes.
— U-listed wastes. These discarded commercial chemical products
include off-specification products, container residuals, spill residue
runoff (pure or mixed with non-active ingredients such as
colorants, flavoring agents, emulsifiers, fragrances, water, etc.),
technical grades (e.g., 95% pure Acetone), off-specification
species, or active ingredients that have spilled or are unused and
that have been, or are intended to be, discarded. Waste codes
range from U001 to U411. Examples of healthcare facility wastes
that fit into this category are ethylene oxide (Ul 15), some waste
Pharmaceuticals such as lindane (U129) and selenium sulfide
(U205), and some waste chemotherapy drugs such as
chloroambucil (U035).
— P-listed wastes. Like U-listed wastes, these discarded commercial
chemical products include off-specification products, container
residuals, spill residue runoff spill residue runoff (pure or mixed
with non-active ingredients such as colorants, flavoring agents,
emulsifiers, fragrances, water, etc.), technical grades (e.g., 95%
pure Acetone), off-specification species, or active ingredients that
have spilled or are unused and that have been, or are intended to
be, discarded. Waste codes range from P001 to P205. These
wastes are considered acutely hazardous waste and as little as 2.2
Ibs of these wastes generated in a given calendar month, or one
quart of these wastes stored in a satellite accumulation area
designates a facility as a large quantity generator. An example of a
healthcare facility waste in this category is epinephrine (P-042).
Table III-l below lists some specific examples of RCRA hazardous waste from
healthcare facilities.
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Table III-l: Examples of RCRA Listed Hazardous Waste Found in Healthcare Facilities
Chemical or Device Containing Chemical
RCRA Listing
Note: This list is not exhaustive but provides some common healthcare hazardous wastes.
Solvents used in the laboratory such as xylene, ethanol, toluene, and
methanol. Solvents are also used in inks for forms and menus.
2-Chloroethyl Vinyl Ether
3 -Methy Ichloranthrene
Acetone
Acetyl Chloride
Acrylonitrile
Aniline
Bromoform
Cacodylic Acid
Carbon Tetrachloride
Chloral Hydrate
Chlorambucil
Chloroform
Creosote
Cresols
Cyclophosphamide
Daunomycin
Dichlorobenzenes
Ethyl Acetate
Ethyl Carbamate
Ethyl Ether
Ethylene Oxide
Formaldehyde
Formic Acid
Hexachloroethane
Hexachlorophene
Lindane
Maleic Anhydride
Melphalan
Mercury
Methanol/Methyl alcohol
Mitomycin C
Xylene, U239
Methanol, U154
Several ethanol compounds are U-listed
U042
U157
U002
U006
U009
U012
U225
U136
U211
U034
U035
U044
U051
U052
U058
U059
U070, U071, U072
U112
U238
U117
U115
U122
U123
U131
U132
U129
U147
U150
U151
U154
U010
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Table III-l: Examples of RCRA Listed Hazardous Waste From
Healthcare Facilities (Continued)
Chemical or Device Containing Chemical
Naphthalene
N-butyl Alcohol
Paraldehyde
p-Chloro-m-Cresol
Phenol
Reserpine
Resorcinol
Saccharin
Selenium Sulfide
Streptozotocin
Tetrachloroethylene
Thiram
Trichloroethylene
Uracil Mustard
Warfarin (Coumarin) < 0.3%
RCRA Listing
U165
U031
U182
U039
U188
U200
U201
U202
U205
U206
U210
U244
U228
U237
U248
Waste codes range from P001 to P205 and should be noted as acutely hazardous waste, as 2.2 Ibs of these
wastes generated in a given calendar month designates a facility as a large quantity generator.
3 -Benzyl Chloride
Arsenic
Arsenic Trioxide
Chloropropionitrile
Cyanide Salts
Epinephrine
Nicotine
Nitroglycerin (unless the state adopted the federal exclusion for
healthcare facilities)
Osmium Tetroxide
Phentermine
Phenylmercuric Acetate
Physotigmine
Physotigmine Salicylate
Potassium Silver Cyanide
P028
P012
P012
P027
P030
P042
P075
P081
P087
P046
P092
P204
P188
P099
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Table III-l: Examples of RCRA Listed Hazardous Waste From
Healthcare Facilities (Continued)
Chemical or Device Containing Chemical
Sodium Azide
Sodium azide is often used as a preservative in a variety of laboratory
reagents usually at concentrations of less than 0. 1%. It is not the sole
active ingredient in these cases and would not be a P-listed waste.
Warfarin (Coumarin) > 0.3%
Mercury compounds such as thimerosal, amalgam, and mercury-
containing fixatives. Mercury-containing equipment such as
thermometers, sphygmomanometers (blood pressure measuring
device), thermostats, weighted feeding tubes and fluorescent bulbs. If
the state adopted the Universal Waste Rule, then fluorescent bulbs are
considered universal waste.
Lead-containing equipment such as lead aprons, bitewings, lead pigs,
lead shielding removed during construction or renovation, batteries,
and computer monitors. If the state adopted the Universal Waste Rule,
then batteries are considered universal waste.
Silver from X-rays. Silver can come from fixer/developer solutions or
from film or from devices employed to harvest silver.
RCRA Listing
P105
P001
Mercury is listed as U151, but several
other mercury compounds are also
listed. The RCRA toxicity
characteristic (discussed below) also
lists mercury (D009) and requires a limit
of0.2mg/L.
The RCRA toxicity characteristic
(discussed below) lists lead (D008) and
requires a limit of 5.0 mg/L.
The RCRA toxicity characteristic
(discussed below) lists silver (D01 1)
and requires a limit of 5.0 mg/L.
Sources: EPA Region 2 presentation dated February 2004, entitled "Identification and Management of Regulated
Hazardous Waste, A Workshop Geared Toward Healthcare Facilities" and H2E's web page, at
http://www.h2e-online.ors/pubs/chemmin/master.pdf.
Note that some chemicals used in healthcare are toxic and harmful to the
environment, but RCRA does not list them as hazardous waste. These include glutaraldehyde
and many chemotherapy drugs (other than the nine that are listed). A best management practice
is to handle such materials as if they were hazardous waste, to protect workers, patients, and the
environment. For an explanation of RCRA requirements, see Section VI of this Notebook.
• Characteristic Waste - Even if waste does not appear on one of the
hazardous waste lists, it still might be regulated as hazardous waste if it
exhibits one or more of the following characteristics:
— Ignitability. (40 CFR § 261.21) Ignitable wastes create fires under
certain conditions, are spontaneously combustible, and have a flash
point of less than 60°C (140°F), are ignitable compressed gas, or
are an oxidizer (such as a chlorate or peroxide). The waste code
for these materials is D001. They are liquids, other than aqueous
solutions containing less than 24 percent alcohol by volume and
with a flash point less than 60 °C (140 °F).
— Corrosivity. (40 CFR § 261.22) Corrosive wastes are acids or
bases that are aqueous and have a pH less than or equal to 2 or
greater than or equal to 12.5; or are liquid capable of corroding
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metal containers, such as storage tanks, drums, and barrels. A
liquid is considered corrosive if it can corrode steel at a rate of at
least 0.25 inches per year at 55° C (130° F). Wastes are aqueous if
they contain 20 percent water, measured quantitatively or
separated from the waste by pressure or vacuum filtration as
described in EPA Method 1311. Note, waste that is not aqueous
and contains no liquid falls outside the definition of EPA
corrosivity. Examples include pharmaceutical compounding
chemicals such as sodium hydroxide solution. The waste code for
these materials is D002.
— Reactivity. (40 CFR § 261.23) Reactive wastes are unstable under
normal conditions. They can cause explosions, toxic fumes, gases,
or vapors when mixed with water. They can be a cyanide or
sulfide-bearing waste that can generate fumes in a quantity
sufficient to present a danger to human health when mixed with an
acid or base. They may be capable of detonation or a forbidden
explosive, or a Class A or Class B explosive, as defined in
Department of Transportation regulations in 49 CFR Part 173.
Examples include picric acid and lithium-sulfur batteries (such as
those used in electronic thermometers). The waste code for these
materials is D003.
— Toxicity Characteristic. (40 CFR § 261.24) Toxicity characteristic
wastes are harmful or fatal when ingested or absorbed. When
toxicity characteristic wastes are disposed of on land,
contaminated rain or liquid may drain (leach) from the waste and
pollute ground water. Toxicity is defined through a laboratory
procedure called the Toxicity Characteristic Leaching Procedure
(TCLP). Toxicity characteristic healthcare wastes include those
exceeding regulatory values for chloroform, lindane, m-cresol,
mercury and mercury compounds (thimerosal), and certain metals
(such as arsenic). A number of other pesticides and solvents are
also regulated under the TCLP rule. The waste codes for these
materials range from D004 to D043. Research chemicals (TSCA
exempt) do not always have toxicity data established for them.
Most of the time these chemicals are incinerated as hazardous
waste because not enough information is available. For mixed
reagents, the toxic effects should be considered additive.
Highlighted below are eight hazardous waste types that are commonly used in
healthcare facilities: mercury, chemotherapy and antineoplastic chemicals, formaldehyde,
photographic chemicals, radionuclides, solvents, anesthetic gases, and toxic, corrosive, and
miscellaneous chemicals.
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Healthcare Industry Activity Descriptions
• Mercury - The primary sources of mercury waste at most hospitals
include:
— Broken or obsolete medical equipment - sphygmomanometers,
thermometers, tilt switches (e.g. in electric wheel chairs),
intraocular pressure reducers (little bags of mercury used in past
for eye surgery), esophageal dilators, cantor tubes, and miller
abbott tubes.
— Broken or obsolete components of facility equipment or capital
medical equipment and/or calibration or process monitoring
devices - manometers, barometers, oven and refrigerator
thermometers, thermostats, mercury switches (tilt switches, reed
switches, float switches), flow meters, flame sensors, boiler gauge
controls, and fluorescent light bulbs. These can be found in
pulmonary and blood gas labs, HVAC and facilities areas, laundry,
kitchen, and laboratories as well as general areas.
— Laboratory reagents and chemicals - as a preservative (e.g.,
thimerosol) or contaminant.
— Plumbing - pipes and fittings, especially drain traps, can be
contaminated with mercury because of spills that occurred in the
past.
Mercury wastes are decreasing in quantity due to the substitution of solid
state electronic sensing instruments (thermometers, blood pressure gauges,
etc.), and greater awareness of the hazards of mercury in the workplace.
Mercury is also found as a preservative in many pharmaceuticals
(thimerosal or phenylmercuric acetate); however, this is less common as
awareness of the health and environmental hazards has increased. Finally,
mercury has been identified as a "tramp" contaminant in a number of
other common products including bleach. In these cases, the mercury is
not intentionally added to the product.
• Chemotherapy and Antineoplastic Chemicals - Nine of the
chemotherapy and antineoplastic drugs of concern from a waste
perspective are on either the P or the U list of RCRA hazardous wastes,
which was created in the 1970s. These are: Chlorambucil (Leukeran)
(U035), Cyclophosphamide (Cytoxan, CTX, Neosar, Procytox) (U058),
Daunomycin (Daunorubicin, Cerubidine, DaunoXome, Rubidomycin,
Liposomal Daunorubicin) (U059), Diethylstilbestrol (Diethylstilbesterol,
DBS, Stilbestrol, Honvol, Stilbesterol) (U089), Melphalan (Alkeran, L-
PAM) (U150), Mitomycin C (Mitomycin, Mutamycin) (U010),
Streptozotocin (Streptozocin, Zanosar) (U206), Uracil Mustard (U237),
and Arsenic Trioxide (Trisenox) (P012). Since that time, hundreds of new
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formulations have come into the healthcare marketplace due to advances
in pharmaceutical research. Some of these substances may have RCRA
characteristics, which would place them in the hazardous waste category.
It is important to note that not all chemotherapy medications are
considered RCRA characteristic or listed wastes. However, because a
single drug may have more than a dozen synonym names, determining
collection and disposal methods for these drugs can be confusing and
time-consuming. Healthcare facilities will need to determine the best
collection method (e.g., maintain a list of RCRA characteristic or listed
chemotherapy and antineoplastic drugs so that they may be collected and
disposed of as RCRA waste or collect all chemotherapy and antineoplastic
as RCRA waste) for their facility.
• Formaldehyde - Formaldehyde can be a significant source of hazardous
waste at many hospitals. Formaldehyde (usually found in a dilute form
called formalin) may be used in pathology, autopsy, dialysis, and in some
nursing units. Formaldehyde is a U-listed waste that is regulated as an
unused chemical product. Formaldehyde use in healthcare applications
has diminished in recent years as greater understanding of the
occupational risks and hazards has been recognized. In some cases,
formalin that had been used to preserve specimens is discharged to the
sewer. Healthcare facilities should determine if the spent formalin meets
the definition of a characteristic waste (e.g. ignitability). Even if the waste
is not hazardous, it is still a best management practice not to dispose of
formalin down the drain, even if sanitation authorities allow such disposal.
Some facilities that still use formalin in quantity have found that
commercially available distillation and filtration technologies are cost-
effective ways to reclaim reusable formalin. Additionally, some states
may permit the use of formalin recycling units.
• Photographic Chemicals - Many healthcare facilities offer X-ray and
radiology services. In the past, nearly all X-rays were developed using
wet processing and chemicals. The photographic developing solutions
used in X-ray departments consisted of two parts, a fixer and a developer.
For facilities using the wet processing method for developing, the silver-
containing effluent from the fixer solution is passed through a filter or is
otherwise treated to recover this precious 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. Discharges containing potentially regulated
chemicals should be evaluated to determine if they contain hazardous
waste, and if allowed by the POTW, approved for discharge in writing
(See Section VIA. RCRA Domestic Sewage Exclusion). Some hospitals
utilize X-ray services that also provide silver recovery, through ion
exchange or electrostatic techniques, as part of the customer service
package.
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Healthcare Industry Activity Descriptions
Much has changed in radiology in the past decade. New films contain less
silver and can be developed with dry processing. Digital imaging has
taken the place of the standard X-ray. Many facilities are moving away
from traditional radiology practice and going to a PAX-it brand system
and digital X-rays. Facilities that have made this change have
dramatically reduced the pollution outputs of fixer/developer and silver
associated with films. New low-silver content films are also available on
the market.
• Radionuclides - Radioactive wastes are generated in nuclear medicine
and clinical testing laboratory departments. At some hospitals, short-lived
radioactive materials in nuclear medicine are retained on site until they
decay to nonhazardous levels. Depending on what the waste material is, it
is then disposed of as solid or hazardous waste. For longer-lived
radionuclides, storage times may be more limited and decay might only
reduce the radionuclide to levels that can be more easily managed as low-
level waste. Note that "mixed wastes" (defined by RCRA as low-level
radioactive waste that is also hazardous) must be identified as such and
disposed of properly. In cases where 'sharps' waste is associated with the
radioactive material, such wastes are stored on site for proper decay, then
disposed of as biohazardous waste once they are judged to be
indistinguishable from natural background radiation.
• Solvents - Solvent wastes are typically generated by various activities
throughout a hospital, such as pathology, histology, engineering, morgue,
and laboratories. Volumes of solvent wastes generated at many hospitals
are small. Specific solvents used in medical settings include halogenated
compounds such as methylene chloride, chloroform, freon,
trichloroethylene, and 1,1,1-trichloromethane. Other solvents include
nonhalogenated compounds such as xylene, acetone, ethanol, isopropanol,
methanol, toluene, ethyl acetate, and acetonitrile. Xylene, methanol, and
acetone are the most frequently used solvents at many hospitals.
Solvent waste (e.g., xylene, acetone, and methanol) are normally handled
as hazardous waste. Some of these wastes are absorbed in tissue
specimens, which are then treated instead as infectious wastes. Solvent
wastes are typically stored in 30- or 55-gallon drums and can be recycled
on site in solvent distillation units, or transported off site for recycling or
for disposal as hazardous waste. Healthcare facilities should check with
their state regulations before installing recycling units.
• Anesthetic Gases - Nitrous oxide, 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
cartridges or cylinders that are attached directly to the anesthesia
equipment. Used containers may be returned to the supplier. The
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halogenated anesthetic agents are supplied in liquid form, in glass bottles.
Once empty, the bottles and any residual must be properly disposed of.
Waste anesthetic gases are generally removed from the operating room, or
the site of application, in one of two ways. At some larger hospitals, a
scavenging unit is attached to the anesthesia unit to remove the waste
gases. The scavenging unit may have a charcoal filter that absorbs
halogenated anesthetic gases but not nitrous oxide. Spent charcoal filters
are sent off site as hazardous waste. If there is no scavenging unit, or if
the scavenging unit does not have a filter, then vacuum lines are used to
collect waste anesthetic gases and vent them to the outside. These waste
gases may cause air emission concerns.
• Toxics, Corrosives, and Miscellaneous Chemicals - Poisons, oxidizers,
and caustics are used throughout most hospitals, generally in small
quantities. Waste oils and solvents from maintenance may also be
considered hazardous wastes as may some boiler water conditioning
chemicals. Major toxic, corrosive, and miscellaneous chemical wastes
include:
— Sterilants (e.g., ethylene oxide),
— Disinfecting cleaning solutions,
— Utility wastes: boiler feed water treatment residuals (resin
regeneration brine, spent resin), boiler blowdown, boiler cleaning
(layup) wastes, cooling tower blowdown, and cooling tower
sludges/sediments, and
— Maintenance wastes: waste lube oils, vacuum pump oils, cleaning
solvents, paint stripping wastes, and leftover paints and painting
accessories.
Certain Pharmaceutical Waste
Pharmacies store and dispense medications and maintain a small inventory of
chemicals for compounding purposes. Healthcare facilities routinely discard partial vials, TVs,
and other unused drugs. In cases where medication formularies change, and unused
Pharmaceuticals accumulate, these items must be properly managed (see the discussion of
reverse distribution below). In some cases, the items are RCRA listed or RCRA characteristic
wastes. Some preparations of pharmaceuticals may also involve the use of solvents, which also
may be RCRA hazardous waste. For these chemicals, disposal should follow the RCRA
hazardous waste requirements explained in Section VI. Table III-l lists more pharmaceutical
wastes. For resources and more overview information refer to:
http://www.h2e-onlme.orff/tools/chem-pharm.htm
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Reverse distribution is a product management strategy that allows pharmacies to
return unused products to the manufacturer for potential credit, often through a reverse
distributor. Pharmacies can remove pharmaceuticals that are not going to be used from their
inventory, and quarantine them as a "product for return." The reverse distributor will either
return them to the manufacturer for credit and final disposition or properly discard them if they
cannot be used. (Note: It is not legal for a reverse distributor to redistribute outdated drugs,
which are considered adulterated by FDA.) With this practice, unused/unexpired
Pharmaceuticals can be returned as product. This includes materials that have gone beyond the
manufacturer's expiration date. Healthcare facilities should be careful not to use reverse
distribution as a waste management strategy or as a means of avoiding proper disposal of waste
(i.e., items that are obviously waste with no potential for reuse.) See the Returns Industry
Association web page for more information: http://www.returnsindustry.com.
Commingled Waste
There are several examples of commingled wastes that need special consideration.
These are wastes that include characteristics of different waste streams, that fall under different
regulatory regimes, and pose special management concerns.
• Commingled "biohazardous" and chemical wastes (e.g., tissue soaked
in formalin) - Many tissue samples are kept by healthcare institutions,
labs, and research facilities in containers of formalin or formaldehyde. As
a commingled waste, management techniques should be applied to
separate the substances, as appropriate, and properly characterize, treat,
and dispose of the residuals.
• Mixed radioactive wastes - Many healthcare facilities generate low-level
radioactive waste as a by-product of administrating radiopharmaceuticals,
radioimmunology, and nuclear medicine procedures. Contaminated
materials may include solid wastes, biohazardous wastes, and chemical
wastes. For healthcare facilities, low-level waste includes clothing, linens,
cleaning materials, medical tubes, swabs, injection needles, syringes, and
laboratory animal carcasses and tissues that came into contact with
radioactivity. To manage low-level radioactive waste, hospitals normally
store materials on site, either until the materials are no longer radioactive
(and can be handled as municipal solid waste (MSW) or state Regulated
Medical Waste (RMW)), or until enough material has accumulated for
transfer to a proper disposal facility. If the low-level radioactive waste is
mixed with a hazardous waste, it meets the RCRA definition of a "mixed
waste" and cannot be disposed of as MSW or RMW. Separating the
hazardous and nonhazardous radioactive wastes prior to decay storage will
help prevent hazardous waste from entering the solid waste stream during
post-decay disposal.
• Commingled nonhazardous and hazardous wastes - EPA's "Mixture
Rule" states that mixtures of solid waste and listed hazardous waste must
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be regulated as hazardous waste. There are two ways to determine if a
material is regulated under the mixture rule: (1) if the material is a mixture
of a solid waste and a hazardous waste, and the mixture exhibits one or
more of the characteristics of hazardous waste; or (2) if the material is a
mixture of a solid waste and a listed waste. The mixture rule is intended
to discourage generators from mixing wastestreams.
However, the mixture rule does have a number of exemptions for
wastewaters that are subject to the Clean Water Act [see 40 CFR
261(a)(2)(iv)]. One exemption is for laboratory wastewater that either (1)
does not exceed one percent of the total wastewater flow, or (2) has an
average concentration of toxic constituents less than one part per million.
Pressurized Containers and Ignitable Compressed Gas
Pressurized containers sometimes use a flammable propellant (the can is labeled
"Flammable"), in which case they are hazardous waste (D001, ignitable). Ignitable compressed
gas is also hazardous waste (D001). Healthcare facilities should dispose of these as D001 waste.
Some examples of pressurized containers and ignitable compressed gas include:
• Oxygen gas cylinders;
• Liquid nitrogen cylinders;
• Ethyl chloride (chloroethane); and
• Fluoro-ethyl (25 percent ethyl chloride, 75 percent
di chl or otetrafluor ethane).
In addition, propellants may contain chlorofluorocarbons (CFCs), which may be
F- or U-listed hazardous wastes. CFC-containing wastes should be managed separately from
incineration wastes. Finally, large quantities of aerosols should be stored in a secure, fire-safe
area to prevent fire hazards.
Universal Waste
Under a special provision of RCRA, universal waste is exempted from Subtitle C
requirements and are regulated under the Universal Waste Rule (40 CFR §273). There are four
types of universal waste: batteries containing hazardous substances (e.g., lead, acid, nickel, or
cadmium), pesticides containing RCRA hazardous components that are recalled or sent to a
collection program, mercury-containing thermostats, and spent fluorescent lamps and other
hazardous lamps (e.g., with mercury or lead). Note that many states manage their own universal
waste programs and many have included electronic wastes in their universal waste programs.
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EPA created the Universal Waste Rule (40 CFR §273) in May 1995. Universal
waste labeling and storage requirements are less stringent than for hazardous waste. This allows
hospitals to more easily recycle batteries, thermostats, and fluorescent lamps. However,
hospitals must still comply with special requirements for labeling, storage, and manifesting.
More specific information can be found at the EPA web site:
http://www.epa.gov/epaoswer/hazwaste/id/umvwast.htm More information on management of
universal wastes at hospitals can be found at: http://www.h2e-onlme.org/tools/umvwast.htm
III.B.4. Wastes by Media Category
Hospitals generate several types of media-specific wastes, as described below.
Wastewater
Healthcare facilities wastewater sources include:
• Sinks, floor drains, showers, toilets, dish and laundry washing machines,
and tubs;
• Photographic development drains from radiology (X-rays), other imaging,
and dentists; and
• Stormwater.
A large healthcare facility contains thousands of drains. Proper drain disposal
practices should be in place in each area. Most facilities discharge sink, shower, toilet, and tub
wastewater to POTWs, known as indirect discharge. Some facilities may discharge this
wastewater directly to surface water, known as direct discharge. All drains that discharge
directly should be given special consideration to ensure that no hazardous chemicals are being
sent down the drain. Photographic development (X-ray) wastewater is generally filtered to
recover silver before it is discharged. Section VI discusses the Clean Water Act (CWA)
regulatory requirements for stormwater and direct and indirect discharges from healthcare
facilities. Mechanical shop floor drains should drain to a POTW and not simply empty into the
soil. Drains that empty to the soil would be considered a Class V Injection Well, which would
require a permit under the Underground Injection Control Program of the Safe Drinking Water
Act.
EPA conducted a Preliminary Data Summary8 on hospitals in 1989 and sampled
four hospitals. Although five pollutants were detected at levels higher than expected for
municipal wastewater (e.g., silver, phenols, barium, acetone, and mercury), the discharge
concentrations of these pollutants were determined to be low enough that they would not cause
pass-through or interference at POTWs.
8 EPA, 1989. Preliminary Data Summary for the Hospital Point Source Category, EPA-440-l-89-060-n, September
1989.
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Healthcare facilities generate stormwater from building and parking lot areas or
from aboveground or underground oil or fuel storage tank areas. Hospitals with construction
areas of one acre or larger need stormwater permits. Public hospitals in urban areas may
discharge to municipal separate storm sewer systems (MS4s) and must also comply with
stormwater regulations, as discussed in Section VI of this Notebook.
Healthcare facilities with underground storage tanks (USTs) or aboveground
storage tanks (ASTs) need to consider the Oil Pollution Prevention requirements (discussed in
Section VI of this Notebook). Facilities with fleet vehicles, such as ambulances, may keep fuel
or oil in USTs or ASTs and may also have USTs for on-site diesel generators.
The management of unused prescription drugs may involve oversight by state and
local governments and several federal agencies, including the EPA. The Agency does not
currently have specific regulations regarding the disposal of expired or waste prescription
medications into sanitary sewer systems, nor does EPA's Office of Water have analytical
methods to assess the existence of many pharmaceutical compounds in water or wastewater. The
Agency, however, is aware of increasing concerns about the potential for pharmaceuticals in
water and is reviewing the current state of knowledge and coordinating with other governmental
and research agencies.
Air Emissions
At hospitals, air emissions come from air conditioning and refrigeration, boilers,
medical waste incinerators (if on site), asbestos, paint booths, ethylene oxide sterilization units,
emergency generators, anesthesia, laboratory chemicals, and laboratory fume hoods.
Hospital/medical/infection waste incinerators (HMIWI) are used by hospitals,
healthcare facilities, and commercial waste disposal companies to burn hospital waste and/or
medical/infectious waste. When burned, hospital waste and medical/infectious waste may emit
various air pollutants, including hydrochloric acid, dioxin/furan, and the toxic metals lead,
cadmium, and mercury (as discussed in Section IV.C of this Notebook).
IILC. Assessment of Wastes Generated by Functional Activity
Table III-2 identifies 18 key functions and major activities that are likely to be
found within health sector institutions. The chart can be used to identify the types of EPA
regulated wastes likely to be found and the areas in which they would be generated.
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Activity Descriptions
Table III-2: Healthcare Facility Wastes
Functional Activities
Wastes Produced
Administrative Activities and Services
• Offices
• Billing services
• Medical records
• Public relations/marketing
• Nursing care documentation
• Human resources
• Security
• Social services/care management
• Retail services
• Shipping and receiving
• Printing/copying
Municipal solid waste from all service areas
Batteries from cell phones, special pagers, PDAs, digital
cameras, and communication devices
Mercury-containing switches from greeting cards and other
'gifts' in the gift shop
Solvents possibly associated with a print shop
Oils from a printing press
Toner cartridges from copiers and printers
Cleaning chemicals associated with retail establishments
Kitchen grease associated with retail food establishments
Wastewater from retail services
Support Services
• Information services
• Food services
• Laundry services
• Pharmacy
• Central sterile reprocessing
• Biomedical engineering
Municipal solid waste from all service areas
Biohazardous waste from laundry services and central sterile
reprocessing
Electronics/computer wastes (CRTs, hard drives) from
information services, and biomedical engineering
Chemicals associated with cleaning, laundry, and food services
(decalcifiers, degreasers, chlorine bleach)
Pesticides associated with cleaning services or food services
RCRA listed and RCRA characteristic Pharmaceuticals from the
pharmacy
EtO from central sterile reprocessing
High-level disinfecting agents associated with central sterile
reprocessing
Cleaning chemicals
Peracetic acid from central sterile reprocessing
Batteries (nicad, lithium, mercuric oxide, and others) from
biomedical engineering
Kitchen grease from food services
Degreasers, solvents from food services or laundry
Mercury-containing devices such as thermometers in
refrigerators, incubators, and heating units
Wastewater from all service areas including food services and
laundry services
Air emissions from laundry services, refrigeration, and
sterilization
Sharps waste from the pharmacy, central sterile, and from
accidental disposal in laundry and food service
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Table III-2: Healthcare Facility Wastes (Continued)
Functional Activities
Wastes Produced
Facilities Management, Engineering and
Maintenance, and Plant Operations
Housekeeping
• Maintenance shops (paint, electric,
plumbing)
• Heating Ventilation and Air
Conditioning (HVAC)
• Waste treatment
• Water treatment
• Fleet management
• Grounds keeping
• Pest management
Municipal solid waste from all facility areas
Air emissions from boilers
Cleaning chemicals
Chemicals associated with paint shop - turpentine, strippers,
solvents, adhesives
Chemicals associated with electric and plumbing shop including
oils, adhesives
Chemicals associated with air handling system
Chemicals associated with water treatment systems (decalcifiers,
disinfecting solutions)
Radioactive or mixed waste residues in water treatment system,
drains and piping
Chemicals associated with elevator care and maintenance
(hydraulic fluids)
Chemical associated with groundskeeping and pest management
Mercury-containing switches, manometers, pressure gauges,
fluorescent lamps, and thermostats
PCB-containing fluorescent light ballasts and electrical
transformers
Asbestos
Pressurized gas canisters/containers from all facility areas
Wastewater from drains, water treatment, and fleet management
Air emissions from HVAC systems and maintenance shops
(paint booths)
Laboratory Services
• Hematology
• Microbiology
• Chemistry
• Blood Bank
• Surgical Pathology
• Histology
Municipal solid waste from all service areas
Biohazardous waste from all service areas
Mixed biohazardous wastes
Chemicals associated with laboratory testing including: alcohols,
xylene, toluene, formaldehyde, b5 fixatives, picric acid, other
acids and bases chemicals, and cleaning solutions (see chemical
inventory in each laboratory area to identify RCRA listed and
characteristic wastes)
Mercury-containing devices such as calibration manometer,
water bath thermometer, incubator and refrigerator thermometers
Cleaning chemicals
Radioactive or mixed waste residues
Pressurized gas cylinders (blood gas analysis area)
Wastewater from sinks and drains
Air emissions from laboratory chemicals and hoods
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Activity Descriptions
Table III-2: Healthcare Facility Wastes (Continued)
Functional Activities
Wastes Produced
Diagnostic Services
• Endoscopy
• Cardiac Catherization lab
• Radiology (CT, MRI, digital imaging)
• Nuclear medicine
• Sleep studies (EEC)
Municipal solid waste from all service areas
Biohazardous waste from all service areas
Mixed waste from tissue samples and chemical, or radioactive
and solid, or radioactive and chemical
Glutaraldehyde or other disinfectant/cleaner associated with
endoscopy
RCRA listed and RCRA characteristic Pharmaceuticals
Formalin for tissue samples obtained from any of the listed
diagnostic services
Silver from radiology films, fixer and developer
Radioisotopes from nuclear medicine
Collodion (ether/alcohol) from EEG areas
Cleaning chemicals
Lead shielding from radiology
Wastewater from sinks and drains and photographic developing
Air emissions from sterilization and disinfection
Surgical Services
• Ambulatory outpatient services
• Surgery
• Post-anesthesia care
• Preoperative services
• Anesthesia
Municipal solid waste from all service areas
Biohazardous waste from all service areas
Mixed waste from tissue samples
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers,
sphygmomanometers, and esophageal dilators)
Used batteries (Nicad, lithium, other)
Waste anesthetic gases and compressed gas cylinders
Cleaning solutions; high-level disinfectants
Phenol
Collodion
Formalin
If surgical pathology unit is present in surgical services area,
look for xylene, toluene
Wastewater from sinks and drains
Air emissions from anesthetic gases
Inpatient Care Services
• Medical surgical care
• Orthopedic care
• Neurology care
• Urology care
• Cardiac care
• Psychiatric/behavioral health
• Geriatric care
• Palliative care
• Maternal child care (labor and
delivery /birthing, postpartum care,
nursery, pediatrics)
• Pediatric care
• Cancer care
• Rehabilitative care
Municipal solid waste from all service areas
Biohazardous waste from most service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Cleaning solutions; high-level disinfectants
Chemicals related to leatherwork, plastic casting, etc. for
rehabilitation/prosthesis device producing settings
Wastewater from sinks and drains
Air emissions from sterilization and disinfection
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Table III-2: Healthcare Facility Wastes (Continued)
Functional Activities
Wastes Produced
Critical Care Services
• Surgical intensive care
• Medical intensive care
• Pediatric intensive care
• Cardiac intensive care
• Burn care
• Neonatal intensive care
Municipal solid waste from all service areas
Biohazardous waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Used batteries (Nicad, lithium, other)
Cleaning solutions; high-level disinfectants
Wastewater from sinks and drains
Air emissions from sterilization and disinfection
Emergency Care Services
Municipal solid waste from all service areas
Biohazardous waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers,
sphygmomanometers, and especially hypothermia thermometers)
Chemical or biological agents from decontamination
(chemical/biological) area for incoming patients
Waste anesthetic gases and compressed gas cylinders
Cleaning solutions; high-level disinfectants
Formalin
Silver from radiology films, fixer and developer
Lead shielding from radiology
Wastewater from sinks and drains, ensure that decontamination
area drains connect to containment tank for potentially hazardous
fluids.
Air emissions from sterilization and disinfection, ensure that
decontamination area ventilation system connects to filter or
separate system for potentially hazardous pollutants
Respiratory Care Services
• Pulmonary function testing
• Oxygen therapies
Municipal solid waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Compressed gas cylinders (oxygen tank management)
Used batteries
Cleaning solutions; high-level disinfectants
Wastewater from sinks and drains
Air emissions from sterilization and disinfection
Dialysis
• Hemodialysis
• Peritoneal dialysis
Municipal solid waste from all service areas
Biohazardous waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Formaldehyde, formalin
Cleaning solutions; high-level disinfectants
Wastewater from sinks and drains
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Table III-2: Healthcare Facility Wastes (Continued)
Functional Activities
Wastes Produced
Physical Therapy
Occupational Therapy
Municipal solid waste from all service areas
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Cleaning solutions
Chemicals related to leatherwork, plastic casting, etc. for
rehabilitation/prosthesis device producing settings
Wastewater from sinks and drains
Outpatient Services (Nonsurgical)
• Womens' health/gynecology
• General medicine
• Family practice
• Specialty clinics (orthopedics,
urology, pulmonology, allergy)
• Pediatrics
• Rehabilitative services
Municipal solid waste from all service areas
Biohazardous waste (mostly sharps)
RCRA listed and RCRA characteristic Pharmaceuticals from
sample medications
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Cleaning solutions; high-level disinfectants
Wastewater from sinks and drains
Oncology/Cancer Care Services
• Radiation oncology
• Chemotherapy
• Lead molds - Cerrobend
Municipal solid waste from all service areas
Biohazardous waste
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Chemotherapy waste - RCRA listed and RCRA characteristic
Chemotherapy waste - non-RCRA regulated
Mixed radioactive and hazardous waste
Radioisotopes from nuclear medicine
Cleaning solutions; high-level disinfectants
Wastewater from sinks and drains
Dentistry
• Oral surgery
• Periodontics
• Oral healthcare
Municipal solid waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Waste anesthetic gases and compressed gas cylinders
Residual mercury amalgam
X-Ray materials; lead shields
Cleaners, disinfectants
Wastewater from sinks and drains
Air emissions from sterilization and disinfection
Biohazardous and sharps waste
Animal Research and Testing
Municipal solid waste from all service areas including animal
care
Biohazardous waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Research chemicals
Radioactive or mixed waste residue
Wastewater from sinks and drains
Air emissions from laboratory chemicals and hoods, and from
sterilization and disinfection
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Table III-2: Healthcare Facility Wastes (Continued)
Functional Activities
Wastes Produced
Clinical Research
Municipal solid waste from all service areas
Biohazardous waste from all service areas
RCRA listed and RCRA characteristic Pharmaceuticals
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
Research chemicals
Wastewater from sinks and drains
Air emissions from laboratory chemicals and hoods, and from
sterilization and disinfection
Construction and Renovation
Municipal solid waste from all service areas
Mercury-containing monitoring equipment (thermometers and
sphygmomanometers)
PCB-contaminated light ballasts
Asbestos
Radioactive or mixed waste residue in drains and piping
Stormwater
Lead paint
IILD.
Management of Waste Streams
Healthcare facilities may treat, recycle, or dispose of the waste streams that they
produce. This subsection presents some examples of management techniques (and example
waste types). This is not meant to be a comprehensive list, but an introduction only; refer to the
sources at the end of this Notebook for more detail.
EPA ranks options for managing waste in descending order of preference. This
ranking encourages reliance on those approaches that minimize the generation of waste and
environmental releases. SOURCE REDUCTION is assigned the highest priority because it
emphasizes eliminating or reducing wastes at the point of generation. Purchasing a digital
thermometer, rather than one containing mercury, for example, reduces the heavy metal content
in the waste and reduces the need for recycling, treatment, or disposal. Source reduction is
typically less expensive than collecting, treating, and disposing of waste. It also reduces risks for
workers, the community, and the broader environment.
REUSE is the next preferred option. Implementing measures to reuse products
and packages for their original purpose reduces purchasing costs and packaging wastes as well as
wastes from patient care activities. Healthcare facilities find that reusable linens, reusable
patient supplies, such as bedpans and emesis basins, as well as reusable dishes and cutlery for
food service are generally economically and environmentally preferable to their disposable
counterparts, although there are costs incurred in cleaning and sterilizing equipment for reuse.
RECYCLING encourages regenerating materials or reclaiming constituents of the
waste stream into usable items. Paper and paper products, such as corrugated cardboard, glass
food and beverage containers, metals, and certain plastics may be recyclable. However, facilities
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should evaluate the local environmental and economic consequences associated with collecting
and recycling materials as well as the associated energy and resource costs.
TREATMENT to reduce the volume or the potentially harmful environmental
impacts of the waste is ranked at the lower end of the hierarchy. Medical waste treatment
technologies include autoclaving, hydropulping, pyrolysis, microwave, incineration, chemical
treatment, and irradiation. Treatment precedes disposal, the least favored option. Ultimately,
however, some wastes and medical waste treatment residues require land disposal. The costs of
treatment and disposal are significant, and both have inherent environmental impacts, including
emissions to air and water.
Reduction/Prevention
The amount of almost all wastes produced through healthcare activities can be
reduced. This can be as easy as a manufacturer using less packaging or replacing corrugated
shipping containers with reusable totes. It can also mean not using certain materials (e.g.,
mercury) that become problematic wastes, through a technique called Environmentally
Preferable Purchasing (EPP). This technique can be used by the purchasing agency for any
healthcare facility. For more information regarding EPP go to http://www.epa.gov/opptmtr/epp/.
Waste can also be prevented through vendor return programs, which encourage
product stewardship. A common program is returning cartridges from printers and copiers.
Many healthcare facilities are now signing contracts for computers and peripherals that require
the vendor to take back units when new units are purchased. There is also a "returns" industry
for pharmaceuticals that takes back unused pharmaceuticals as product, not waste.
Segregation
As wastes are generated, the most important management technique to ensure
worker safety, ensure proper treatment and disposal, and minimize environmental risk, is to
strictly segregate wastes. The general principle is to segregate wastes so that most of the waste
ends up in categories that can be reused, recycled, or that are safer and cheaper to dispose of
(e.g., municipal solid waste). The principle of segregation is most commonly used to reduce the
generation of biohazardous wastes, to ensure that only those wastes truly contaminated or posing
a risk are placed in "red" bags or sharps containers. This principle is also very important when
considering separating wastes for recycling and for management of chemical wastes.
Reuse
Common chemicals (xylene, formalin, alcohol) used in some activities can be
reprocessed and reused. Newer technologies have made this option safer and more affordable.
A number of common medical devices have now been designed for reprocessing
and reuse (e.g., pulse oximeters). Numerous other reusable items can be used in healthcare
activities including linens, gowns, drapes, bedpans, dishware, utensils, and cutlery.
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Recycling
Much of the municipal solid waste generated from healthcare activities is easily
recyclable, when one considers that up to 40-50 percent of the waste from most activities is
paper and cardboard. Another large portion consists of other commonly recycled metals, plastics
and glass. Aggressive recycling programs can divert a very large portion of waste from
healthcare activities.
Pressurized containers, universal wastes, and construction and demolition debris
are also commonly recycled materials generated at healthcare institutions.
Composting
Some hospitals have identified options for segregating and disposing of food
waste and landscaping discards at authorized composting operations.
Landfill
Waste from healthcare activities that is classified as municipal solid waste is often
sent to a landfill for final disposal. In some states or tribal regions, untreated biohazardous
wastes may be sent to landfills under special conditions. Proper segregation is important to keep
hazardous materials from being disposed of in landfills, many of which have specific bans on
such items.
Incineration (Off-site Municipal Plant)
Waste from some healthcare activities classified as municipal solid wastes may be
sent to a municipal solid waste incinerator. The waste ash will then have to be disposed of as
either municipal solid waste or hazardous ash depending on testing. A key issue in the
incineration of healthcare wastes is that the municipal solid waste stream from healthcare tends
to be rich in PVC plastics, which when combusted can produce dioxins.
Medical Waste Incinerator (On-site or Off-site)
Depending on state or tribal regulation, at least a small portion of biohazardous
waste, including sharps, may have to be incinerated. This will likely include pathological wastes
and wastes contaminated with small amounts of chemotherapy substances. The incineration of
large amounts of biohazardous wastes has decreased in the United States, due to concerns over
emissions and the implementation of the EPA air emission regulations for Hospital/Medical/
Infectious Waste Incinerators (HMIWI). Most treatment has moved to other noncombustion
technologies.
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Noncombustion Biohazardous Treatment Technologies (e.g., Autoclave/
Microwave Treatment/Chemical Mechanical Treatment) (On-site or Off-site)
The majority of biohazardous wastes is now being treated using noncombustion
technologies. More than 40 certified noncombustion treatment technologies are in use or being
tested in the United States. These devices use heat and pressure or chemicals to render the
wastes generally noninfectious and suitable for disposal in landfills.
Hazardous Waste Treatment Facilities, Incinerators, Landfills
Of the wide variety of hazardous materials generated through healthcare
activities, some will have to be packaged and transported for special treatment and disposal at
specialized licensed facilities to manage hazardous waste. These range from waste oils to toxic
chemicals such as phenol.
Treatment at POTWs
Many wastes, from body fluids, to kitchen food scraps, to a wide mix of
chemicals, cleaners and disinfectants are discharged to the wastewater system, and must be
managed by a POTW. Stormwater run-off from facilities may also have to be discharged to
these treatment plants or to a municipally maintained stormdrain network. Local and state
regulations may specifically require pollutant prevention measures, waste segregation, and/or
treatment of these waste streams prior to discharge.
Treatment/Control On-site
A variety of technologies to pretreat wastewater and various air emissions (e.g.,
ethylene oxide) have been used at healthcare facilities to reduce direct emissions.
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IV. WASTE AND EMISSIONS PROFILE
This section provides information on the volume of waste released by the
healthcare industry. The Toxics Release Inventory (TRI) is a publicly available EPA database
that contains information on toxic chemical releases and other waste management activities
reported annually by certain covered industry groups as well as federal facilities. Because only
federal facilities in the healthcare industry are required to report pollutant release and other
waste management information to TRI, little quantitative waste information is available for this
sector. The data provided in this section are for hospitals, the segment of the healthcare industry
for which the most data are available.
IV.A. Solid, Biohazardous, and Hazardous Waste Production Data for the
Healthcare Industry
According to the information published in the SHEA9 position paper on medical
waste, the United States healthcare industry generates 6,670 tons per day of waste, most of
which is solid or municipal waste. In January 1992, it was estimated that approximately 15
percent of this waste was infectious waste, or about 1,000 tons per day. A small fraction of
healthcare waste is hazardous chemical or radioactive waste.
There have been limited studies evaluating healthcare waste comprehensively.
Those studies were often conducted in preparation for a waste treatment technology, or were
conducted on a small segment of healthcare wastes. Healthcare waste has continued to shift
qualitatively as medical advances have occurred, changing the nature of many procedures, and
thus wastes, within the industry. Laparoscopic procedures, cautery devices, and laser surgery
have all contributed to procedures that generate less biological waste. Advances in
pharmaceutical technology have reduced the need for surgical interventions. Adjustments in
healthcare reimbursements have contributed to decreased length of stay in hospitals and
increases in home care and outpatient or ambulatory healthcare. The supply industry has
streamlined many aspects of product packaging, and the use of plastics instead of glass has
lessened the weight of many products. Medical waste definitions vary from state to state, which
can impact the waste segregation programs set up in a given facility.
IV.A.1. Municipal Solid Waste
Of the approximately 3.4 billion pounds of solid waste produced annually by
hospitals, more than half is composed of paper and cardboard. Figure IV-1 demonstrates the
composition of hospital solid waste.
9 Rutala WA, Mayhall CG, "The Society for Hospital Epidemiology of American (SHEA) Position Paper: Medical
Waste." Infection Control Hospital Epidemiology. 1992; 13:38-48.
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Figure IV-1: Hospital Solid Waste Composition
12%
3%
15%
53%
17%
n Paper • Food/Organics n Plastic n Metals • Other
Source: Healthcare Without Harm, "Setting Healthcare's
Environmental Agenda" Conference Proceedings: Waste
Management White Paper.
Much of the waste that is considered municipal solid waste (MSW) is composed
of corrugated cardboard, paper, glass, plastics, wood, metals, food waste, leaf and yard waste,
and a variety of mixed materials. For hospitals in areas that have community infrastructures to
support recycling, up to 40 percent of the solid waste can be recyclable. Other wastes that can
also be recycled include kitchen grease, durable goods (furnishings), toner cartridges, and X-ray
film.
IV.A.2.
Biohazardous Waste
As stated above, in January 1992, it was estimated that approximately 15 percent
(an estimated 1,000 tons per day) of hospital waste was infectious waste. Biohazardous waste,
also referred to as infectious waste or regulated medical waste, is that component of healthcare
waste that includes sharps, pathological waste, blood and blood products, blood-soaked items,
and non-regulated chemotherapy waste.
In evaluating biohazardous waste handling, it is important to understand the
distinctions between state EPA biohazardous waste definitions, which help define this category
of waste for treatment and disposal, and Universal Precautions, an OSHA blood-borne pathogens
(BBP) rule, which is designed to protect workers from exposure to blood-borne diseases. The
OSHA BBP rule provides guidance on the use of personal protective equipment when caring for
patients, and has requirements for labeling and handling biohazardous waste, along with other
types of waste.
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It is not uncommon for workers in a healthcare facility to refer to biohazardous
waste as contaminated trash, infectious waste, medical waste, medical infectious waste,
regulated medical waste, or some other similar term. From a regulatory perspective, this waste
stream should be collected in a consistent manner, with sharps being segregated at the source of
generation in leakproof, puncture-resistant containers, and other regulated medical waste
collected in biohazard containers or bags. Pathological wastes, or tissue waste, are also
considered biohazardous waste, and should be collected and labeled for disposal via incineration
(or as otherwise regulated by the state). Nonregulated chemotherapy wastes are also collected in
distinctive containers with the chemotherapy label, packaged for disposal along with
biohazardous waste, and labeled for incineration only (or other technologies that may become
available).
IV.A.3. Hazardous Chemical Waste
The healthcare industry is not required to report pollutant release and other waste
management information to the TRI. Therefore, little quantitative hazardous chemical waste
generation information is available for this sector. However, healthcare facilities tend to
generate small quantities of various hazardous chemicals relative to the amount of municipal
solid waste or biohazardous waste. The amount and type of hazardous chemical waste generated
is directly related to the type of facility and the quantity of various products used.
Hazardous chemical waste generation is related to key functions within the
healthcare sector. These include laboratory testing areas, facility maintenance areas,
groundskeeping areas, and some diagnostic areas. Facilities that include research units usually
generate greater volumes and more diverse hazardous chemicals. A small amount of
Pharmaceuticals commonly in use are also listed or characteristic RCRA wastes. EPA has found
that most hospitals tend to be small quantity generators unless they are part of a large facility,
such as a university or military base, in which case they tend to be large quantity generators.
Facilities may also be temporarily large quantity generators when disposing of waste chemicals
during laboratory cleanouts.
IV.B. Wastewater Discharge Data for the Healthcare Industry
A majority of healthcare facilities discharge wastewater to POTWs. These
facilities complete discharge monitoring reports (DMR) according to their state, tribal, and local
water discharge guidelines, but there is not a centralized data collection system for the
information.
Facilities that discharge directly to waters of the United States are considered
direct dischargers. Effluent discharge data from these facilities are collected in EPA's Permit
Compliance System (PCS). According to calendar year 2000 data from PCS, there are only three
major dischargers in the healthcare industry. Dischargers are classified as major based on an
assessment of six characteristics: (1) toxic pollutant potential; (2) flow/stream flow volume;
(3) conventional pollutant loading; (4) public health impact; (5) water quality factors; and
(6) proximity to nearby coastal waters.
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The database includes data for only a limited set of minor dischargers when the
states choose to include these data. As a consequence, extensive data are not available for minor
dischargers in PCS; data for 103 minor direct dischargers are in PCS.
The 106 direct dischargers in healthcare that are included in PCS fall into the
categories in Table IV-1 (note that PCS uses Standard Industrial Classification (SIC) codes).
Table IV-1: Direct Dischargers Included in PCS
SIC Code
8011
8021
8051
8052
8059
8062
8063
8069
8071
8082
8092
8099
SIC Description
Offices & Clinics of Medical Doctors
Outpatient Care Facilities
Skilled Nursing Care Facilities
Intermediate Care Facilities
Nursing and Personal Care, NEC
General Medical & Surgical Hospitals
Psychiatric Hospitals
Specialty Hospitals, Except Psychiatric
Medical Laboratories
Home Health Care Services
Kidney Dialysis Centers
Health & Allied Services, NEC
Total
Minor
Dischargers
4
2
21
18
18
20
7
4
3
1
1
4
103
Major
Dischargers
0
0
0
0
0
2
1
0
0
0
0
0
3
Source: PCS 2000 data.
Table IV-2 provides the total pounds of pollutants discharged annually by these
106 facilities. The totals shown are a result of summing the pounds per year contained in the
PCS 2000 data. Note that only annual discharges of one pound or greater are shown.
Table IV-2: Pollutant Discharge from Direct Discharging Healthcare Facilities
Parameters
Solids, Total Dissolved
Oxygen, Dissolved (DO)
Phosphorus, Total (As P)
Solids, Total Dissolved- 180 Deg. C
Oil & Grease Freon Extr-grav Meth
Solids, Total Dissolved (IDS)
Chloride (As Cl)
Pounds Per Year
8,065,304
822,943
739,632
430,840
300,913
199,682
190,842
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Table IV-2: Pollutant Discharge from Direct Discharging Healthcare Facilities
(Continued)
IV.C.
Parameters
Solids, Total Suspended
BOD, 5-day (20 Deg. C)
BOD, Carbonaceous 05 Day, 20C
Sulfate (As S)
Nitrogen, Ammonia Total (As N)
Hardness, Total (As CaCO3)
Oxygen Demand, Chem. (Low Level) (Cod)
Chlorine, Total Residual
Nitrogen, Total (As n)
Nitrite Plus Nitrate Total 1 Det. (As N)
Nitrogen, Nitrate Total (As N)
Nitrogen, Kjeldahl Total (As N)
Carbon, Tot Organic (TOC)
Oxygen Demand, Chem. (High Level) (COD)
Sulfide, Total (As S)
Magnesium, Total (As Mg)
Bromine Chloride
Zinc, Total (As Zn)
Fluoride, Total (As f)
Copper, Total (As Cu)
Hydrocarbons, inH2O, IR, CC14 Ext. Chromat
Surfactants (MBAS)
Zinc Total Recoverable
Copper Total Recoverable
Silver, Total (As Ag)
Pounds Per Year
100,996
36,244
20,821
15,504
10,061
7,796
4,961
1,374
730
632
547
413
205
176
106
77
40
30
16
9
4
3
2
2
1
Source: PCS 2000 data.
Air Emissions from the Healthcare Industry
Hospitals generate air emissions from medical waste incinerators, boilers,
sterilization chemicals, air conditioning and refrigeration, and laboratory fume hoods. Air
emissions data for certain pollutants are available from the National Emission Trends (NET)
database (1999), and hazardous air pollutant emissions data are available from the National
Toxics Inventory (NTI) database (1996). These databases have since been replaced by the
National Emission Inventory database, but no final data are yet available. For the SIC codes
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80xx (Health Services), the total emissions for volatile organic compounds (VOC), nitrogen
oxides (NOX) and hazardous air pollutants (HAPs) are shown in Table IV-3.
Table IV-3: Total Emissions for VOC, NOx, and HAPs (Tons/Year)
SIC Code
8011
8051
8052
8059
8061
8062
8063
8069
8071
8081
8082
8092
8093
8099
8050
SIC Description
Offices and Clinics of Medical Doctors
Skilled Nursing Care Facilities
Intermediate Care Facilities
Nursing And Personal Care, NEC
Hospitals
General Medical & Surgical Hospitals
Psychiatric Hospitals
Specialty Hospitals, Except Psychiatric
Medical Laboratories
Outpatient Care Facilities (1977)
Home Health Care Services
Kidney Dialysis Centers
Specialty Outpatient Clinics, NEC
Health And Allied Services, NEC
Nursing and Personal Care Facilities
Total, All Health Services Subsectors
VOC
7
16
9
0
1,204
115
53
17
2
0
16
0
1,445
NOx
74
88
1
228
6
12,440
3,412
760
15
0
126
2
68
4
17,429
HAP
5
0
5
0
607
53
31
15
1
0
14
731
Source: Environmentally Conscious Manufacturing Strategic Initiative Group at the National
Center for Manufacturing Sciences (NCMS).
Incinerator Emissions
In the September 15, 1997 Federal Register Notice (FRN) for the Hospital/
Medical/Infectious Waste Incinerators (HMIWI) Final Rule, EPA identified approximately 1,139
small HMIWI, 692 medium HMIWI, 463 large HMIWI, and 79 commercial HMIWI in
operation. EPA estimated that, as a result of the final rule, 93 to 100 percent of small
"nonremote" HMIWI, 60 to 95 percent of medium HMIWI, and as many as 35 percent of large
HMIWI would cease operation. All 79 commercial units and 114 small units meeting the
"remote" criteria were assumed to remain in operation. Facilities that ceased operation were
assumed to find alternate methods of waste disposal.
As a result of the HMIWI rule, most facilities have phased out their on-site
incinerators. Based on the January 2004 inventory conducted of the existing hospital/infectious/
medical waste incinerators, only 111 units are in operation in all the EPA regions. A list of those
facilities currently operating incinerators can be found at:
http://www.epa.ffov/ttn/atw/129/hmiwi/2004hmiwi inventory.xls.
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Boilers
Many hospitals operate industrial boilers, which can generate criteria pollutants
(e.g., NOX, SO2, particulates, CO) and hazardous air pollutants (HAPs). NOX emissions from
combustion in boilers and waste incinerators is the most serious criteria air pollutant generated
by the healthcare industry. Currently, information is not available on the number of boilers, and
their associated emissions, in the healthcare industry. EPA recently finalized a rule for
industrial/commercial/institutional boilers. EPA's air toxics web site
http://www.epa.gov/ttn/atw/boiler/boilerpg.html provides information regarding EPA's HAP
regulations for industrial/commercial/institutional boilers and process heaters. Because the rule
only applies to major sources (i.e., those that emit at least 10 tons per year of a specific HAP or a
combined total of 25 tons per year of all HAPs), most medical facilities will be exempt from the
regulations. However, medical facilities that are colocated with other HAP-emitting facilities,
such as on military bases or college/university campuses, could be subject to the new standards if
the "site" as a whole meets the definition of major.
Most hospital boilers are subject to the federal New Source Performance
Standards (NSPS) regulations. The applicable regulations can be found at 40 CFR Part 60
Subparts Db and DC. Depending on the type of fuel combusted, the regulations have emission
standards for sulfur dioxide, nitrogen oxides and particulate matter. Additionally, expansion of
the facility may lead to Clean Air Act Prevention of Significant Deterioration (PSD)/New Source
Review (NSR) requirements. See Section VI of this Notebook for more information.
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V. POLLUTION PREVENTION OPPORTUNITIES
Pollution prevention is a way to reduce the impact that a business makes on the
environment. This includes reducing waste, emissions, accidental releases, fires, global waste
and emissions, and depletion of raw materials and using nonrenewable energy. The healthcare
industry has numerous opportunities to prevent pollution. By implementing well-planned
pollution prevention strategies, facilities can improve efficiencies, save money, minimize
adverse environmental impacts, and offer a healthier workplace. Opportunities vary from
facility to facility and relate to the volumes and types of activities.
This section is intended to provide the reader with an understanding of some of
the most common pollution prevention opportunities available to the healthcare industry. Many
programs are not specifically covered by this document. For more information on the various
pollution prevention opportunities available to the healthcare industry, visit the industry web
sites discussed in Section VIII of this document.
V.A. General Pollution Prevention Opportunities
V.A.I. Environmental Management Systems (EMS)
Environmental Management Systems work to apply the building blocks of
effective organizational management (accountability, assigned responsibilities, employee
involvement, written policies, training, periodic review and corrective action, senior
management support and involvement) to environmental performance. They do this by
challenging a hospital to identify all of its significant environmental impacts, determine which
are most important, and set performance-based objectives and targets to minimize these impacts
on an ongoing basis. A comprehensive EMS will include all feasible aspects of pollution
prevention.
EPA has developed a resource titled "Healthcare Guide to Pollution Prevention
Implementation through Environmental Management Systems," which is a comprehensive
resource for understanding the components of an EMS and for developing an EMS specific to a
healthcare facility. The first edition of this document can be found at:
http://www.epa.gov/region02/healthcare/.
V.A.2. Purchasing/Product Substitution/Source Reduction
Selection of less toxic or less polluting products can reduce pollution generation.
Source reduction opportunities exist in many functional areas within healthcare. Purchasing
products with minimum waste or minimum toxicity (i.e., environmentally preferable purchasing
(EPP) strategy) can reduce the waste generated at the facility. Web sites with resource
information for source reduction include Hospitals for a Healthy Environment (H2E) at
www.h2e-online.org and the Sustainable Hospitals project at www.sustainablehospitals.org.
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Examples of these approaches in healthcare include:
• Non-mercury-containing products and devices - Purchasing and using
non-mercury-containing fixatives in the laboratory and technologies for
vital sign monitoring (thermometers and sphygmomanometers) help to
reduce mercury pollution.
• Purchasing a less hazardous product for use in adhering electrodes to
the scalp for EEGs - Using less hazardous products instead of flexible
collodion, which is made from alcohol and ether, is a direct strategy for
source reduction.
• Mattress selection (reduces solid waste generation) - Using mattresses
with built-in egg crates reduces the need for foam mattress overlays.
Healthcare bedding items are changed out every 5 to 7 years, or more
frequently depending on usage. Patient comfort, ease of cleaning, and bed
sore prevention are goals to be considered in bedding purchases.
Selecting mattresses with built-in, rather than disposable, egg-crate foam
layers, allows for the desired attributes to be available in a semidurable,
versus readily disposable, product.
• Respiratory care products (reduces solid waste generation) - Using
reusable respiratory therapy products can help reduce waste volumes.
Specific products such as ambu bags (used in respiratory resuscitation)
and ventilator circuit tubing (used as a channel for air in ventilators) are
available as reusable products. The energy, chemicals, labor, and space
needs for having a reusable/reprocessing function on site should be
evaluated. In cases where the cost benefit is favorable, this strategy makes
sense.
• Microfiber mopping - This type of product substitution can have multiple
benefits including reduced water and cleaner/disinfectant use and disposal
(reduces cost, chemical hazards, storage space), less weight to lift
(ergonomic benefit, lower potential for injury), reduced mopping time
(more productive use of staff, lower labor cost), reduced opportunity for
slips and falls on a wet floor, no cross-contamination, and preferred by
patients because it is quieter and less intrusive.
V.A.3. Process Change
Process changes are intentional modifications in activities that reduce pollution.
Examples of this are abundant in healthcare. Some of the process changes that have
environmental benefits also have other benefits, such as cost containment or improved quality of
a service or product.
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Examples of process changes in healthcare include:
• Switch to digital imaging for radiology processing (reduces silver
waste outputs). Digital imaging and PAX-it brand systems use digital
images instead of silver-laden X-ray films; this negates the need for fixer/
developer solutions, which also contain silver, and reduces water
consumption.
• Right-sizing formaldehyde collection containers (reduces formalin
waste outputs). This practice involves having a variety of sizes of
collection containers filled with the preserving fluid (usually formalin),
and matching the tissue sample to the appropriate container size.
Previously, many facilities stocked only a few sizes of container, with the
smallest being a 4-ounce container. Carrying seven or eight different size
containers allows the practitioner to select the most appropriate size
container based on specimen size. In one case study, this approach
reduced formalin use by as much as 70 percent, and minimized waste
formalin by a similar amount. The facility saved money by using less
formalin, purchasing smaller containers, and saving on space, as greater
quantities of the smaller containers could be stored on site.
• Pharmaceutical Return Programs (reduces pharmaceutical product
outputs). Implementing a pharmaceutical returns program can be a
valuable practice in reducing pollution associated with pharmaceuticals.
The change involves switching from disposal via drains, solid waste
receptacles, and biohazard waste receptacles to a system where unused
and partially used pharmaceutical products are returned to a reverse
distribution company for cataloging, return credit, characterization, and
disposal. Note, reverse distribution should only be used for items that are
not expired and not for pharmaceuticals that are obviously waste with no
potential for reuse. More information on the return program can be found
at http://www.returnsindustry.com.
• Improve pharmaceutical dispensing practices and minimize product
packaging. Minimizing the amount of wasted pharmaceuticals produced
through inefficient dispensing practices can help reduce the amount of
pharmaceuticals that the healthcare facility needs to purchase.
Additionally, minimizing the amount of packaging will help reduce the
amount of municipal waste produced.
• Improved segregation and management of chemotherapy
medications. Setting up concise waste segregation programs for
managing chemotherapy wastes can reduce pollution and improve worker
safety. Some chemotheraputic drugs are RCRA listed. Other
chemotherapy medications may be RCRA characteristic. Best
management of such wastes involves setting up management programs to
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separate bulk chemotherapy wastes (where there is an identifiable residual
amount present) from non-regulated chemotherapy wastes (e.g., gloves,
personal protective equipment, and packaging from non-regulated
materials), which can usually be packaged and disposed of with biohazard
waste. These are fine distinctions and require careful planning and staff
education. This type of program, coupled with a reverse distribution
program for unused pharmaceutical products, can mitigate pharmaceutical
waste outputs that can impact all media.
• Improved waste segregation systems (reduces biohazardous waste
outputs, can increase solid waste outputs and recyclable waste
outputs). Establishing waste segregation systems that allow for the
separate collection of solid wastes, recyclable wastes, and biohazardous
wastes increases the likelihood that wastes can be collected and handled in
the most appropriate and cost-effective fashion. In the case of
biohazardous waste collection, by implementing staff education, installing
appropriately labeled and convenient containers, and establishing relevant
collection schedules, an organization can realize substantive reductions in
biohazardous waste outputs and costs. In large part, this results from staff
having the option to discard packaging wastes and other waste materials
that are not contaminated, as solid waste or a recyclable waste.
V.A.4. Recycling
Waste volumes can dramatically be reduced if systems are in place to capture
recyclable materials such as cardboard, paper, glass and aluminum beverage containers, scrap
metals, wood waste, kitchen grease, and selected plastics. Recycling success and opportunities
are usually linked to recycling infrastructure at the community level.
Opportunities for Reducing Solid Waste
Setting up programs to recycle paper, cardboard, glass, plastic, wood and other
types of waste can dramatically reduce a facility's solid waste output. Other factors to consider
include:
• Paper wastes - measures must be implemented to ensure the
confidentiality of patient information.
• Beverage container collection/recycling (aluminum and plastic) - suitable
storage and timely collection schedules are needed to prevent rodent and
insect problems and foul odors, and to minimize the environmental benefit
if the facility has to use pesticides.
• Durable goods such as furniture, equipment, pallets - these items can be
recycled and reduce waste volumes. Mattresses are a bulky and
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problematic waste for many facilities; they can hire companies that
recycle bedding materials to collect and recycle bedding.
• Environmentally Preferable Purchasing (EPP) - Purposely purchasing
recycled materials or materials made of recycled products in place of non-
recycled materials reduces solid waste generation. Examples of products
containing recycled materials are available on www.epa.gov/cpg.
• Universal Wastes - Collecting universal wastes separately helps streamline
recycling efforts for facilities as these wastes are regulated by streamlined
management rules. Universal wastes found in healthcare facilities include
nickel cadmium or sealed lead-acid batteries, mercury-containing
thermostats, and lamps that have a hazardous component.
Opportunities for Reducing Hazardous Waste Through Recycling Initiatives
As technologies continue to advance, more opportunities for recycling hazardous
waste become available. For example,
• Reducing waste solvents, alcohols, formalin, and formaldehyde - hospital
laboratories can use technologies that recycle solvents, formalin, and
alcohols, making them essentially continually reusable products, that can
be used over and over. There is a very small residual, referred to as 'still
bottoms' that is generated during the recycling process and requires
disposal as a hazardous waste. Healthcare facilities should check with
their state regulations before installing recycling units.
• Reducing fluorescent bulb wastes - Collecting fluorescent bulbs for
recycling as a universal waste reduces the measurable volume of
hazardous waste.
V.B. Pollution Prevention Opportunities by Waste Type
Table V-l highlights some examples of pollution prevention and waste
management strategies by each waste type. Facilities can use this table with Table III-2 in
Section III of this Notebook to help recognize the areas where these waste categories are
generated. These strategies are meant to be illustrative examples and not a comprehensive list.
For more information on recycling opportunities in the healthcare industry, visit the web sites
discussed in Section VIII of this document.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Municipal Solid
Waste
Cardboard, paper, boxboard,
magazines, newspaper, metals (steel
and aluminum), glass, plastics, food
waste, leaf and yard waste, mixed
materials, mattresses, furniture,
pallets, carpet, packaging materials
Work with suppliers to reduce the amount of
packaging waste that must be disposed of.
Recycle materials as local infrastructure permits.
Donate durable/bulky goods for reuse in other
settings (consider zoos, veterinary clinics, local
shelters, etc.).
Collect packaging materials for reuse (foam peanuts,
foam inserts, airbag inserts).
Recycle mattresses and carpeting with specialty
recyclers.
Consider composting programs (on site or off site)
for organic wastes such as food waste, leaf and yard
wastes. Provide food scraps that can't be used as
livestock feed to local farms.
Educate employees about the importance of source
reductions, reuse, and recycling.
Reduce packaging, use double-sided printing
capabilities, reuse items when feasible, use e-mail
and electronic communications among staff, and use
electronic forms.
Change to reusable drapes, gowns, and linens where
appropriate.
Purchase mattresses with built-in comfort pads to
eliminate the use of disposable ones.
File insurance claims and purchase orders
electronically instead of mailing paper forms.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Municipal Solid
Waste
(Continued)
Construction and demolition wastes
(C&D)
Place standard forms on the computer to view and
send electronically.
Reduce cafeteria waste by offering discounts for
those who use their own coffee mugs, soda cups, and
food trays.
Use old linens as rags.
Develop reusable containers for vendor shipments.
Switch to reusable plates for patient care.
Switch from cloth sterilization wrappers to reusable
sterilization canisters.
Reduce duplicate items in admissions kits.
Purchase recycled-content products and supplies for
the cafeteria and office areas as well as for
maintenance and janitorial operations.
Look for information and consider implementing a
municipal waste reduction strategy under the EPA
WasteWi$e program, which provides technical
assistance, goal setting, and recognition for
accomplishments: www.epa.sov/wastewise.
Much construction and demolition waste consists of
wood waste, mortar products, metals, and mixed
materials. Separate these wastes by material type
and recycle or reuse them in other settings.
Conduct drain trap cleanouts prior to construction
and renovation projects, especially in areas where
activities that used mercury-containing products
were conducted (e.g.: former patient care areas,
former laboratory settings, former reprocessing and
supply decontamination areas, former dental suites/
clinics).
Handle C&D wastes that contain lead, asbestos or
mercury as hazardous waste or in adherence to
regulatory guidelines.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Biohazardous
Waste,
Regulated
Medical Waste
(RMW)
Sharps waste, blood and blood
products, pathological waste,
selected isolation wastes, cultures
and stocks from laboratories, blood-
soaked bandages, etc.
Sharps - collect sharps waste in leakproof, puncture-
resistant, cadmium-free containers. In some regions,
reusable sharps collection container programs are
available. This can reduce overall volumes
associated with collection container wastes. Educate
staff to ensure that sharps containers are solely for
sharps, and items such as batteries or broken
mercury thermometers should NEVER be discarded
in such containers.
RMW - use cadmium-free red bags to collect waste.
Where feasible, explore using reusable
packing/shipping containers to eliminate cardboard
shipping boxes. Ensure that staff have proper
education about what items can be discarded into
biohazardous waste containers/red bags. Note: in
Oncology and Pharmacy, ensure that only non-
regulated chemotherapy is disposed of in biohazard
waste containers.
Non-regulated chemotherapy waste is allowed to be
discarded in biohazardous waste in some states while
other states require that it is collected in yellow bags.
Set up systems that collect 'soft' non-regulated
chemotherapy wastes in the required bags and
'sharp' non-regulated chemotherapy wastes in rigid
leakproof containers. This measure will reduce the
volume of packaging wastes. Label this waste 'for
incineration only" (or for other technologies as they
become available) and label the waste at point of
generation.
Pathological waste - label pathological wastes for
appropriate treatment such as incineration only, or
other treatment technologies that become available
such as plasma arc or alkaline treatment. Ensure that
formalin or formaldehyde has been decanted from
specimens prior to packaging for disposal.
Pollution prevention strategies for this category of
wastes can also be associated with selection of
disposal route/technology.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Biohazardous
Waste,
Regulated
Medical Waste
(RMW) (cont.)
These can include:
1) Minimizing use of incineration.
2) Consider on-site treatment technologies such as
autoclaving or chemical/mechanical systems for the
majority of RMW to reduce pollution associated
with transporting wastes great distances over
roadways.
3) Use drain disposal for liquid wastes (such as
common body fluids) that are routinely generated
and flushed down the toilet in household settings.
Hazardous
Waste
Solvents
Selected Pharmaceuticals
Ethylene oxide (EtO)
Mercury-containing equipment or
compounds
Lead-containing equipment
Collect and recycle solvents.
Identify RCRA listed and characteristic
Pharmaceuticals. Implement inventory control and
management options. As a product management
strategy, utilize a reverse distribution company for
unused/unexpired product returns. Monitor auto
dispensing machines for expired Pharmaceuticals.
Dispose of residual amounts of liquid properly.
Minimize use of EtO where possible.
Discontinue use of mercury-containing instruments
and chemicals. Notify suppliers/vendors of NO
MERCURY policy. Send mercury-containing
products for reclamation (retorting).
Identify lead-containing supplies and equipment,
particularly in radiology areas, and designate for
reuse, recycling or hazardous waste disposal. Note:
Much lead-shielding material, when no longer
suitable for use in intended purpose, can be adapted
for other uses within the radiology department.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Hazardous
Waste (cont.)
Hazardous chemicals
Implement chemical purchasing, inventory and
management systems in laboratory settings, plant
operations, boiler areas, paint, electric and plumbing
shops, and other areas. Label and store waste in
accordance with RCRA regulations. Use secondary
containment measures for storage of hazardous
chemicals and storage of hazardous chemical wastes.
Develop appropriate facilities to store hazardous
chemical wastes. Have spill preparedness systems in
place, secondary containment, neutralizing agents,
and other resources to minimize problems associated
with managing hazardous materials and wastes.
Seek less harmful alternatives through
environmentally preferable products from such
places as the Sustainable Hospital Project
(www. sustainablehospitals. org).
Radioactive
Wastes
Radioactive materials and residues in
drains and piping
Work with radiation safety officer to establish
protocols for radioactive waste decay, strategies to
minimize the amounts of radioactive wastes
generated, etc.
Pressurized
Containers
Gas cylinders, gas cartridges, aerosol
cans, oxygen farms
Eliminate any gas cylinders on site that are not
currently in use or that do not have a specific
purpose. Return to vendor for recycling where
possible.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Universal
Wastes
Mercury-containing thermostats, and
spent fluorescent lamps and other
hazardous lamps. Hazardous waste
batteries, hazardous waste pesticides
- recalled or sent to collection
program. States may have additional
universal wastes such as electronics.
Collect and recycle mercury-containing bulbs and
thermostats.
Develop a separate storage area for universal wastes;
use proper labeling and storage methods.
Contact the vendor or service representative to
determine if mercury-free alternatives exist.
Discontinue use, where feasible, of mercury-
containing switches, thermostats, etc.
Clearly label the device as one containing mercury
and requiring special care and handling. Maintain a
list of where mercury-containing devices are located
in the facility.
Train and advise maintenance staff to routinely
monitor for leakage and to respond appropriately if a
leak occurs.
Develop a maintenance protocol for when the article
needs to be recalibrated, handled, or replaced.
Have mercury spill cleanup materials available in
areas where mercury cannot be phased out in the
near term (e.g., boiler switches in boiler room areas).
When the device needs replacement due to age or
efficiency, replace it with a nonmercury alternative.
Construction and
Demolition
Debris
containing
asbestos or other
hazardous
material
Asbestos
Mercury
Lead
PCBs from old fluorescent lights and
transformers
Conduct thorough walk-throughs prior to
renovations to identify possible sources of asbestos,
mercury, or lead materials.
Conduct drain trap cleanouts prior to renovations in
areas that once used mercury-containing products or
materials.
Work with a certified vendor to manage lead or PCB
waste materials as they are encountered during
renovations.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Wastewater
Potentially, any hazardous substance
in any clinical area
Oils
Hydraulic fluid
Chemical spills
Recycle and heat recovery from
boilers, cooling towers, and laundry
facilities wastewater
Identify all direct discharge drains within the facility.
Examine materials used and stored in proximity to
the drains. If materials are potentially problematic
(e.g., oils, hydraulic fluids, formaldehyde, or other
hazardous chemicals), ensure that drain mat covers,
spill cleanup materials, and training for spills are part
of the operations plan for the area.
Examine decontamination areas in emergency
departments (areas where victims of chemical or
biological exposures are cleansed prior to receiving
medical treatment) to ensure that systems are in
place to capture contaminated fluids resulting from
decontamination activities.
Stormwater
Runoff from building, lawns, parking
areas, underground storage tank
areas, aboveground storage tank
areas, disturbed soils during
construction
Identify storm drains outside the facility, and explore
what substances might be inadvertently discharged
into them. For example, if the on-site solid waste
compactor is uphill from the nearest storm drain,
ensure that spill cleanup materials are nearby in the
event of a hydraulic fluid leak in the compactor. If
the loading dock (shipping and receiving) is near a
storm drain, ensure that spill cleanup materials are
nearby in the event of a chemical spill (e.g., from a
large barrel of floor stripper or other potentially toxic
substance).
Minimize use of fertilizers and pesticides.
Clean oil spills from vehicles.
Cover storage tanks areas.
Have spill cleanup materials readily available in
relevant locations.
Ensure staff have adequate training to respond to
spills to minimize resulting damage.
For construction project, use Stormwater best
practices to keep sediment and other contaminants
out of run-off.
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Table V-l: Pollution Prevention and Waste Management Strategies by Waste Category
(Continued)
Waste
Category
Specific Wastes/Emissions Found
in this Category
Waste Management Strategy
Air Emissions
Air conditioning and refrigeration
units
Boilers
Medical waste incinerators
Asbestos removal
Paint booths
EtO sterilizers
Anesthesia services
CFC/Freon management systems.
Use steam generated from incinerators to partially
replace boilers. Purchase ENERGY STAR qualified
boilers, which use about 10% less energy than a
standard boiler.
Minimize biohazardous waste quantities to reduce
frequency of needing to run incinerator. Establish
definitive waste segregation programs to minimize
inappropriate segregation of hazardous wastes (e.g.,
mercury spill cleanup materials) in biohazardous
waste stream. Minimize the use of PVC (polyvinyl
plastic) products and packaging materials to reduce
the likelihood of creating dioxin emissions (2,3,7,8
dioxin).
Work with a certified vendor to conduct this process
safely.
Install a filtering ventilation system to collect paint
fumes.
Minimize use of EtO where feasible. Use EtO
scavenging units on external stacks. Use air
monitoring systems within the facility to monitor for
EtO leaks.
Employ scavenger systems.
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VI. SUMMARY OF FEDERAL STATUTES AND REGULATIONS
This section discusses the federal regulations that may apply to the healthcare
sector. The purpose of this section is to highlight and briefly describe the applicable federal
requirements, and to provide citations for more detailed information. The four following
subsections are included:
• Section VIA contains a list of regulations specific to this industry;
• Section VLB contains a list of regulations by waste category;
• Section VI.C contains a list of pending and proposed regulatory
requirements; and
• Section VI.D contains a list of additional applicable non-EPA regulations.
The descriptions within Section VI are intended solely for general information.
While EPA has made every effort to ensure the accuracy of this information, depending upon the
nature or scope of the activities at a particular facility, these summaries may or may not
necessarily describe all applicable environmental requirements. Moreover, they do not
constitute formal interpretations or clarifications of the statutes and regulations. States and local
regulating bodies may impose more stringent requirements than those established by EPA and
other federal agencies. It is beyond the scope of this compliance chapter to list the requirements
of all federal, state and local regulatory bodies. For further information, consult the Code of
Federal Regulations (CFR) and other state, tribal, or local regulatory agencies.
To search the CFR, go to the Electronic Code of Federal Regulations (e-CFR) at
http://www.gpoaccess.gov/ecfr/. The e-CFR consists of two linked databases: the "current Code"
and "amendment files." The Office of Federal Register updates the current Code database
according to the effective dates of amendments published in the Federal Register. The Federal
Register is the official daily publication for rules, proposed rules, and notices of federal agencies
and organizations, as well as executive orders and other presidential documents. The Federal
Register can be searched at http://www.gpoaccess.gov/fr/index.html.
VI.A. Industry-Specific Requirements
The healthcare industry is affected by multiple federal environmental statutes. In
addition, the industry is subject to numerous laws and regulations from state, tribal, and local
governments designed to protect and improve the nation's health, safety, and environment.
Table VI-1 summarizes the major federal regulations affecting air, water, and waste outputs from
the healthcare industry.
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Table VI-1: Summary of Potentially Applicable EPA Regulations
Water Programs (CWA and SWDA)
40 CFR Part 112
40 CFR Part 122
40 CFR Part 141
40 CFR Part 142
40 CFR Part 143
40 CFR Part 144
40 CFR Part 145
40 CFR Part 146
40 CFR Part 147
40 CFR Part 148
40 CFR Part 403
40 CFR Part 430
40 CFR Part 460
Oil Pollution Prevention
EPA- Administered Permit Programs: The National Pollutant Discharge Elimination
System
National Primary Drinking Water Regulations
National Primary Drinking Water Regulations Implementation
National Secondary Drinking Water Regulations
Underground Injection Control ("UIC") Program
State UIC Program Requirements
UIC Program: Criteria and Standards
State UIC Programs
Hazardous Waste Injection Restrictions
General Pretreatment Regulations for Existing and New Sources of Pollution
Effluent Guidelines for Direct Dischargers
Effluent Guidelines for the Hospital Point Source Category
Solid and Hazardous Wastes (RCRA)
40 CFR Part 260
40 CFR Part 261
40 CFR Part 262
40 CFR Part 263
40 CFR Part 264
40 CFR Part 265
40 CFR Part 266
40 CFR Part 268
40 CFR Part 273
40 CFR Part 279
40 CFR Part 280
Hazardous Waste Management System
Identification and Listing of Hazardous Waste
Standards Applicable to Generators of Hazardous Waste
Standards Applicable to Transporters of Hazardous Waste
Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and
Disposal Facilities
Interim Status Standards for Owners and Operators of Hazardous Waste Treatment,
Storage, and Disposal Facilities
Standards for the Management of Specific Hazardous Wastes and Specific Types of
Hazardous Waste Management Facilities
Land Disposal Restrictions
Standards for Universal Waste Management
Standards for the Management of Used Oil
Technical Standards and Corrective Requirements for Owners and Operators of
Underground Storage Tanks ("USTs")
Hazardous Substances and Chemicals, Environmental Response, Emergency Planning, and Community
Right-to-Know Programs (CERCLA and EPCRA)
40 CFR Part 302
40 CFR Part 355
40 CFR Part 370
40 CFR Part 372
Designation, Reportable Quantities, and Notification
Emergency Planning and Notification
Hazardous Chemical Reporting: Community Right-to-Know
Toxic Chemical Release Reporting: Community Right-to-Know
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Table VI-1: Summary of Applicable EPA Regulations (Continued)
Air Programs (CAA)
40 CFR Section 52.21
40 CFR Part 60
40 CFR Part 61
40 CFR Part 62 Subpart
HHH
40 CFR Part 63
40 CFR Part 68
40 CFR Part 70
40 CFR Part 82
Prevention of Significant Deterioration of Air Quality
Standards of Performance for New Stationary Sources
National Emission Standards for Hazardous Air Pollutants, Subpart M, National
Emission Standard for Asbestos
Federal Plan Requirements for Hospital/Medical/Infectious Waste Incinerators
National Emission Standards for Hazardous Air Pollutants for Source Categories (all
applicable provisions)
Chemical Accident Prevention Provisions
State Operating Permit Programs
Protection of Stratospheric Ozone
All applicable provisions of State Implementation Plan Regulations (promulgated pursuant to Section 1 10 of the
Clean Air Act) including the New Source Review regulations
Toxic Substances (TSCA)
40 CFR Part 745
40 CFR Part 761
40 CFR Part 763
Lead-Based Paint Poisoning Prevention in Certain Residential Structures
Poly chlorinated Biphenyls (PCBs) Manufacturing, Processing, Distribution in
Commerce, and Use Prohibitions
Asbestos
Pesticide Programs (FIFRA)
40 CFR Part 160
40 CFR Part 162
40 CFR Part 170
40 CFR Part 171
40 CFR Part 172
Good Laboratory Practice Standards
State Registration of Pesticide Products
Worker Protection Standard
Certification of Pesticide Applicators
Experimental Use Permits
Note that, in the healthcare industry, compliance with environmental regulations
may be handled in many different ways. Though ideally all employees should help comply,
official responsibility could lie at the corporate level, it could lie within the healthcare facility as
either a centrally or non-centrally organized activity, or it could be part of a function for
vendored-out services. EPA observes that the organizations that successfully achieve
compliance engage all or many employees in the various facility operations.
Clean Water Act
The primary objective of the Federal Water Pollution Control Act, commonly
referred to as the Clean Water Act (CWA), is to restore and maintain the chemical, physical, and
biological integrity of the nation's surface waters. Pollutants regulated under the CWA are
classified as either "toxic" pollutants (priority pollutants); "conventional" pollutants, such as
biochemical oxygen demand (BOD), total suspended solids (TSS), fecal coliform, oil and grease,
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and pH; or "nonconventional" pollutants, including any pollutant not identified as either
conventional or priority.
The CWA regulates both direct (those that discharge directly to waters of the
United States) and indirect dischargers (those who discharge to POTWs). The National Pollutant
Discharge Elimination System (NPDES) permitting program (CWA Section 402) controls direct
discharges into navigable waters. NPDES permits, issued by either EPA or an authorized state
(EPA has authorized 45 states, one territory, and no tribes to administer the NPDES program),
contain industry-specific, technology-based and water-quality-based limits and establish
pollutant monitoring and reporting requirements. A facility that proposes to discharge into the
nation's waters must obtain a permit prior to initiating a discharge. A permit applicant must
provide quantitative analytical data identifying the types of pollutants present in the facility's
effluent. The permit will then set forth the conditions and effluent limitations under which the
facility may discharge.
EPA has established technology-based discharge standards for hospitals that are
direct dischargers. These standards limit 5-day biochemical oxygen demand (BOD5) and total
suspended solids as a mass value calibrated per 1,000 occupied beds. pH is also limited. In
contrast, water-quality-based discharge limits are based on federal or EPA-approved state or
tribal water quality criteria or standards that were designed to protect designated uses of surface
waters, such as supporting aquatic life or recreation. These standards, unlike the technology-
based standards, generally do not take into account technological feasibility or costs. Water
quality criteria and standards vary from state to state and site to site, depending on the use
classification of the receiving body of water. Most states and territories follow EPA effluent
guidelines, which propose aquatic life and human health criteria for many of the 126 priority
pollutants. The permitting agency (EPA or the authorized state) is obligated to impose the more
stringent of these two types of limits in the permit issued to the applicable hospital.
As stated in Section III.B.4 of this document, healthcare facilities wastewater
sources include sinks, drains, showers, toilets, and tubs; photographic development drains from
radiology (X-rays), other imaging, and dentists; and stormwater. The healthcare industry is
subject to various provisions of the CWA including:
• Wastewater Discharges - NPDES Effluent Limitations and Guidelines for
Direct Dischargers (guidelines for direct discharging hospitals with more
than 1,000 occupied beds) and General Pretreatment Standards.
• Stormwater Permits: Municipal separate storm sewer systems (MS4),
such as those from hospitals, and construction activities are subject to
stormwater permitting requirements.
• Oil Pollution Prevention Requirements: Hospitals that have a total
aboveground oil storage capacity exceeding 1,320 gallons or an
underground storage capacity exceeding 42,000 gallons are subject to spill
prevention control and countermeasure (SPCC) plan requirements.
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Wastewater Discharges
As stated above, the water regulations establish different permitting programs for
direct and indirect wastewater discharges. EPA's NPDES web site http://cfpub.epa.gov/npdes
provides technical and regulatory information about the NPDES permit program that controls
water pollution by regulating point sources (e.g., pipe, ditch) that discharge pollutants into
waters of the United States. Most hospitals are indirect dischargers.
• Indirect Dischargers: Hospitals that are indirect dischargers are subject to
regulations by the local sewer authority. At present, approximately 1,500
of the nation's largest municipalities are required to implement industrial
pretreatment programs that include issuing industrial user permits to
significant industrial users. Some municipalities have determined
hospitals to be significant industrial users.
Most municipalities have established local prohibitions that apply
specifically to medical waste discharges. For example, some
municipalities have set a prohibition on "all medical waste." Other
prohibitions include, for example, no discharge of discernible body parts,
no human remains greater than 0.5 inches in diameter, and/or no
radioactive wastes. The ability of municipalities to establish prohibitions
to meet their specific needs/interests is very flexible.
Federal Pretreatment Regulations prohibit discharges of fire or explosion
hazards; corrosive discharges (pH < 5.0); solid or viscous pollutants; heat
(in amounts that cause the treatment plant influent to exceed 104 degrees
F); pollutants that cause toxic gases, fumes, or vapors; and any other
pollutant (including oil and grease) that will interfere with or pass through
the treatment plant.
• Direct Dischargers: There are very few direct discharging hospitals as
reported to PCS in 2004 (e.g., 11 with non-major NPDES permits and 1
with major NPDES permit using SIC Code 806). Hospitals that are direct
dischargers of process and sewer wastes must be permitted (i.e., obtain a
permit) for any point source discharge of pollutants to waters of the
United States. These permits are issued either by EPA or the state, where
the state has been authorized to implement the NPDES Permit Program.
The federal regulations establish the permit application and permit
requirements. Specific numeric limitations that apply to a medical facility
depend on the more stringent limits determined by the applicable
technology-based discharge standards (40 CFR 460) and water quality
standards for the receiving stream of the discharge. For detailed
information on numeric limitations, contact your EPA Regional
pretreatment coordinator. Contact information can be found at the
following web site.
http://cfpub.epa.sov/npdes/contacts.cfm ?program id=0&tvt>e =NPDES
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Stormwater Discharges
The Stormwater program is part of the NPDES program and is designed to prevent
the discharge of contaminated Stormwater into navigable waters. See the web site at:
http://cfpub. epa. gov/npdes/home. cfm ?program __/' d= 6
Phase I of the Stormwater program was promulgated in 1990 and applied to
medium and large municipal separate storm sewer systems (MS4), certain industrial facilities
(not hospitals), and any construction activity disturbing greater than 5 acres (large construction
sites).
Phase II of the Stormwater program was promulgated in 1999 and applies to small
municipal separate storm sewer systems (MS4) and construction activity greater than 1 acre and
less than 5 acres (small construction sites). Hospitals located in urbanized areas are regulated
under this new rule. Any hospital located in urbanized or rural areas that are planning
construction activities should look into obtaining a Stormwater NPDES permit for construction.
The term MS4 does not solely refer to municipally owned storm sewer systems,
but rather is a term with a much broader application that can include, in addition to local
jurisdictions, state departments of transportation, universities, local sewer districts, hospitals,
military bases, and prisons. A MS4 also is not always just a system of underground pipes - it can
include roads with drainage systems, gutters, and ditches. Hospitals in urbanized areas should
consult with their state NPDES authority to evaluate whether a permit authorization is required.
The regulatory definition of an MS4 is provided in 40 CFR 122.26(b)(8). General
Stormwater information can be found at http://cfpub.epa.gov/npdes/home.cfm7program id=6
and the Stormwater Phase II Compliance Assistance Guide, at
http://www. epa.gov/npdes/pubs/comguide.pdf.
Aboveground or Underground Oil Storage Containers
EPA's oil spill program web site, http://www. epa.gov/oilspill/, provides
information about EPA's program for preventing, preparing for, and responding to oil spills that
occur in and around inland waters of the United States. If a hospital uses or stores oil it may be
subject to the Spill Prevention Control Countermeasure (SPCC) rule. Hospitals with an above
ground oil storage capacity of greater than 1,320 gallons, or total completely buried oil storage
capacity greater than 42,000 gallons must prepare and implement a SPCC plan to prevent any
discharge of oil into or upon navigable waters of the United States or adjoining shorelines.
On July 16, 2002, EPA promulgated a revised final SPCC Regulation which
became effective August 17, 2002. EPA subsequently extended the regulatory compliance
schedule included in the new SPCC rule.
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The current compliance dates for the new rule are:
• February 17, 2006: Facilities must prepare and a Professional Engineer
(P.E.) certify an SPCC Plan in accordance with the new SPCC rule by this
date.
• August 18, 2006: The revised SPCC Plan must be implemented.
In the interim, facilities are required to maintain their existing SPCC Plan and amend it in
accordance with 40 CFR §112.5.
CWA Common Areas for Inspections
While an EPA inspector is authorized to examine a wide range of documents and
operations, he/she will probably be interested in three areas of a hospital: wastewater discharges,
stormwater discharges, and any aboveground or underground oil storage containers.
Typical Records an EPA Inspector May Ask to Review under the CWA
• Industrial User permit (IU permit) for discharges to the local municipality
(indirect discharge). Most hospitals are indirect dischargers.
• Spill Prevention, Control, and Countermeasure (SPCC) Plan. The plan is
to prevent any discharge of oil into or upon navigable waters of the United
States or adjoining shorelines.
• Phase II stormwater permits under the NPDES program for public
hospitals located in an urbanized area.
• NPDES construction stormwater permits (Phase I and Phase II) are also
required for any construction activity greater than 1 acre for any hospital
located in urban or rural areas.
• NPDES general permit for discharging directly to a water body (direct
discharge).
EPA 's Office of Water operates a Water Resource Center with a 24-hour voice
mail system for publication orders or reference questions at (202) 566-1729 (e-mail address:
center.water-resource(a),epa.gov). Long-distance callers in the United States may also use the
Wetlands Helpline ((800) 832-7828), operating weekdays from 8:30 a.m. to 4:30 p.m., EST,
excluding federal holidays. Visit the Office of Water web site (http://www. epa.gov/water/) and
the NPDES web site (http://cfpub. epa. gov/npdes/) for additional material.
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Safe Drinking Water Act
The Safe Drinking Water Act (SDWA) mandates that EPA establish regulations
to protect human health from contaminants in drinking water. The law authorizes EPA to
develop national drinking water standards and to create a joint federal-state (or federal-tribal)
system to ensure compliance with these standards. The SDWA also directs EPA to protect
underground sources of drinking water by controlling underground injection of fluid wastes.
EPA has developed primary and secondary drinking water standards under its
SDWA authority. EPA and authorized states and territories enforce the primary drinking water
standards, which are contaminant-specific concentration limits that apply to certain public
drinking water supplies. Primary drinking water standards consist of maximum contaminant
level goals (MCLGs), which are nonenforceable health-based goals, and maximum contaminant
levels (MCLs), which are enforceable limits set generally as close to MCLGs as possible,
considering cost and feasibility of attainment.
A hospital would be considered a nontransient, noncommunity water system (i.e.,
a public water system) if it regularly serves at least 25 of the same persons 6 months per year
from its own water source. The hospital would thus be required to comply with SDWA
monitoring and reporting requirements. Healthcare facilities that have their own drinking water
treatment to comply with MCLs should be aware that they could generate hazardous or
radioactive waste (e.g., some areas have elevated arsenic levels in groundwater.)
Part C of the SDWA mandates EPA to protect underground sources of drinking
water from inadequate injection practices. EPA has published regulations codified in 40 CFR
Parts 144 to 148 to comply with this mandate. The Underground Injection Control (UIC)
regulations break down injection wells into five different types, depending on the fluid injected
and the formation that receives it. The regulations also include construction, monitoring, testing,
and operating requirements for injection well operators. All injection wells have to be
authorized by permit or by rule depending on their potential to threaten Underground Sources of
Drinking Water (USDW). RCRA also regulates hazardous waste injection wells and a UIC
permit is considered to meet the requirements of a RCRA permit. EPA has authorized
delegation of the UIC for all well classes in 34 states, implements the program directly in 10
states and all Indian country areas, and shares responsibility with 6 states. For a hospital, an
injection well can constitute any bored, drilled or driven shaft or a dug hole, where the depth is
greater than the largest surface dimension that is used to discharge fluids underground as well as
any on-site drainage systems, such as septic systems, cesspools, and stormwater wells, that
discharge fluids only a few feet underground. Hospitals and doctors' offices must make sure that
what they pour down a drain goes to a sewer, and not to a drywell or septic system.
The SDWA also provides for a federally implemented Sole Source Aquifer
program, which prohibits federal funds from being expended on projects that may contaminate
the sole or principal source of drinking water for a given area, and for a state-implemented
Wellhead Protection program, designed to protect drinking water wells and drinking water
recharge areas.
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EPA 's Safe Drinking Water Hotline, at (800) 426-4791 (or (703) 412-3330 for
local and international calls), answers questions and distributes guidance pertaining to SDWA
standards (e-mail: hotline-sdwa(q),epa.gov). The Hotline operates from 9:00 a.m. through 5:00
p.m., EST, excluding federal holidays. Visit the web site at www. epa.gov/ogwdw for additional
material.
Resource Conservation and Recovery Act
The Resource Conservation and Recovery Act (RCRA) aims to manage the
disposal of waste from municipalities and industries. It regulates facilities that generate,
transport, treat, store, or dispose of hazardous waste. Under RCRA, most healthcare facilities
are hazardous waste generators. RCRA hazardous waste regulations are in the Code of Federal
Regulations (CFR), Title 40, Parts 260 to 280. A series of hazardous waste evaluation
flowcharts are available on EPA Region 2's web site at
http://www.epa.gov/region02/healthcare/. The flowcharts are based on the federal requirements.
Most states are authorized the hazardous waste program and may have more stringent
requirements. Healthcare facilities should check with their states for additional requirements.
Although RCRA is a federal statute, most states are authorized to administer the
RCRA hazardous waste program under their own authority. Currently, EPA has authorized 48
of the 50 states and two United States territories to administer various provisions of RCRA
Subtitle C. States must have regulations consistent with and at least as stringent as the federal
program; some states have additional reporting requirements. Healthcare facilities should
contact their state or tribal authority to determine which state or tribal requirements apply to their
business. RCRA does not enable EPA to authorize tribal hazardous waste programs in lieu of
the federal program; therefore, EPA directly implements RCRA hazardous waste programs in
Indian country, but tribes may have their own, independent hazardous waste programs.
RCRA defines hazardous waste as a subset of solid waste. Solid waste is defined
as garbage, refuse, sludge, or other discarded material (including solids, semisolids, liquids, and
contained gaseous materials). Once a waste is considered solid waste, determine if it is
hazardous waste. EPA defined hazardous wastes as either listed or characteristic. If a waste is
specifically named on one of four lists of hazardous wastes, it is a listed waste. If a waste
exhibits one of four characteristics, it is a characteristic waste. Section III.B.3 describes the
listed and characteristic hazardous wastes commonly found in the healthcare field.
Under RCRA, a facility must determine its generator status. Reporting and other
regulatory requirements are different for each generator type. Hazardous waste generators are
divided into three categories, according to how much hazardous waste they generate in a
calendar month:
• Large Quantity Generators (LQGs) generate greater than or equal to
1,000 kg (approximately 2,200 Ibs) of hazardous waste per month, or
greater than 1 kg (approximately 2.2 Ibs) of acutely hazardous waste per
month. EPA considers acute hazardous wastes the P-listed wastes. If
facilities generate more than 1 kg (approximately 1 quart) of acutely
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hazardous waste, then they are LQGs and must comply with all LQG
reporting requirements. See Table III-l for a list of some common acute
and toxic healthcare hazardous wastes.
• Small Quantity Generators (SQGs) generate greater than 100 kg
(approximately 220 Ibs) but less than 1,000 kg of hazardous waste per
month and/or less than 1 kg (approximately 2.2 Ibs) of acutely hazardous
waste per month.
• Conditionally Exempt Small Quantity Generators (CESQGs) generate
less than or equal to 100 kg of hazardous waste per month, and less than
or equal to 1 kg of acutely hazardous waste per month. Not all states
recognize the CESQG classification.
• Large Quantity Handler of Universal Waste (LQHUW) store greater
than 5,000 kg of universal waste on site.
• Small Quantity Handler of Universal Waste (SQHUW) store less than
5,000 kg or about 11,000 Ibs of universal waste (all types combined) on
any given day during the calendar year.
Entities that generate hazardous waste are subject to Federal standards applicable
to generators of hazardous waste (e.g., hazardous waste manifest, pre-transportation,
recordkeeping and reporting, etc). Storage of hazardous waste generally requires a permit under
RCRA hazardous waste regulations, but provisions under RCRA do allow generators to
"accumulate" hazardous waste on site without a permit or interim status as long as they comply,
among other things, with the technical standards for the containment unit(s). The length of time
a generator is allowed to accumulate hazardous waste on site without a permit or interim status
depends on the generator's classification. For instance, Large Quantity Generators may
accumulate any quantity on-site for 90 days or less without a permit or interim status. Small
Quantity Generators may accumulate no more than 6,000 kg of hazardous waste without a permit
or interim status for 180 days or less (or for 270 days or less depending on transport distance).
CESQGs may accumulate 1,000 kg of waste, 1kg acute waste, or 100 kg residue or contaminated
soil from a cleanup of an acute hazardous waste spill. Generators also may treat hazardous
waste in accumulation tanks or containers (in accordance with the requirements of 40 CFR Part
262.34) without a permit or interim status. Facilities that treat, store, or dispose of hazardous
waste generally are required to obtain a RCRA permit.
Generator status is determined by calendar month; therefore, one month a facility
may be a CESQG, and the rest of the year it may be an SQG. In this case, it might be easier to
comply with SQG reporting requirements for consistency. On the other hand, if the facility is
usually an SQG, a store room or laboratory cleanout might push it into being an LQG. In
exceptional cases like this when it is a one time occurrence, some states have made exceptions so
that the cleanout does not trigger LQG status.
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Generators "count" the amount of waste generated, by adding up the total weight
of all quantities of characteristic and listed waste generated at a particular facility. Certain
wastes, such as those that are reclaimed or recycled continuously on site, are not counted under
the federal regulations but might be counted under some state regulations. Facilities should also
determine if their state has adopted the universal waste rule, which would cover mercury-
containing thermostats, certain batteries, and fluorescent light bulbs. Universal wastes do not
count toward determining generator status.
Most RCRA requirements are not industry-specific but apply to any company that
generates, transports, treats, stores, or disposes of hazardous waste. Below are some important
RCRA regulatory requirements that apply to healthcare facilities:
Identification of Solid and Hazardous Wastes (40 CFR Part 261) establishes the
standard to determine whether the material in question is considered a solid waste and, if so,
whether it is a hazardous waste or is exempted from regulation.
Standards for Generators of Hazardous Waste (40 CFR Part 262) establishes the
responsibilities of hazardous waste generators including obtaining an EPA identification number,
preparing a manifest, ensuring proper packaging and labeling, meeting standards for waste
accumulation units, and recordkeeping and reporting requirements. Generators can accumulate
hazardous waste on site for up to 90 days (or 180 days depending on the amount of waste
generated) without obtaining a permit. If the waste must be transported more than 200 miles
away for recovery, treatment, or disposal, the generator may accumulate the waste for up to 270
days.
Standards for Transporters of Hazardous Waste (40 CFR Part 263) apply to
persons transporting manifested shipments of hazardous waste within the United States.
Transport requires an EPA identification number, a hazardous waste manifest, compliance with
Department of Transportation (DOT) requirements, and proper recordkeeping.
Land Disposal Restrictions (LDRs) (40 CFR Part 268) are regulations prohibiting
the disposal of hazardous waste on land without prior treatment. Under the LDRs program,
materials must meet treatment standards prior to placement in a RCRA land disposal unit
(landfill, land treatment unit, waste pile, or surface impoundment). Generators of waste subject
to the LDRs must provide notification of such to the designated TSD facility to ensure proper
treatment prior to disposal.
Used Oil Management Standards (40 CFR Part 279) impose management
requirements affecting the storage, transportation, burning, processing, and re-refining of used
oil. For parties that merely generate used oil, regulations establish storage standards. A party
considered a used oil processor, re-refiner, burner, or marketer (one who generates and sells off-
specification used oil directly to a used oil burner), must meet additional tracking and paperwork
requirements.
RCRA contains unit-specific standards for all units used to store, treat, or dispose
of hazardous waste, including Tanks and Containers. Tanks and containers used to store
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hazardous waste with a high volatile organic concentration must meet emission standards under
RCRA. Regulations (40 CFR Part 264-265, Subpart CC) require generators to test the waste to
determine the concentration of the waste, to satisfy tank and container emissions standards, and
to inspect and monitor regulated units. These regulations apply to all facilities that store such
waste, including large quantity generators accumulating waste prior to shipment off site.
Underground Storage Tanks (USTs) containing petroleum and hazardous
substances are regulated under Subtitle I of RCRA. Subtitle I regulations (40 CFR Part 280)
contain tank design and release detection requirements, as well as financial responsibility and
corrective action standards for USTs. The UST program also includes upgrade requirements for
existing tanks that were to be met by December 22, 1998.
Boilers and Industrial Furnaces (BIFs) that use or burn fuel containing hazardous
waste must comply with design and operating standards. BIF regulations (40 CFR Part 266,
Subpart H) address unit design, provide performance standards, require emissions monitoring,
and, in some cases, restrict the type of waste that may be burned.
Imminent Hazard RCRA Section 7003 gives EPA a broad and powerful
enforcement tool to use in abating imminent hazards caused by hazardous or solid wastes.
Section 7003 states that upon receipt of evidence that the past or present handling, storage,
treatment, transportation, or disposal of any solid waste or hazardous waste may present
imminent and substantial endangerment to human health or the environment, EPA may bring suit
against any person who has contributed or who is contributing to the handling of the waste to
restrain the person, order the person to take any action that may be necessary, or both. This
authority is used only in extreme circumstances.
Some wastes have special exclusions for practices that are not considered to be
hazardous, as determined by federal policy. Several exclusions and exemptions pertain
specifically to healthcare facilities. Keep in mind that some states do not recognize the federal
exclusions. Some federal exclusions, exemptions, and other special circumstances that are
relevant to healthcare facilities are listed below:
• Domestic Sewage Exclusion. Mixtures of domestic sewage and other
wastes that discharge to a sewer system to a POTW for treatment are
excluded from the definition of solid waste. For example, employees may
generate a hazardous waste by washing hands with a soap containing a
listed hazardous waste. The mixture will be going through a POTW;
therefore, it is excluded from the facility's hazardous waste "count."
Generators need to contact their local POTW for prior approval. Note that
wastes must actually reach the POTW to be covered by this exclusion.
Waste that volatilizes in the drain or corrodes the pipes does not reach the
POTW.
• Point Source Exclusions. Point source discharges of industrial waste
waters that are subject to regulation under Section 402 of the CWA are
excluded from the definition of solid waste.
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• De Minimis Exclusion. Small quantities of some solvents and other
chemicals are exempt from the regulations when they are mixed with
wastewater in a wastewater treatment system discharging, according to the
Clean Water Act.
• Elementary Neutralization Unit. Tanks used for neutralizing waste that
is hazardous solely because of its corrosive characteristic are excluded
from the permitting requirements.
• Nitroglycerine Formulation. As of August 14, 2001, federal
regulations of nitroglycerine formulations are exempt from hazardous
waste regulation as long as they do not exhibit the characteristic of
reactivity. Medicinal nitroglycerine are typically not reactive and
therefore would not be regulated. This interpretation is based on the
revised mixture and derived-from rules [40 CFR 261.3(g)(l)]. Healthcare
facilities should check with their state environmental regulatory agency to
see if this rule applies in the state in which they operate.
• Wastewater Treatment Unit. Any hazardous waste tank system used to
store or treat the wastewater that is managed at an on-site wastewater
treatment facility with an NPDES permit or that discharges to a POTW is
exempt from the RCRA regulations. Most healthcare facilities do not
perform this type of wastewater treatment but instead perform elementary
neutralization, discussed below.
• Mixed Wastes. In May 2001, EPA issued a rule offering a conditional
exemption from RCRA requirements for mixed waste as long as it is
managed in accordance with NRC or Agreement State licenses (40 CFR
Part 266, Subpart N). This exemption covers on-site storage and means
that facilities no longer have to obtain RCRA storage permits for mixed
waste stored beyond 90 days. The rule has been adopted by 20 states, but
is authorized in only two.
• Reverse Distribution of Pharmaceuticals Unused pharmaceutical
products shipped to reverse distributors are not considered discarded and
are therefore not classified as hazardous waste. The materials must be
shipped as product and not identified as waste. Check with state
regulatory authorities to understand specific restrictions or requirements in
each state.
• Epinephrine Syringes. Epinephrine residue in syringes is not considered
P042 under federal RCRA hazardous waste rules. Some states may not
have adopted this policy. See also http://www.epa.gov/epaoswer/hotlme/
94report/12 94. txt. Note that this federal interpretation does not apply to
epinephrine in other formulations (such as vials), and note that the syringe
may still be hazardous waste by characteristic.
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Typical Physical Features to Inspect under RCRA
• Universal waste storage area;
• Used oil storage areas;
• Vehicle maintenance facilities;
• Battery storage areas;
• Building maintenance and repair shops;
• Laboratories;
• Bulk storage tank farms;
• Transfer terminals;
• Secondary containment structures;
• Tank peripheral piping, manifolds, filling and dispensing areas;
• Dispenser pumps and check valves;
• Tank sumps, manway areas;
• Leak detection equipment;
• Overflow alarms or other audible and visual alarms, sight gauges;
• Fill ports, catchment basins;
• Oil/water separators;
• Cleanup equipment (e.g. absorbent materials, fuel recovery pumps,
personal protective gear);
• Hazardous waste generation sites (x-ray, chemotherapy, morgue,
pathology);
• Waste storage areas;
Satellite accumulation points;
Vehicles used for transport;
Container storage areas; and
Shop activities.
Typical Records an Inspector May Ask to Review under RCRA
• Notification of Hazardous Waste Activity (EPA ID No.);
Hazardous waste manifests;
Manifest exception reports;
Biennial reports;
Inspection logs;
Land disposal restriction certifications;
Employee training documentation;
Hazardous substance spill control and contingency plan;
Material Safety Data Sheets (MSDSs);
Inventory records;
Spill records - Spill Prevention Control and Countermeasure (SPCC)
Plans;
Emergency plan documents;
Placarding of hazardous waste and hazardous materials;
Permits, if issued;
Waste analysis plan(s);
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• Operating record;
• Universal waste transportation/shipping records;
• Used oil analysis records;
• Used oil transportation related documentation; and
• Underground Storage Tanks (UST) leak detection performance and
maintenance including the following:
— Monitoring results over the last 12 months,
— Most recent tank tightness test(s),
— Manual tank gauging records,
— Copies of performance claims provided by leak detection
equipment manufacturers,
— Records of recent maintenance, repair and calibration of on-site
leak detection equipment,
— Records of required inspections and test of corrosion protection
systems,
— Records of repairs or upgrades of UST systems,
— Site assessment results of closed USTs,
— Results of AST integrity assessments, sampling, monitoring,
inspection and repair work,
— Notification forms and registration records for all in-service,
temporarily out-of service, and permanently closed tanks, and
— Waste determinations.
RCRA information is available to the public on the web at www. epa.gov/osw. The
Office of Solid Waste (OSW) has also compiled a list of phone numbers and waste program web
sites maintained by EPA Regional offices and state environmental agencies to help users locate
site-specific information on RCRA facilities within their states. This compilation is found at
www.epa.gov/epaoswer/osw/comments.htm. This site also provides links to the RCRA OnLine
database (www.epa.gov/rcraonline), to a searchable database of Frequently Asked Questions
(FAQs) about RCRA, and to an on-line order form for RCRA publications
(www.epa.gov/epaoswer/osw/publicat.htm). More information on RCRA Subtitle C can be found
at www.epa.gov/epaoswer/osw/hazwaste.htm. State specific information related to RCRA can be
found at www.herc.org.
See Section VI.C of this document for information pertaining to pending
regulations under RCRA.
Universal Waste Rule
EPA created the Universal Waste Rule to encourage and streamline recycling
efforts. It allows facilities to count wastes as universal instead of hazardous, which does not
count toward generator status. Segregating universal wastes from the rest of the hazardous waste
streams can save hospitals money on disposal costs, as well as on recordkeeping. Federal
universal wastes include hazardous waste batteries, mercury-containing thermostats, certain
pesticides, and fluorescent light bulbs. Facilities should make sure that their state or territory has
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adopted these universal wastes. Some states may have additional types of waste such as
electronics on their list of universal wastes. Section III.B.3 also discusses this rule.
Medical Waste Tracking Act
In 1988, Congress enacted the Medical Waste Tracking Act under RCRA Subtitle
J, which directed EPA to begin a two-year demonstration program for medical waste tracking.
The demonstration program operated from June 1989 to June 1991. The program is expired and
no federal tracking requirements are in place; however, many states have developed similar
tracking and management programs.
Emergency Planning And Community Right-To-Know Act
This act, also known as Superfund Amendments and Reauthorization Act (SARA)
Title III, was designed to promote emergency planning and preparedness at both the state and
local level. It provides citizens, local governments, and local response authorities with
information regarding the potential hazards in their community. EPCRA requires the use of
emergency planning and designates state and local governments as recipients of information
regarding certain chemicals used in the community. SARA Title III, better known as EPCRA,
originated from the Comprehensive Environmental Response, Compensation, and Liability Act
(CERCLA, or better known as the Superfund law). Like EPCRA Section 304, CERCLA also
has hazardous substance release reporting regulations under CERCLA Section 103; 40 CFR Part
302. Under CERCLA, the person in charge of a facility is required to report to the National
Response Center ((800) 424-8802 or www.nrc.uscg.mil) "immediately upon knowledge of a
reportable release" any environmental release of a listed hazardous substance that equals or
exceeds a reportable quantity.
EPCRA establishes the following types of reporting obligations for facilities that
store or manage specified chemicals:
Emergency Planning (Sections 302 and 303)
Any healthcare facility that has any chemical listed on the extremely hazardous
substances list at or above its planning threshold quantity must perform the following:
• Notify the State Emergency Response Commission (SERC) and Local
Emergency Planning Committee (LEPC) within 60 days of receiving the
shipment (or producing the substance) on site;
• Provide the LEPC with a facility representative who will participate in the
emergency planning process; and
• Provide requested information for the LEPC necessary for development
and implementation of the emergency plan.
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Emergency Release Notification (Section 304)
If there is a reportable release into the environment of a hazardous substance,
healthcare facilities must provide an emergency notification and a written follow-up notice to the
LEPC and SERC (for any area likely affected). A release is reportable under EPCRA Section
304 if the amount of hazardous substance releases meets or exceeds the minimum reportable
quantity set in the regulations. Two types of chemicals fall under this regulation: 1) extremely
hazardous substances; and 2) CERCLA hazardous substances.
Annual Inventory (Sections 311 and 312)
Under EPCRA Section 311 requirements, healthcare facilities must submit copies
of hazardous chemical material safety data sheets (MSDS) or a list of MSDS chemicals to the
LEPC, SERC, and local fire department. Under Occupational Safety and Health Administration
(OSHA) regulations, employers must maintain a MSDS for any hazardous chemical stored or
used in the work place.
Under EPCRA Section 312, healthcare facilities that meet Section 311
requirements for a hazardous chemical must submit an annual inventory report for that chemical.
The inventory report (called a Tier II report) must be submitted to the LEPC, SERC, and local
fire department by March 1 of each year.
Certain chemicals are exempt from the EPCRA Section 311 and 312 definition of
a hazardous chemical. One exemption that applies to the healthcare industry is the exemption of
medical and research lab materials (i.e., any substance, to the extent it is used in a research
laboratory or a hospital or other medical facility under the direct supervision of a technically
qualified individual). A technically qualified individual meets the following definition:
• Capable of understanding the health and environmental risks associated
with the chemical substance that is used under his or her supervision
because of education, training, or experience, or a combination of these
factors;
• Responsible for enforcing appropriate methods of conducting scientific
experimentation, analysis, or chemical research to minimize such risks;
and
• Responsible for the safety assessments and clearances related to the
procurement, storage, use, and disposal of the chemical substance as may
be appropriate or required within the scope of conducting a research and
development activity.
In addition, EPCRA requirements do not apply to the transportation, including
storage, of any substance, with the exception of Section 304 reporting. Therefore, materials
being distributed or stored incident to transportation (i.e., under active shipping papers) would
not be included in a facility threshold determination under Sections 311 and 312.
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EPCRA Section 313 (Toxic Release Inventory. TRD
The healthcare industry primarily falls under SIC codes 0741 and 0742
(veterinary services), 4119 (land ambulances), 4522 (air ambulances), 80 (hospitals and doctors'
offices/clinics), 83 (social services), and 8734 (veterinary testing laboratories). These SIC codes
are not required to report to TRI (i.e., submit annual reports of toxic chemical releases) under
EPCRA Section 313. Federal facilities however, are subject to EPCRA Section 313. These
include federal hospitals such as veterans hospitals, military hospitals, or clinics in federal
prisons.
Healthcare facilities that are defined as auxiliary facilities (i.e., supports another
establishments's activities) can assume the SIC code of the covered establishment that it
supports. For the purposes of TRI, auxiliary facilities are defined as one primarily engaged in
performing support services for another establishment(s) of a facility (in a covered SIC code)
and is in a different physical location than the primary facility. If the healthcare facility meets
this definition, the facility meets the SIC code criterion.
Typical Records an EPA Inspector May Ask to Review under the EPCRA
• Proof of notification for all environmental releases of a listed hazardous
substance. "Failure to notify" violation will be sited if the National
Response Center, State Hotline, and LEPC is not notified in a timely
fashion.
• Emergency Response Plans.
MSDS.
• Tier I or Tier II inventory reporting forms. This inspection is done
together with the MSDS. The inspector will look at what materials are
stored and in what quantity and if they are subject to reporting
requirements. The federal government prefers the more detailed Tier II
inventory form.
• EPA Toxic Release Inventory Form R for federal healthcare facilities
report on every chemical manufactured, processed, or used. Form R
contains facility identification information and chemical specific
information (toxic chemical identity; mixture component; activity and
uses; maximum amount of chemical on site during calendar year; quantity;
transfers; discharges; on-site waste treatment; on-site energy recovery; on-
site recycling; source reduction/recycling).
Visit these web sites for more information: http://yosemite. epa.gov/oswer/
ceppoweb.nsf/content/EPCRA.htm andhttp://www.epa.gov/ceppo/pubs/hotline/hazchem.html.
Visit the TRI web site (http://www. epa. gov/tri/) for more details. "List of Lists" is a
consolidated list of chemicals subject to EPCRA and CAA Section 112(r) used to help facilities
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handling chemicals determine whether they need to submit reports under Sections 302, 304, 311,
312, or 313 ofEPCRA and, for a specific chemical, what reports may need to be submitted. It
will also help facilities determine whether they will be subject to accident prevention regulations
under CAA Section 112(r) and lists "unlisted hazardous wastes" under RCRA. It is available at
http://www.epa.gov/ceppo/pubs/title3.pdf
Clean Air Act
The CAA and its amendments are designed to "protect and enhance the nation's
air resources so as to promote the public health and welfare and the productive capacity of the
population." The CAA consists of six sections, known as Titles, which direct EPA to establish
national standards for ambient air quality and for EPA, states, and tribes to implement, maintain,
and enforce these standards through a variety of mechanisms. Under the CAA, many facilities
are required to obtain operating permits that consolidate their air emission requirements. State,
tribal, and local governments oversee, manage, and enforce many of the requirements of the
CAA. CAA regulations appear at 40 CFR Parts 50-99.
As discussed in Section III.B.4 of this document, healthcare air emissions come
from air conditioning and refrigeration, boilers, medical waste incinerators (if on site), asbestos,
paint booths, ethylene oxide sterilization units, emergency generators, anesthesia, laboratory
chemicals, and laboratory fume hoods.
Pursuant to Title I of the CAA, EPA has established national ambient air quality
standards (NAAQSs) to limit levels of "criteria pollutants," including carbon monoxide, lead,
nitrogen dioxide, particulate matter, ozone, and sulfur dioxide. Geographic areas that meet
NAAQSs for a given pollutant are designated as attainment areas; those that do not meet
NAAQSs are designated as nonattainment areas. Under Section 110 and other provisions of the
CAA, each state must develop a State Implementation Plan (SIP) to identify sources of air
pollution and to determine what reductions are required to meet federal air quality standards.
Tribes may, but are not required, to develop Tribal Implementation Plans (TIP), which play the
same role as SIPs, but apply within Indian country. Revised NAAQS for particulates and ozone
became effective in 2004.
Title I also authorizes EPA to establish New Source Performance Standards
(NSPS), which are nationally uniform emission standards for new and modified stationary
sources falling within particular industrial categories. NSPSs are based on the pollution control
technology available to that category of industrial source (see 40 CFR Part 60).
New Source Performance Standards
NSPS at 40 CFR 60 include process-specific operational standards. Individual
states may impose stricter requirements. The following NSPS are particularly relevant to the
healthcare industry:
• Boilers - Most hospital boilers are subject to the NSPS regulations. The
applicable regulations can be found at 40 CFR Part 60, Subparts Db and
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DC. Subpart Db applies to the larger boilers (greater than 100 million
BTU/hr) that were constructed after June 19, 1984. Subpart DC applies to
the smaller boilers (between 10 and 100 million BTU/hr) that were built
after June 8, 1989. Depending on the type of fuel combusted, the
regulations have emission standards for sulfur dioxide, nitrogen oxides,
and particulate matter. The NSPS also have requirements for monitoring
and recordkeeping. http://www. epa.gov/ttn/atw/boiler/boilerpg.html.
• Medical Waste Incinerators - Under the CAA, EPA regulates air
emissions from hospital and/or medical/infectious wastes incinerators
(HMIWI). The applicable regulations can be found at 40 CFR Part 60,
Subparts EC and Ce. Subpart EC applies to HMIWI that were constructed
after June 20, 1996. Subpart Ce applies to HMIWI that were constructed
before June 20, 1996. When burned, medical waste may emit air
pollutants, including hydrochloric acid (Hal), dioxins and furans, and
metals, such as lead (Pb), cadmium (Cd), and mercury (Hg). Therefore,
EPA has developed emission standards that apply to incinerators used by
hospitals and healthcare facilities as well as those used by commercial
waste treatment and disposal companies to treat medical waste. The
emission guidelines are intended to meet the requirements of the CAA,
and states must establish standards that are at least as protective. These
standards will result in reductions in the air emissions of concern from
HMIWI. For additional information visit:
http://www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html.
Hazardous Air Pollutants
Under Title I, EPA establishes and enforces National Emission Standards for
Hazardous Air Pollutants (NESHAPs), nationally uniform standards oriented toward controlling
specific hazardous air pollutants (HAPs). Section 112(c) of the CAA further directs EPA to
develop a list of source categories that emit any of 188 HAPs, and to develop regulations for
these categories of sources. To date, EPA has listed 185 source categories and developed a
schedule for establishing emission standards. The emission standards are being developed for
both new and existing sources based on "maximum achievable control technology" (MACT).
The MACT is defined as the control technology achieving the maximum degree of reduction in
the emission of the HAPs, taking into account cost and other factors. Air toxics regulations
apply to several operations at healthcare facilities. The NESHAPs that apply to the industry are:
• Asbestos (40 CFR 61 Subpart M) - A hospital that performs demolition
and renovation operations will be subject to the CAA NESHAP for
asbestos. Asbestos must be removed prior to demolition or renovation and
proper precautions must be made such as wetting down the material to
keep in intact. No asbestos is to be stripped, removed, or otherwise
handled or disturbed unless at least one authorized representative trained
in NESHAP asbestos regulations is present. A written notice of intention
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to demolish or renovate must be submitted to EPA at least 10 working
days prior to the start of construction.
• Industrial, Commercial and Institutional Boilers and Process Heaters
(40 CFR 63 Subpart DDDDD) - This NESHAP may apply at hospitals that
are major hazardous air pollutant emitters under the CAA. A major
emitter is defined as emitting 10 tons/year of a single HAP or 25 tons/year
of combined HAPS. For additional information visit:
www.epa.gov/ttn/atw/boiler/boilerpg/html.
Chemical Accident Prevention Provisions
The CAA sets forth a list of regulated substances and thresholds, a petition
process for adding or deleting substances to the list of regulated substances, requirements for
owners or operators of stationary sources concerning the prevention of accidental releases, and
state accidental release prevention programs.
Title V Permits
Title V of the CAA requires that all "major sources" (and certain minor sources)
obtain an operating permit. Healthcare facilities that qualify as a major source are required to
have a Title V permit, and may be required to submit information about emissions, control
devices, and the general process at the facility in the permit application. Permits may limit
pollutant emissions and impose monitoring, recordkeeping, and reporting requirements.
Monitoring requirements for many facilities with Title V permits are specified in
the Compliance Assurance Monitoring (CAM) regulations. For facilities that meet emissions
requirements on their permits by using pollution control equipment, CAM may require that the
facilities monitor the control equipment to assure that it is operated and maintained as prescribed
in their permits.
Refrigerant Recycling Rule
The purpose of Section 608 of the CAA is to maximize the recovery and
recycling of refrigerants during the servicing and disposal of stationary air conditioning and
refrigeration equipment. Requirements include prohibition of venting, service requirements,
equipment certification, leak repair, proper disposal, and recordkeeping. More information can
be found at http://www.epa.gov/region02/cfc/.
EPA's Clean Air Technology Center, at (919) 541-0800 (in Spanish: (919) 541-
1800) or http://www. epa.gov/ttn/catc, provides general assistance and information on CAA
standards (e-mail: catcmail(a),epamail.epa.gov). The Stratospheric Ozone Information Hotline,
at (800) 296-1996, or the Ozone Depletion web site (www. epa.gov/ozone). provides general
information about regulations promulgated under Title VI of the CAA. RCRA information
pertaining to questions about accidental release prevention under CAA Sectionll2(r), is
available in the RCRA OnLine database (www.epa.gov/rcraonline). a searchable database of
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Frequently Asked Questions (FAQs) about RCRA, and through an on-line order form for RCRA
publications (www.epa.gov/epaoswer/osw/publicat.htm). Information on air toxics can be
accessed through the Unified Air Toxics web site at http://www. epa.gov/ttn/atw/. In addition, the
Clean Air Technology Center's web site includes recent CAA rules, EPA guidance documents,
and updates of EPA activities. Visit the Office of Air and Radiation (OAR) homepage for more
information: (http://www.epa.gov/air/).
See Section VI.C of this document for information pertaining to pending
regulations under CAA.
Toxic Substances Control Act
The Toxic Substances Control Act (TSCA) granted EPA authority to create a
regulatory framework to collect data on chemicals in order to evaluate, assess, mitigate, and
control risks that may be posed by their manufacture, processing, and use. TSCA provides a
variety of control methods to prevent chemicals from posing unreasonable risk. It is important to
note that pesticides as defined in the Federal Insecticide, Fungicide, and Rodenticide Act
(FIFRA) are not included in the definition of a "chemical substance" when manufactured,
processed, or distributed in commerce for use as a pesticide. Healthcare facilities may be subject
to TSCA through:
• Lead hazard reduction regulations;
• Hexavalent chromium regulations under 40 CFR 749.68, replace
hexavalent chromium compounds with phosphate based chemicals for
water treatment in industrial cooling towers;
• Polychlorinated Biphenyls (PCB) hazard reduction regulations; and
• Asbestos hazard reduction regulations.
TSCA Regulations for Lead
• National Lead Laboratory Accreditation Program (TSCA Section
405(b)) establishes protocols, criteria, and minimum performance
standards for laboratory analysis of lead in paint, dust, and soil.
• Hazard Standards for Lead in Paint, Dust, and Soil (TSCA Section
403) establishes standards for lead-based paint hazards and lead dust
cleanup levels in most pre-1978 housing and child-occupied facilities.
• Training & Certification Program for Lead-Based Paint Activities
(TSCA Section 402/404) ensures that individuals conducting lead-based
paint abatement, risk assessment, or inspection are properly trained and
certified, that training programs are accredited, and that these activities are
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conducted according to reliable, effective, and safe work practice
standards.
• Pre-Renovation Education Rule (TSCA Section 406(b)) ensures that
owners and occupants of most pre-1978 housing are provided information
concerning potential hazards of lead-based paint exposure before
beginning certain renovations on that housing.
• Lead-Based Paint Disclosure Rule (TSCA Section 1018) requires
disclosure of known lead-based paint and/or lead-based paint hazards by
persons selling or leasing housing constructed before the phase-out of
residential lead-based paint use in 1978.
TSCA Regulations for PCBs
The PCB regulations and requirements apply to both PCB waste materials and
PCBs still in use. Because of potential harmful effects on human health and the environment,
federal law banned U.S. production of PCBs as of July 2, 1979. However, PCB-containing
materials may be present at facilities and PCB-laden wastes may be generated during
renovations.
Items with a PCB concentration of 50 ppm or greater are regulated for disposal
under 40 CFR Part 761. Some potential sources of PCBs include:
• Mineral-oil filled electrical equipment such as motors or pumps
manufactured prior to July 2, 1979;
• Capacitors or transformers manufactured prior to July 2, 1979;
• Plastics, molded rubber parts, applied dried paints, coatings or sealants,
caulking, adhesives, paper, Galbestos, sound-deadening materials,
insulation, or felt or fabric products such as gaskets manufactured prior to
July 2, 1979;
• Fluorescent light ballasts manufactured prior to July 2, 1979;
• Waste or debris from the demolition of buildings and equipment
manufactured, serviced, or coated with PCBs; and
• Waste containing PCBs from spills, such as floors or walls contaminated
by a leaking transformer.
The general requirements for handling PCB materials and equipment include:
identifying and labeling the material, notifying EPA, properly storing the material, and properly
disposing of the material.
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TSCA Regulations for Asbestos
EPA and the OSHA have promulgated rules regulating asbestos production, use,
and disposal. OSHA regulates private sector and some public sector employees' exposure to
asbestos and specifies work practices and engineering controls for removing and handling
asbestos. Along with EPA and OSHA, some states also have established asbestos requirements
that extend the federal requirements. Asbestos programs implemented under TSCA include the
following:
• Asbestos Hazard Emergency Response Act (AHERA), which regulates
asbestos contained in schools and all public and commercial buildings
including hospitals; requires the development of management plans;
specifies work practices and engineering controls for removing and
handling asbestos; and sets emissions limitations in schools after an
abatement activity is completed. EPA Region 6 provides a list of
suspected asbestos-containing materials at:
http://www.epa. gov/Region06/6pd/asbestos/asbmatl. htm.
Typical Physical Features to Inspect for Lead-based Paint PCBs. and Asbestos
under TSCA
• PCB storage areas;
• Equipment, fluids, and other items used or stored at the facility containing
PCBs. PCBs are most likely to be found in electrical equipment such as
transformers, capacitors, and possibly fluorescent light ballasts (in older
fixtures);
• Pipe, spray-on, duct, and troweled cementitious insulation and boiler
lagging; and
• Ceiling and floor tiles.
EPA 's TSCA Assistance Information Service, at (202) 554-1404 (e-mail: tsca-
hotline(q),epa. gov). answers questions and distributes guidance pertaining to TSCA standards.
The Service operates from 8:30 a.m. through 5:00 p.m., EST, excluding federal holidays. For
more information on TSCA programs for lead, visit the web site
www. epa.gov/lead/regulation.htm. EPA 's PCB Homepage includes links to the regulatory text
(40 CFR Part 761) as well as lists of approved PCB waste handlers: http://www.epa.gov/pcb/.
EPA operates the Asbestos Ombudsman Clearinghouse/Hotline ((800) 368-5888, or (202) 260-
0490) to provide general asbestos information. Also visit the EPA Asbestos Management &
Regulatory Requirements web site (http://www. epa.gov/asbestos/help.html) for additional
material.
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Federal Insecticide, Fungicide and Rodenticide Act
FIFRA was first passed in 1947 and amended numerous times, most recently by
the Food Quality Protection Act (FQPA) of 1996. FIFRA provides EPA with the authority to
oversee, among other things, the registration, distribution, sale and use of pesticides. The Act
applies to all types of pesticides, including insecticides, herbicides, fungicides, rodenticides and
antimicrobials. FIFRA covers both intrastate and interstate commerce.
Product Registration
Under Section 3 of FIFRA, all pesticides (with few exceptions) sold or distributed
in the United States must be registered by EPA. Pesticide registration is very specific and
generally allows use of the product only as specified on the label. Each registration specifies the
use site (i.e., where the product may be used) and the amount that may be applied. The person
who seeks to register the pesticide must file an application for registration. The application
process often requires either the citation or submission of extensive environmental, health, and
safety data.
Use Restrictions
As a part of the pesticide registration, EPA classifies the product as unclassified,
general use, or restricted use (40 CFR Section 152.160(a)). The Administrator may prescribe
restrictions relating to the product's composition, labeling, or packaging. For pesticides that
may cause unreasonable adverse effects on the environment, including injury to the applicator,
EPA may require that the pesticide be applied either by, or under the direct supervision of, a
certified applicator.
Good Laboratory Practices
EPA prescribes good laboratory practices under 40 CFR Part 160 for conducting
studies that support research or marketing permits for pesticide products regulated by EPA.
These practices are intended to assure the quality and integrity of the submitted research data.
Typical Physical Features to Inspect for under FIFRA
• Personnel protection equipment;
• Pesticide application equipment;
• Pesticide storage areas, including storage containers; and
• Cleaning disinfectants and labels.
Typical Records a EPA Inspector May Ask to Review under the FIFRA
• Records of pesticides purchased (purchase orders, inventory);
• Pesticide application records;
• Description of the pest control program;
• Certification status of pesticide applicators;
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• Pesticide disposal manifests;
• Contract files; and
• Recent ventilation rating for pesticide fume hood and pesticide
mixing/storage areas.
Antimicrobials
In healthcare settings, EPA regulates disinfectants that are used on environmental
surfaces (housekeeping and clinical contact surfaces). Disinfectants intended for use on clinical
contact surfaces (e.g., light handles, radiograph!c-ray heads, or drawer knobs) or housekeeping
surfaces (e.g., floors, walls, or sinks) are regulated by EPA, under the authority of FIFRA. Under
FIFRA, any substance or mixture of substances intended to prevent, destroy, repel, or mitigate
any pest, including microorganisms but excluding those in or on living man or animals, must be
registered before sale or distribution. To obtain a registration, a manufacturer must submit
specific data regarding the safety and the effectiveness of each product.
FIFRA requires users of products to follow the labeling directions on each
product explicitly. The following statement appears on all EPA-registered product labels under
the Directions for Use heading: "It is a violation of federal law to use this product
inconsistent with its labeling." This means that users, including the healthcare industry, must
follow the safety precautions and use directions on the labeling of each registered product. Not
following the specified dilution, contact time, method of application, or any other condition of
use is considered misuse of the product.
The Centers for Disease Control (CDC) recommends disinfecting environmental
surfaces or sterilizing or disinfecting medical equipment, and medical facilities should use
products approved by EPA unless no such products are available for use against certain
microorganisms or sites. However, if no registered or approved products are available for a
specific pathogen or use situation, medical facilities are advised to follow the specific guidance
regarding unregistered or unapproved (e.g., off-label) uses for various chemical germicides. For
example, no antimicrobial products are registered for use specifically against certain emerging
pathogens (e.g., Norwalk virus), potential terrorism agents (e.g., variola major or Yersinia
pestis), or Creutzfeldt-Jakob disease agents.
Microorganisms vary in their resistance to disinfection and sterilization, enabling
CDC's designation of disinfectants as high-, intermediate-, and low-level, when compared with
EPA's designated organism spectrum. However, exceptions to this general guide exist, and
manufacturers' label claims and instructions should always be followed.
For more information on the use of hospital disinfectants, refer to: MMWR
Recommendation and Report on Dental Infection Control Guidelines, (http://www.cdc.gov/
mmwr/preview/mmwrhtml/rr5217al.htm} and Guidelines for Environmental Infection Control in
Health-Care Facilities, (http://www. cdc.gov/mmwr/preview/mmwrhtml/rr5210al.htm}.
Additional information on FIFRA and the regulation of pesticides can be
obtained from a variety of sources, including EPA 's Pesticide Program at
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Federal Statutes and Regulations
http://www.epa.gov/pesticides, EPA 's Office of Compliance, Pesticide Compliance Assistance at
http://www. epa.gov/compliance/assistance/pesticides/index.html. EPA 's Office of Compliance
Agriculture and Ecosystem Division at http://www.epa.gov/compliance/assistance/
sectors/agriculture, html, or The National Agriculture Compliance Assistance Center, (888) 663-
2155 or http://www. epa.gov/agriculture/ (e-mail: agcenter(q),epa.gov). Other sources include the
National Pesticide Information Center, (800) 858-7378 or http://npic. orst. edu/, and EPA 's
Antimicrobial hotline , (703) 308-0127, operating weekdays from 9:00 a.m. to 4:00 p.m., EST,
excluding federal holidays (e-mail: info antimicrobial(a),epa. gov) or web site,
http://www. epa.gov/oppad001/.
VLB. Regulations by Waste Category
Table VI-2 lists the applicable regulations for each waste category.
Table VI-2: EPA Regulations by Waste Category
Waste
Category
Municipal Solid
Waste
Biohazardous
Waste, Regulated
Medical Waste
(RMW)
Hazardous Waste
Pressurized
Containers
Universal Wastes
Construction and
Demolition Debris
Wastewater
Stormwater
Specific Wastes Found in this Category1
Cardboard, paper, boxboard, magazines,
newspaper, metals (steel and aluminum), glass,
plastics, food waste, leaf and yard waste, mixed
materials, mattresses, furniture, pallets, carpet,
packaging materials
Sharps waste, blood and blood products,
pathological waste, selected isolation wastes,
cultures and stocks from laboratories, non-regulated
chemotherapy waste, blood-soaked bandages, etc.
Solvents, selected Pharmaceuticals, ethylene oxide
(EtO), mercury -containing equipment or
compounds, lead-containing equipment, hazardous
chemicals
Gas cylinders, gas cartridges, aerosol cans, oxygen
farms
Mercury -containing thermostats, and spent
fluorescent lamps and other hazardous lamps.
Hazardous waste batteries, hazardous waste
pesticides - recalled or sent to collection program
Asbestos, mercury, lead, C&D debris
Potentially, any hazardous substance in any clinical
area, oils, hydraulic fluid, chemical spills
Contaminated runoff from building, lawns, parking
areas, underground storage tank areas, aboveground
storage tank areas, and disturbed soils from
construction sites
Applicable Statute
RCRA, EPCRA, FIFRA
RCRA, CAA
RCRA
RCRA
RCRA
RCRA, CWA, CAA, TSCA
CWA
CWA, FIFRA
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Table VI-2: EPA Regulations by Waste Category (Continued)
Waste
Category
Air Emissions
Specific Wastes Found in this Category1
Air conditioning and refrigeration, boilers, medical
waste incinerators, asbestos, paint booths,
sterilization using ethylene oxide, emergency
generators, anesthesia
Applicable Statute
CAA, EPCRA
See Section III for more examples.
VI.C. Pending and Proposed Regulatory Requirements
The following pending and proposed regulations affect the healthcare industry:
Clean Water Act
EPA is working with dental offices to begin collecting dental amalgam before it
enters the waste stream. As part of its pretreatment standards review process, EPA is reviewing
industrial sources of mercury, including dental facilities, for potential technology-based options
for controlling mercury discharges to wastewater treatment plants. In addition, the Agency is
working with wastewater treatment plants to begin implementing best management practices for
collecting mercury from other industrial sources, as well as modifying surface water discharge
permits to reflect stricter requirements in mercury discharges. See EPA's Effluent Guidelines
Program web site (http://www.epa.gov/guide/) for more information.
Clean Air Act
Ethvlene Oxide (EtQ}
Some hospitals use ethylene oxide as a sterilant for certain types of healthcare
supplies and devices, primarily due to manufacturers' recommended practice to ensure the
sterility of a product. Hospital sterilizers are one of 55 area source categories may be subject to
Area Source Category NESHAP regulations. Go to:
http://www.epa.gov/ttn/atw/urban/arearules.html for more information.
Resource Conservation and Recovery Act
Universal Waste Regulations
In June 2002, EPA proposed to add mercury-containing equipment to the
universal waste list. The Universal Waste Rule allows facilities to streamline the waste
management of certain widely generated hazardous wastes. The waste management
requirements of universal wastes are less strict than those for other RCRA listed hazardous
wastes. Visit the web site www.epa.gov/epaoswer/hazwaste/id/univwast/regs.htm for more
information.
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VI.D. Additional Applicable Regulations (Non-EPA Administered)
The following non-EPA administered environmental or wastes related regulations
affect the healthcare industry:
Mercury Ordinances/Resolutions
Many states have passed ordinance and resolutions banning the manufacture or
sale of mercury-containing items, such as thermometers, thermostats, and switches containing
mercury.
"One Plan "/Integrated Contingency Plan
The "One Plan" (EPA HQ), also known as Integrated Contingency Plan (ICP),
allows a facility to comply with multiple federal planning requirements by consolidating them
into one functional emergency response plan. A number of statutes and regulations,
administered by several federal agencies, include requirements for emergency response planning.
A particular facility may be subject to one or more of the following federal regulations:
• EPA's Oil Pollution Prevention Regulation (SPCC and Facility Response
Plan Requirements) - 40 CFR Part 112.7(d) and 112.20-.21;
MMS's Facility Response Plan Regulation - 30 CFR Part 254;
RSPAs Pipeline Response Plan Regulation - 49 CFR Part 194;
USCG's Facility Response Plan Regulation - 33 CFR Part 154, Subpart F;
• EPA's Risk Management Programs Regulation - 40 CFR Part 68;
OSHA's Emergency Action Plan Regulation - 29 CFR 1910.38(a);
OSHAs Process Safety Standard - 29 CFR 1910.119;
OSHA's HAZWOPER Regulation - 29 CFR 1910.120; and
• EPA's RCRA Contingency Planning Requirements - 40 CFR Part 264,
Subpart D, 40 CFR Part 265, Subpart D, and 40 CFR 279.52.
In addition, facilities may also be subject to state emergency response planning
requirements that this guidance does not specifically address. Facilities are encouraged to
coordinate development of their ICP with relevant state and local agencies to ensure compliance
with any additional regulatory requirements.
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Visit the National Response Team's Integrated Contingency Plan Guidance (One
Plan) web site for more information:
http://yosemite. epa.gov/oswer/ceppoweb. nsf/content/sta-loc. htm
Federal Hazardous Materials Transportation Law (HAZMAT)
The Department of Transportation (DOT), along with other agencies, regulates
the transportation of hazardous materials (including certain medical wastes) under 49 CFR Parts
171-180. The regulations cover five areas: (1) hazardous materials definition/classification; (2)
hazard communication; (3) packaging requirements; (4) operational rules; and (5) training.
Biohazardous wastes are classified as a Class 6 DOT hazard.
The Hazardous Materials Information Center can be contacted at (800) HMR-
4922 ((800) 467-4922) or (202) 366-4488, Monday through Friday from 9:00 am to 5:00pm
EST. Visit the HAZMAT web site at http://hazmat. dot, gov/hazhome. htm for additional material.
Nuclear Regulatory Commission (NRC)
The NRC, under authority of the Atomic Energy Act, regulates the use of nuclear
by-product material in the fields of nuclear medicine, radiation therapy, and research. The
nuclear by-product material is regulated by either the NRC or the state (currently 33 states have
agreements with NRC to regulate the by-product material). The NRC issues licenses to
authorized users and provides regulations and guidance for the use of nuclear by-product
material. Note that radium, a radioactive material that has historically been used in
brachytherapy and may be present in healthcare facilities, is not regulated by NRC. It is only
regulated by states (although legislation is pending that would bring it under NRC authority).
Visit the NRC web site (http://www. nrc. gov) for more information.
Occupational Safety and Health Administration (OSHA)
OSHA provides regulatory standards to protect workers from injury. OSHA
requirements that apply to healthcare facilities include the Bloodborne Pathogens Standard
(1910.1030), Hazardous Waste Operations and Emergency Response (HAZWOPER) Standard
(1910.120), and Asbestos Standards (1910.1001) for any renovation work.
Visit the OSHA web site (http://www.osha.gov/) for more information. OSHA
also has a Hospital eTool (http://www.osha.gov/SLTC/etools/hospital/mainpage.html) that
addresses the following areas: administration, central supply, clinical services, dietary,
emergency, engineering, heliport, housekeeping, ICU, laboratories, laundry, pharmacy, surgical
suite, healthcare wide hazards, and other healthcare wide hazards.
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U.S. Postal Service (USPS)
The Domestic Mail Manual, C023, as well as D.O.T. have certain requirements
and restrictions for mailing or shipping hazardous pharmaceuticals to patients (i.e. consumer
commodities that are hazardous). USPS also has regulations pertaining to mailing sharps,
biological specimens, and other healthcare related materials.
Visit the USPS web site and reference the Domestic Mail Manual at
(http://pe. usps.gov/) for more information.
National Institutes of Health, Centers for Disease Control (CDC)
The CDC publishes guidelines and recommendations for the healthcare industry
on many areas including infection control, sterilization, hand hygiene, and immunizations.
Visit the CDC web site (www.cdc.gov) for more information. The CDC web site
also has access to the National Institution of Safety and Health (NIOSH) publication, Preventing
Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Settings
(http://www.cdc.gov/niosh/docs/2004-165/)
U.S. Department of Health and Human Services (HHS)
The HHS provides information on laws and regulations pertaining to healthcare
from a variety of organizations including the Food and Drug Administration, Centers for
Medicare and Medicaid Services, Health Resources and Services Administration, Substance
Abuse and Mental Health Services Administration, and Indian Health Services.
Visit the HHS web site (www.hhs.gov) for more information.
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Healthcare Industry Compliance and Enforcement History
VII. COMPLIANCE AND ENFORCEMENT HISTORY
VILA. Background
Until recently, EPA focused much of its attention on ensuring compliance with
specific environmental statutes. This approach allows the Agency to track compliance with the
Clean Air Act, the Resource Conservation and Recovery Act, the Clean Water Act, and other
environmental statutes. Within the last several years, the Agency has begun to supplement
single-media compliance indicators with facility-specific, multimedia indicators of compliance.
In doing so, EPA is in a better position to track compliance with all statutes at the facility level,
and within specific industrial sectors.
A major step in building the capacity to compile multimedia data for industrial
sectors was the creation of EPA's Integrated Data for Enforcement Analysis (IDEA) system.
IDEA has the capacity to "read into" the Agency's single-medium databases, extract compliance
records, and match the records to individual facilities. IDEA uses the Facility Registry System
(FRS) maintained Master Source ID identification number to "glue together" separate data
records from EPA's databases. This is done to create a "master list" of data records for any
given facility. Some of the data systems accessible through IDEA are: AIRS (Air Facility
Indexing and Retrieval System, Office of Air and Radiation), PCS (Permit Compliance System,
Office of Water), RCRAInfo (Resource Conservation and Recovery Information System, Office
of Solid Waste), NCDB (National Compliance Data Base, Office of Prevention, Pesticides, and
Toxic Substances), CERCLIS (Comprehensive Environmental and Liability Information System,
Superfund), and TRIS (Toxic Release Inventory System). IDEA also contains information from
outside sources such as Dun and Bradstreet and OSHA.
The IDEA system can match Air, Water, Waste, Toxics/Pesticides/EPCRA, TRI,
and Enforcement Docket records for a given facility, and generate a list of historical permit,
inspection, and enforcement activity. IDEA also has the capability to analyze data by
geographic area and corporate holder. As the capacity to generate multimedia compliance data
improves, EPA will make available more in-depth compliance and enforcement information.
Additionally, sector-specific measures of success for compliance assistance efforts are under
development.
EPA has also developed Enforcement and Compliance History Online (ECHO).
This database was developed in partnership with the Environmental Council of the States
(ECOS), a national association representing state and territorial environmental commissioners.
ECHO provides users detailed facility reports, which include:
• Federal and state compliance inspections;
• Environmental violations;
• Recent formal enforcement actions taken; and
• Demographic profile of surrounding area.
The data in ECHO covers a two-year period of information and includes information drawn from
the following EPA databases:
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Healthcare Industry Compliance and Enforcement History
AIRS;
PCS;
RCRAInfo;
• Integrated Compliance Information System (ICIS);
• Facility Registry System (FRS); and
• U.S. Census Data.
The ECHO database can be found at http://www.epa.gov/echo/mdex.html.
VILB. Compliance and Enforcement Description
This section discusses how EPA collects data on the historical compliance and
enforcement activity of each sector. The Agency compiles compliance and enforcement records
from its data systems to the facility level using the Facility Registry System's (FRS) Master
Source ID, which links records from virtually any of EPA's data systems to a facility record. For
each facility (i.e., Master Source ID), EPA uses the facility-level SIC code that is designated by
IDEA, as follows:
1. If the facility reports to TRI, then the designated SIC code is the primary
SIC reported in the most recent TRI reporting year.
2. If the facility does not report to TRI, the first SIC codes from all linked
AFS, PCS, RCRAInfo, BRS ID/permits are assembled. If more than one
permit/ID exists for a particular program, then only one record from that
data system is used. The SIC code that occurs most often, if there is one,
becomes the designated SIC code.
3. If the facility does not report to TRI and no SIC code occurs more often
than others, the designated SIC code is chosen from the linked programs.
If more than one permit/ID exists for a particular program, then only one
record from that data system is used.
Note that EPA does not attempt to define the actual number of facilities that fall
within each sector. Instead, the information presented in this section reflects the records of a
subset of facilities within the sector that are well defined in EPA databases.
To compare the number of reported facilities in EPA's database to the total sector
universe, most Sector Notebooks contain an estimated number of facilities within the sector
according to the Bureau of Census (See Section II). With sectors dominated by small businesses,
such as metal finishers and printers, the reporting universe in the EPA databases may be small in
comparison to Census data. However, the group selected for inclusion in this data analysis
section should be consistent with this sector's general make-up.
This subsection contains four tables that summarize enforcement and compliance
activities for the healthcare industry. Tables VII-1 and VII-2 look exclusively at the healthcare
industry for the past five years. Tables VII-3 and VII-4 provide a general overview of
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Healthcare Industry Compliance and Enforcement History
compliance and enforcement activities across each of the sectors discussed in a Sector Notebook,
for the past five years. Following this introduction is a list defining each column in the tables
presented in this section. The data in these tables solely reflect EPA, state, and local compliance
assurance activity data that have been entered into EPA databases. EPA ran data queries, for the
past five calendar years (February 19, 1998 to February 19, 2004). For up-to-date compliance
data, visit the Sector Notebook data refresh web page at: http://epa.gov/compliance/resources/
publications/assistance/sectors/notebooks/data_refresh.html.
Because most inspections focus on single-media requirements, the data presented
in this section result from queries of single-medium databases. These databases do not provide
data on whether inspections are state/local- or EPA-led. However, the table presenting the
universe of violations generally measures EPA's and states' efforts within each media program.
The presented data illustrate the variations across Regions for certain sectors10. This variation
may result from state/local data entry variations, specific geographic concentrations, proximity
to population centers, sensitive ecosystems, highly toxic chemicals used in production, or
historical noncompliance. Therefore, the data do not rank regional performance or necessarily
reflect which regions may have the most compliance problems.
VILC. Compliance and Enforcement Data Definitions
Facilities in Search (Tables VII-1, 2, 3, and 4) - the number of the FRS-
maintained Master Source IDs that were designated to the listed SIC code range.
Facilities Inspected (Tables VII-1, 2, 3, and 4) — the number of EPA and state
agency inspections for the facilities in this data search. These values show what percentage of
the facility universe is inspected in a 24- or 60-month period.
Number of Inspections (Tables VII-1, 2, 3, and 4) — the total number of
inspections conducted in this sector. An inspection is counted each time it is entered into a
single-medium database.
Average Months Between Inspections (Tables VII-1 and 3) — the average
length of time, expressed in months, between compliance inspections at a facility within the
defined universe.
Facilities with One or More Enforcement Actions (Tables VII-1 and 3) — the
number of facilities that were party to at least one enforcement action within the defined time
period. This category is broken down further into federal and state actions in subsequent
columns. EPA obtained these data for administrative, civil/judicial, and criminal enforcement
actions. Administrative actions include Notices of Violation (NOVs). A facility with multiple
10 EPA Regions include the following states: 1 (CT, MA, ME, RI, NH, VT); 2 (NJ, NY, PR, VI); 3 (DC, DE, MD,
PA, VA, WV); 4 (AL, FL, GA, KY, MS, NC, SC, TN); 5 (IL, IN, MI, MN, OH, WI); 6 (AR, LA, MM, OK, TX); 7
(IA, KS, MO, ME); 8 (CO, MT, ND, SD, UT, WY); 9 (AZ, CA, HI, NV, Pacific Trust Territories); 10 (AK, ID, OR,
WA).
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Healthcare Industry Compliance and Enforcement History
enforcement actions is counted only once in this column. All percentages that appear are
referenced to the number of facilities inspected.
Total Enforcement Actions (Tables VII-1, 2, 3, and 4) — the total number of
enforcement actions identified for an industrial sector across all environmental statutes. In this
column, a facility with multiple enforcement actions is counted multiple times (e.g., a facility
with three enforcement actions counts as three).
State-Led Actions (Tables VII-1 and 3) ~ the percentage of the total
enforcement actions taken by state and local environmental agencies. Note that this number may
not reflect the total number of state enforcement actions; some states extensively report
enforcement activities to EPA to include in its data systems, while other states may use their own
data systems.
Federal-Led Actions (Tables VII-1 and 3) — the percentage of the total
enforcement actions taken by EPA. This number includes cases that were referred to EPA from
state agencies. Many of these actions result from coordinated or joint state/federal efforts.
Enforcement-to-inspection Ratio (Tables VII-1 and 3) — shows how often
enforcement actions result from inspections; this number is presented for comparative purposes
only. This number simply indicates historically how many enforcement actions can be attributed
to inspection activity. This ratio includes and enforcement actions under the CWA (PCS), CAA
(AFS) and RCRA. Inspections and enforcement actions from the TSCA/FIFRA/EPCRA
databases are not factored into this ratio because most of the actions taken under these programs
are not the result of facility inspections. This ratio also does not account for enforcement actions
arising from noninspection compliance monitoring activities (e.g., self-reported water
discharges) under the CAA, CWA and RCRA.
Media Breakdown of Enforcement Actions and Inspections (Tables VII-2
and 4) — four columns identify the proportion of total inspections and enforcement actions
within EPA's Air, Water, Waste, and TSCA/FIFRA/EPCRA databases.
VII.D. Healthcare Industry Compliance History
Table VII-1 provides an overview of the reported compliance and enforcement
data for the healthcare industry over the past five years (February 19, 1998 to February 19,
2004). These data are broken out by EPA Region, thereby permitting geographical comparisons.
Observations from the data are listed below:
• Regions 2, 3, and 4 contain the most healthcare facilities and conducted
the most inspections;
• Region 3 conducted, by far, the most inspections of healthcare facilities
and had the lowest average time between inspections; and
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Healthcare Industry Compliance and Enforcement History
• Region 2 had both the most enforcement actions, and the most
enforcement actions per inspection.
Table VII-2 provides a more in-depth comparison between the healthcare industry
and other sectors by breaking out the compliance and enforcement data by environmental statute
for the same five-year period (February 19, 1998 to February 19, 2004). These data are also
broken out by EPA Region, thereby permitting geographical comparisons. Observations from
the data are listed below:
• The majority of inspections and actions are conducted under the CAA,
followed by RCRA; and
• Regions 7 and 8 have only conducted enforcement actions under the CAA.
EPA's Region 2 office identified the following most common healthcare facility
violations based on the inspections performed in their region, listed below.
Most Common CAA Healthcare Facility Violations
• Failure to use properly trained and accredited asbestos personnel;
• Failure to notify EPA of asbestos removal projects and to keep required
documentation/records;
• Failure to properly dispose of asbestos debris;
• Failure to have CFC leak rate records for chillers and air conditioning
units more than 50 pounds of charge;
• Failure to have EPA certified technicians for CFC-containing air
conditioning and refrigeration systems;
• Failure to get boilers permitted with the state agency;
• Failure to apply for Title V operating permit;
• Failure to close parts washer lids when not in use; and
• Failure to include spray paint booths and parts degreasers in air permit.
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Healthcare Industry
Compliance and Enforcement History
Table VII-1: 5-Year Enforcement and Compliance Summary for the Healthcare Industry (SIC 8000), By Region
Region
National
1
2
3
4
5
6
7
8
9
10
Facilities in
Search
1,798
205
277
314
321
218
111
142
53
96
59
Facilities
Inspected
1,187
126
136
256
235
120
75
105
40
55
37
Number of
Inspections
3,953
265
391
1,413
854
296
131
268
127
138
67
Average
Months
Between
Inspections
27
46
43
13
23
44
51
32
25
42
53
Facilities with
1 or More
Enforcement
Actions
195
21
66
20
24
25
9
6
1
18
5
Total
Enforcement
Actions
343
31
130
51
37
35
14
11
1
28
5
Percentage of
State Actions
96%
100%
93%
98%
95%
97%
100%
100%
100%
96%
100%
Percentage of
Federal
Actions
4%
0%
7%
2%
5%
3%
0%
0%
0%
4%
0%
Enforcement-
to-inspection
Ratio
0.09
0.12
0.33
0.04
0.04
0.12
0.11
0.04
0.01
0.2
o
oo
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September 2004
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Healthcare Industry
Compliance and Enforcement History
Table VII-2: 5-Year Enforcement and Compliance Summary for the Healthcare Industry (SIC 8000), by Region and Statute
Region
National
1
2
3
4
5
6
7
8
9
10
Faculties In
Search
1,798
205
277
314
321
218
111
142
53
96
59
Faculties
Inspected
1,187
126
136
256
235
120
75
105
40
55
37
Number of
Inspections
3,953
265
391
1,413
854
296
131
268
127
138
67
Total
Enforcement
Actions
343
31
130
51
37
35
14
11
1
28
5
Clean Air Act
% of Total
Inspections
78%
81%
71%
88%
73%
83%
45%
80%
67%
70%
43%
% of Total
Actions
82%
74%
85%
90%
60%
80%
79%
100%
100%
86%
80%
Clean Water Act
% of Total
Inspections
0%
0%
2%
0%
0%
2%
0%
0%
0%
0%
0%
% of Total
Actions
2%
0%
2%
0%
0%
6%
0%
0%
0%
0%
0%
RCRA
% of Total
Inspections
21%
19%
24%
12%
27%
15%
55%
20%
33%
29%
52%
% of Total
Actions
16%
26%
12%
10%
41%
11%
21%
0%
0%
14%
20%
FIFRA/TSCA/EPCRA
% of Total
Inspections
1%
0%
3%
0%
0%
0%
0%
0%
0%
1%
4%
% of Total
Actions
1%
0%
1%
0%
0%
3%
0%
0%
0%
0%
0%
o
VO
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February 2005
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Healthcare Industry Compliance and Enforcement History
Most Common RCRA Healthcare Facility Violations
• Failure to comply with hazardous waste generator regulations and lack of
documentation;
• Failure to comply with Underground Storage Tank regulations and lack of
documentation;
• Improper or lack of hazardous waste labeling;
• Failure to have waste batteries/fluorescent lamps stored in proper
universal waste containers and labeled;
• No or infrequent weekly inspections of hazardous wastes storage/satellite
areas;
• Open containers of hazardous wastes;
• Failure to have hazardous waste determinations on file for all wastes (i.e.,
some pharmaceutical wastes are classified as RCRA hazardous wastes);
• Failure to have procedures in place to ensure spent aerosol containers are
empty before disposal as solid waste;
• Malfunctioning leak detection systems on underground storage tanks;
• Labeling of hazardous waste not done or incorrect;
• Improper disposal of chemotherapy drugs;
• Hazardous waste determination not done or incorrect;
• No or inadequate hazardous waste manifest;
• Disposal of hazardous waste down the drain;
• Improper management of expired pharmaceutical, paints, etc.;
• Lack of contingency plan;
• Lack of or inadequate training for employees in hazardous waste
management;
• Failure to ensure that hazardous waste meets Land Disposal Restrictions;
• Failure to upgrade or close USTs by December 22, 1998; and
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Healthcare Industry Compliance and Enforcement History
• Improper consolidation of wastes from nearby facilities.
Most Common CWA Healthcare Facility Violations
• No permit for noncompliance with wastewater discharges;
• Failure to know about local treatment plant sewer use regulations and
possible prohibited discharges for indirect dischargers;
• No or inadequate secondary containment for storage tanks;
• Improper disposal down floor drains; and
• No Spill Prevention, Control and Countermeasure Plan.
Most Common EPCRA Healthcare Facility Violations
• Failure to report certain accidental chemical releases to the local
authorities along with emissions data; and
• Storage of chemicals (i.e., heating oil and gasoline) on site above
threshold amounts (hazardous chemicals above 10,000 Ibs and/or
extremely hazardous substances present at 500 Ibs or the threshold
planning quantity, whichever is lower).
Most Common FIFRA Healthcare Facility Violations
• Misuse of a registered pesticide product;
• Use of an unregistered product;
• Lack of proper records concerning pest control application within the
hospital and/or on the hospital grounds; and
• Failure to report pesticide poisonings either occurring within the hospital
or of admitted patients.
Common Violations and Problems Found at Hospitals for TSCA Issues
TSCA inspectors are primarily interested in any PCBs and lead-based paint at
hospitals. Typical staff residential area lead paint violations/issues are:
• Failure to notify residents of lead paint in building or lack of knowledge
of any lead hazard; and
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Healthcare Industry Compliance and Enforcement History
• Failure to provide EPA's pamphlet, "Protect Your Family from Lead in
Your Home" as required under 40 CFR Part 745.107(a)(l) (see
http://www.epa.gov/opptintr/lead/leadpdfe.pdf).
Visit the Healthcare Environmental Resource Center at http://www.here.org for
plain language explanations on how to comply with environmental regulations and to learn about
pollution prevention opportunities. The Center web site also links to state rules and permitting
contacts. Its resource sections contain selected compliance assistance and pollution prevention
tools. If you don't have access to the Internet, refer to Section VI and to the Bibliography in
Section IX.B for additional resources.
VILE. Comparison of Enforcement Activity Among Selected Industries
Table VII-3 compares the compliance history of the healthcare sector to the other
industries covered by the industry Sector Notebooks. Observations from these five years of data
are listed below:
• Sixty-six percent of healthcare facilities have been inspected over the past
five years, which is approximately equal to the average (62 percent) for all
other sectors listed;
• The inspected healthcare facilities have been inspected an average of three
times each; and
• The healthcare, ground transportation, and oil and gas extraction
industries have the highest percentage of state-led enforcement actions (96
percent).
Tables VII-4 provides a more in-depth comparison between the healthcare
industry and other sectors by breaking out the compliance and enforcement data by
environmental statute. As in Table VII-3, the data cover the last five years. Observations from
the data are listed below:
• The majority of inspections and actions are conducted under the CAA,
followed by RCRA;
• The healthcare industry has a higher percentage of CAA inspections (78
percent) than the average of the other sectors (60 percent); and
• The healthcare industry has one of the lowest percentages of CWA
inspections and actions of any of the sectors listed in these tables.
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Healthcare Industry
Compliance and Enforcement History
Table VII-3: 5-Year Enforcement and Compliance Summary for Selected Industries
Sector
Healthcare (SIC Code 8000)
Aerospace
Ag Chem Pesticide & Fertilizer
Ag Crop Production
Ag Livestock Production
Air Transportation
Dry Cleaning
Electronics & Computer
Fossil Fuel Elec Power Gen
Ground Transportation
Inorganic Chemical
Iron and Steel
Lumber & Wood Products
Metal Casting
Metal Fabrication
Metal Mining
Motor Vehicle Assembly
Non-Fuel, Non-Metal Mining
Nonferrous Metals
Oil & Gas Extraction
Organic Chemical
Petroleum Refining
Pharmaceutical
Plastic Resins & Fibers
Printing
Pulp and Paper
Facilities In
Search
1,798
764
585
131
53
428
3,345
1,852
3,520
4,970
1,007
683
3,038
1,346
8,279
281
1,886
3,778
531
2,783
1,050
438
572
709
2,384
566
Facilities
Inspected
1,187
526
345
69
17
211
1,620
906
2,543
3,338
629
480
2,045
797
5,092
183
1,211
2,005
327
1,681
787
297
414
502
1,460
467
Number of
Inspections
3,953
2,704
2,123
165
58
619
2,944
2,486
18,758
13,612
5,291
6,060
10,728
3,549
16,568
980
5,531
9,291
2,968
6,371
8,483
5,405
2,108
4,637
4,913
5,830
Average
Months
Between
Inspections
27
17
17
48
55
41
68
45
11
22
11
7
17
23
30
17
20
24
11
26
7
5
16
9
29
6
Facilities with
1 or More
Enforcement
Actions
195
246
138
12
14
80
232
286
1,170
1,084
352
312
872
348
2,138
70
500
522
242
1,120
558
352
174
344
476
336
Total
Enforcement
Actions
343
238
107
7
28
62
178
196
1,582
880
414
536
814
340
1,716
71
448
524
395
949
846
1,335
199
444
435
498
Percentage
of State-Led
Actions
96%
65%
57%
86%
11%
71%
92%
75%
78%
96%
79%
78%
85%
79%
76%
85%
77%
95%
88%
96%
73%
69%
84%
85%
90%
90%
Percentage of
Federal-Led
Actions
4%
35%
43%
14%
89%
29%
8%
25%
22%
4%
21%
22%
16%
21%
24%
16%
23%
6%
12%
4%
27%
31%
16%
15%
10%
10%
Enforcement-
to-inspection
Ratio
0.09
0.09
0.05
0.04
0.48
0.1
0.06
0.08
0.08
0.06
0.08
0.09
0.08
0.1
0.1
0.07
0.08
0.06
0.13
0.15
0.1
0.25
0.09
0.1
0.09
0.09
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February 2005
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Healthcare Industry
Compliance and Enforcement History
Table VII-3: 5-Year Enforcement and Compliance Summary for Selected Industries (Continued)
Sector
Rubber and Plastic
Shipbuilding & Repair
Stone Clay Glass&Concrete
Textiles
Water Transportation
Wood Furniture & Fixtures
Facilities In
Search
3,823
235
3,388
1,226
269
1,652
Facilities
Inspected
2,294
168
2,013
814
158
1,047
Number of
Inspections
9,239
870
12,190
3,859
384
5,515
Average
Months
Between
Inspections
25
16
17
19
42
18
Facilities with
1 or More
Enforcement
Actions
962
96
876
304
40
440
Total
Enforcement
Actions
787
83
930
310
36
382
Percentage
of State-Led
Actions
90%
81%
89%
87%
89%
89%
Percentage of
Federal-Led
Actions
10%
19%
11%
13%
11%
12%
Enforcement-
to-inspection
Ratio
0.09
0.1
0.08
0.08
0.09
0.07
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February 2005
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Healthcare Industry
Compliance and Enforcement History
Table VII-4: 5-Year Enforcement and Compliance Summary by Statute for Selected Industries
Sector
Healthcare
(SIC Code 8000)
Aerospace
Ag Chem Pesticide &
Fertilizer
Ag Crop Production
Ag Livestock Production
Air Transportation
Dry Cleaning
Electronics & Computer
Fossil Fuel Elec Power Gen
Ground Transportation
Inorganic Chemical
Iron and Steel
Lumber & Wood Products
Metal Casting
Metal Fabrication
Metal Mining
Motor Vehicle Assembly
Non-Fuel, Non-Metal Mining
Nonferrous Metals
Oil & Gas Extraction
Organic Chemical
Petroleum Refining
Pharmaceutical
Plastic Resins & Fibers
Printing
Pulp and Paper
Rubber and Plastic
Shipbuilding & Repair
Stone Clay Glass&Concrete
Facilities In
Search
1,798
764
585
131
53
428
3,345
1,852
3,520
4,970
1,007
683
3,038
1,346
8,279
281
1,886
3,778
531
2,783
1,050
438
572
709
2,384
566
3,823
235
3,388
Facilities
Inspected
1,187
526
345
69
17
211
1,620
906
2,543
3,338
629
480
2,045
797
5,092
183
1,211
2,005
327
1,681
787
297
414
502
1,460
467
2,294
168
2,013
Number of
Total
Inspections
3,953
2,704
2,123
165
58
619
2,944
2,486
18,758
13,612
5,291
6,060
10,728
3,549
16,568
980
5,531
9,291
2,968
6,371
8,483
5,405
2,108
4,637
4,913
5,830
9,239
870
12,190
Total
Enforcement
Actions
343
238
107
7
28
62
178
196
1,582
880
414
536
814
340
1,716
71
448
524
395
949
846
1,335
199
444
435
498
787
83
930
Clean Air Act
% of Total
Inspections
78%
52%
55%
50%
53%
38%
26%
31%
75%
78%
48%
61%
75%
60%
45%
56%
60%
97%
64%
97%
47%
57%
40%
51%
65%
67%
71%
59%
85%
% of Total
Enforcement
Actions
82%
43%
34%
71%
89%
23%
35%
14%
88%
76%
54%
67%
76%
59%
46%
52%
56%
99%
70%
98%
55%
83%
49%
59%
66%
75%
73%
34%
87%
Clean Water Act
% of Total
Inspections
0%
3%
12%
0%
0%
1%
0%
4%
18%
0%
13%
13%
1%
3%
2%
28%
1%
1%
9%
0%
12%
15%
7%
19%
0%
26%
1%
6%
1%
% of Total
Enforcement
Actions
2%
3%
8%
0%
7%
7°/
0%
5%
8%
1%
10%
10%
0%
7°/
1%
39%
1%
0%
5%
1%
13%
6%
8%
17%
0%
18%
0%
8%
1%
RCRA
% of Total
Inspections
21%
44%
27%
46%
47%
61%
74%
64%
6%
21%
37%
26%
24%
36%
52%
15%
38%
7°/
27%
3 /o
39%
27%
52%
29%
34%
7%
27%
35%
13%
% of Total
Enforcement
Actions
16%
51%
31%
29%
0%
74%
65%
67%
3%
23%
31%
20%
23%
33%
46%
7%
40%
1%
22%
2%
28%
10%
37%
22%
33%
4%
23%
57%
10%
FIFRA/TSCA/
EPCRA/Other
% of Total
Inspections
1%
0%
6%
4%
0%
0%
0%
1%
0%
0%
1%
0%
1%
1%
1%
1%
0%
0%
0%
0%
9°/
1%
1%
1%
1%
0%
1%
1%
1%
% of Total
Enforcement
Actions
1%
3%
27%
0%
4%
2%
0%
15%
1%
1%
6%
3%
1%
6%
7%
1%
3%
0%
2%
0%
5%
1%
6%
3%
1%
3%
5%
1%
2%
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February 2005
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Healthcare Industry
Compliance and Enforcement History
Table VII-4: 5-Year Enforcement and Compliance Summary by Statute for Selected Industries (Continued)
Sector
Textiles
Water Transportation
Wood Furniture & Fixtures
Facilities In
Search
1,226
269
1,652
Facilities
Inspected
814
158
1,047
Number of
Total
Inspections
3,859
384
5,515
Total
Enforcement
Actions
310
36
382
Clean Air Act
% of Total
Inspections
76%
42%
76%
% of Total
Enforcement
Actions
59%
50%
75%
Clean Water Act
% of Total
Inspections
12%
1%
0%
% of Total
Enforcement
Actions
23%
0%
1%
RCRA
% of Total
Inspections
12%
56%
23%
% of Total
Enforcement
Actions
14%
50%
23%
FIFRA/TSCA/
EPCRA/Other
% of Total
Inspections
1%
1%
0%
% of Total
Enforcement
Actions
3%
0%
2%
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February 2005
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Healthcare Industry Compliance and Enforcement History
VILF. Review of Major Legal Actions
This subsection discusses major legal cases and pending litigation within the
healthcare industry. Following are several press releases that discuss recent major cases
regarding healthcare facilities:
DEPARTMENT OF VETERANS AFFAIRS AGREES TO $133.000 SETTLEMENT FOR
LEAD PAINT DISCLOSURE VIOLATIONS IN MAINE AND MASSACHUSETTS
EXCERPTS FROM: EPA Region 1 Press Release, April 6, 2004, Release # 04-04-04
BOSTON - The U.S. Department of Veterans Affairs has agreed to pay a $10,068
penalty and perform environmental projects worth $123,050 to settle claims by the U.S.
Environmental Protection Agency that it failed to properly inform tenants about potential lead
hazards at employee housing provided by the department.
The three EPA complaints allege violations of the federal Lead Disclosure Rule
for employee housing at VA Medical Centers in Northampton and Bedford, Mass, and Togus,
Maine. The three medical centers include a total of about 41 on-site housing units, which the VA
leases to employees and their families. Settlement of this case represents the first time a federal
facility has paid a penalty for violations of the Lead Disclosure Rule.
In addition to paying the fine, the VA agreed to assign a person to be responsible
for environmental compliance at each facility, and to implement a lead-based paint abatement
project in employee housing at a total cost of $123,050. Of the case penalty, the Bedford facility
will pay $3,080; the Togus facility will pay $3,908; and the Northampton facility will pay
$3,080. This case abates health risks posed by lead paint in 16 units of employee housing divided
between the three locations and addresses the facilities' underlying barriers to compliance.
The case is among numerous lead-related civil and criminal cases EPA New
England has taken to make sure landlords and property owners and managers are complying with
the federal Lead Disclosure Rule. EPA New England's work to implement the Residential Lead-
Based Paint Hazard Reduction Act has included more than 150 inspections around New
England, as well as numerous compliance assistance workshops.
Low-level lead poisoning is widespread among American children, affecting as
many as three million children under the age of six, with lead paint the primary cause. Elevated
lead levels can trigger learning disabilities, decreased growth, hyperactivity, impaired hearing
and even brain damage. Lead is also harmful to adults. Adults can suffer from difficulties during
pregnancy, other reproductive problems, high blood pressure, digestive problems, nerve
disorders, memory and concentration problems, and muscle and joint pain.
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Healthcare Industry Compliance and Enforcement History
EPA ORDERS CLOSURE OF MEDICAL WASTE INCINERATORS AT GUAM
MEMORIAL HOSPITAL
FOR RELEASE: June 2004
HONOLULU — In response to an order from the U.S. Environmental Protection
Agency, the Guam Memorial Hospital Authority has shut down one of its medical waste
incinerators and will soon shut down a second in order to meet federal Clean Air Act standards.
Guam Memorial Hospital Authority has agreed to comply with the EPA's order
by ceasing to operate its incinerators and putting an alternative medical waste treatment method
into place.
The first of two incinerators was shut down on May 18. The second incinerator
was switched to emergency back-up status on June 11 and will be permanently shut down by
Nov. 30. The EPA determined that both incinerators were violating the emissions standards set
by the Clean Air Act.
"It is critical that medical waste incinerators meet all of the required emission
standards to protect the public's health," said Deborah Jordan, the EPA's air division director for
the Pacific Southwest region. "Developing alternative medical waste treatment will further
ensure clean air and proper disposal of medical waste for Guam's residents."
During the initial source tests, one of the incinerators violated the particulate
matter, dioxins and furans, hydrogen chloride and lead emissions limits, while the second
incinerator violated the particulate matter and hydrogen chloride emission limits. At that time,
Guam Memorial Hospital Authority also failed to submit to the EPA the required waste
management plan and necessary incinerator operating parameters and other required data for
both incinerators.
In response to the order, Guam Memorial Hospital Authority has given the EPA a
plan to transport all hospital, medical and infectious waste to a commercial medical waste
treatment and disposal facility while the hospital develops an alternative waste treatment system.
The EPA's order also requires the Guam Memorial Hospital Authority to:
• Provide to the EPA a copy of its waste management plan which will
include plans to separate solid waste from medical waste and other waste
minimization opportunities; and
• Complete the shut down of both incinerators by Nov. 30 and complete
final removal and proper disposal of the two incinerators by Dec. 30.
All medical waste incinerators need to be permitted and have the necessary air
pollution controls to meet all Clean Air Act standards. Medical waste can be a source of
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Healthcare Industry Compliance and Enforcement History
pollution from the pathological and biological waste, along with any chemicals produced during
incineration from plastics and other medical waste materials.
SLOAN-KETTERING FINED FOR FAILURE TO PROPERLY MANAGE
HAZARDOUS WASTE
FOR RELEASE: Tuesday, January 27, 2004
New York, N.Y. - The U.S. Environmental Protection Agency (EPA) announced
today that it has cited Memorial Sloan-Kettering Cancer Center in New York City for violating
numerous hazardous waste management requirements. The Agency is seeking full compliance
and $214,420 in penalties for the violations.
"Hospitals and healthcare facilities must consider the proper handling of
hazardous waste an integral part of their mandates to protect people's health," said Jane M.
Kenny, EPA Regional Administrator. "Chemotherapy waste is an especially toxic waste
produced by many medical facilities. Hazardous waste regulations are in place to help to ensure
that facilities like Sloan-Kettering do not release these or other toxic chemicals into the
environment.
EPA discovered violations of the Resource Conservation and Recovery Act
(RCRA) at Sloan- Kettering during a March 2003 inspection. They included improper storage
and disposal of chemotherapy and dental solid wastes, as well as a general failure to determine
whether they were hazardous wastes. Sloan-Kettering has 30 days to respond to the complaint.
In 2002, EPA started the Hospital and Healthcare Initiative to help hospitals and
healthcare facilities comply with environmental regulations as part of a larger EPA voluntary
audit policy. The Agency established the policy to encourage prompt disclosure and correction
of environmental violations, safeguarding people's health and the environment. Many hospitals
and healthcare facilities were not aware of their responsibilities under various environmental
laws or had failed to implement effective compliance strategies. As part of the initiative, EPA
sent letters to 480 facilities in New Jersey, New York, Puerto Rico and the U.S. Virgin Islands
and held free workshops to help hospitals comply. In addition, the Agency established a web
site that provides information about their duties under the law, and warned hospitals that EPA
inspections of their facilities - with risk of financial penalties - were imminent.
Hospitals that wish to take advantage of the Agency's voluntary self-audit
program can investigate and disclose environmental violations to EPA and, if certain conditions
are met, receive a partial or complete reduction in financial penalties. To date, fourteen
healthcare organizations have entered into voluntary self-audit disclosure agreements with EPA.
The Agency is continuing to conduct inspections. More information about the healthcare
initiative can be found on EPA's web site at: www.epa.gov/Region2/healthcare/mdex.html and
about hazardous waste regulation in general at: www. epa.gov/epaoswer/osw/index.htm.
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Healthcare Industry Compliance and Enforcement History
EPA FINES NASSAU HEALTH CARE CORPORATION FOR VIOLATING
HAZARDOUS WASTE REGULATIONS
FOR RELEASE: Monday, October 20, 2003
New York, N.Y. - The U.S. Environmental Protection Agency (EPA) announced
today that it will seek $279,900 in penalties from the Nassau Health Care Corporation Nassau
University Medical Center in East Meadow, New York for violating numerous requirements of
the federal and New York State hazardous waste regulations. The medical research, diagnostic
and treatment facility must comply with all hazardous waste management requirements under the
Resource Conservation and Recovery Act (RCRA).
"Hazardous waste regulations help to ensure that facilities like Nassau Health do
not release toxic chemicals into the environment and protect workers, patients and visitors at the
hospital," said EPA Regional Administrator Jane M. Kenny. "Many toxic compounds easily
contaminate air, ground or water and exposure can cause or aggravate many illnesses. Though
there were no releases in this case, it is essential that companies with hazardous chemicals in
their waste follow EPA and state regulations very carefully to ensure that they don't endanger
people or the environment."
The discovery of violations at Nassau Health grew out of EPA inspections of the
facility this past winter. These violations included storage or abandonment of several types of
solid waste and chemicals, and failure to determine whether or not they were hazardous wastes.
In addition, the hospital did not have a permit to store hazardous waste, and did not meet the
protective management requirements needed to be exempt from a permit. Hazardous waste
containers were not identified with the required markings or inspected regularly; emergency
response agencies were not notified of hazardous waste being stored; and the hospital did not
minimize the possibility of fire, explosion or unplanned release of hazardous substances into the
environment. Finally, a number of hospital personnel responsible for hazardous waste
management were not trained in how to handle it, and no hazardous waste emergency response
plan was in place. Since the inspection, Nassau Health has been correcting the violations. The
company has 30 days to respond to the complaint.
Nassau Health could have avoided this enforcement action by taking advantage of
EPA's Hospitals and Healthcare Initiative. EPA Region 2 started the Hospital and Healthcare
Initiative in the fall of 2002 to help hospitals and healthcare facilities comply with environmental
regulations as part of a larger EPA Voluntary Audit Policy. The Agency established the policy
to encourage prompt disclosure and correction of environmental violations, safeguarding human
health and the environment. Many hospitals and healthcare facilities were not aware of their
responsibilities under various environmental laws or failed to implement effective compliance
strategies. As part of the initiative, EPA sent letters to 480 facilities in New Jersey, New York,
Puerto Rico and the U.S. Virgin Islands and held free workshops to help hospitals comply. In
addition, the Agency established a web site that provides information about their duties under the
law, and warned hospitals that EPA inspections of their facilities - with risk of financial penalties
- were imminent.
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Healthcare Industry Compliance and Enforcement History
Hospitals can take advantage of the Agency's Voluntary Audit Policy, through
which they can investigate and disclose environmental violations to EPA and, as a compliance
incentive, receive a partial or complete reduction in financial penalties. To date, eleven hospitals
have entered into voluntary self-audit disclosure agreements with EPA.
More information about hazardous waste regulations can be found on EPA's web
site at: http://www.epa.gov/epaoswer/osw/index.htm.
NORTH SHORE PAYS FINES FOR VIOLATING FEDERAL HAZARDOUS WASTE
HANDLING RULES
FOR RELEASE: Thursday, June 12, 2003
NEW YORK, N. Y. - North Shore University Hospital on Community Drive in
Manhasset has agreed to pay $40,000 in penalties to the federal government for violations of the
Resource Conservation and Recovery Act (RCRA) hazardous waste regulations, the U.S.
Environmental Protection Agency (EPA) announced today.
EPA Regional Administrator Jane M. Kenny explained. "The only way hospitals
and other healthcare facilities can ensure that wastes that have the potential to harm people and
the environment are properly handled is to strictly adhere to federal hazardous waste rules."
As part of a region-wide initiative to bring hospitals into compliance with federal
rules, EPA is inspecting healthcare facilities in New York, New Jersey, Puerto Rico and the U.S.
Virgin Islands. The discovery of the violations at North Shore Hospital grew out of EPA
inspections of the facility in April and May of 2002.
EPA issued a complaint last year against North Shore hospital alleging it failed to
determine if spent fluorescent bulbs and chemotherapy waste were hazardous prior to disposal,
and had improperly documented the transport of hazardous waste. The Agency also cited North
Shore for failing to properly label storage drums containing hazardous waste and to minimize the
risk of explosion, fire and release that could have affected people's health and the environment.
As part of the settlement between the facility and EPA, the facility agreed to take corrective
actions that would prevent any recurrence of the violations in the future.
EPA operates a Voluntary Audit Policy, through which the Agency can
substantially reduce civil penalties for those that voluntarily disclose and promptly correct
violations that are identified through self-policing and meet certain other specified conditions,
except in cases involving serious harm to public health or the environment. In most cases, the
punitive component of the penalty may be fully eliminated, but EPA would still be able to collect
any economic benefit as a result of non-compliance.
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Healthcare Industry Compliance and Enforcement History
EPA PROPOSES TO FINE PONCE HOSPITAL FOR ILLEGAL DISCHARGE
FOR RELEASE: Wednesday, November 19, 2003
New York, N.Y. - The U.S. Environmental Protection Agency (EPA) has
proposed a $137,500 penalty against Quality Health Services of Puerto Rico, Inc. (Hospital San
Cristobal) for discharging wastewater to a small creek, a tributary to the Rio Inabon, in violation
of the federal Clean Water Act. The EPA issued a complaint based on the hospital's continuing
failure to comply with the requirements of its wastewater discharge permit.
"Wastewater discharge permits protect public health and the environment," said
EPA Regional Administrator Jane M. Kenny. "The hospital has been out of compliance since
February 2000. As a healthcare facility, Hospital San Cristobal should understand the
importance of properly managing its waste."
The September 30, 2003 complaint charges that Quality Health Services violated
the requirements of its National Pollutant Discharge Elimination System (NPDES) permit, issued
under the Clean Water Act. In March 2003, EPA inspected the hospital and ordered Quality
Health Services to comply with the requirements of its NPDES permit. However, Quality Health
Services allegedly continued to violate the Clean Water Act (for a total of 226 times from
February 2000 through May 2003) with its discharge of sanitary wastewaters from the hospital's
wastewater treatment plant. Specifically, the discharge exceeded permit limitations for
ammonia, biochemical oxygen demand, color, fecal coliform, flow, fluoride, nitrate-nitrite,
phenolics, phosphorus, silver, sulfide, surfactants and zinc. Under federal regulations, Quality
Health Services has the right to request a hearing on the proposed penalty.
NEW YORK PRESBYTERIAN HOSPITAL
BASED ON NOVEMBER 2004 PRESS RELEASE
New York Presbyterian Hospital was charged with failing to provide tenants,
including pregnant women and families with young children, with the required lead paint hazard
information (i.e., failing to provide a lead warning statement, statement disclosing any
knowledge of lead-based paint, and list of any existing records or reports pertaining to lead-
based paint, nor obtaining a statement by the lessee of receipt of a lead hazard information
pamphlet.) These failures are violations of 42 U.S.C. Section 4852d(b)(5) and § 409 of TSCA,
15U.S.C. §2689.
Lead poisoning presents an environmental health hazard for young children living
in apartments constructed before 1978, due to the potential chipping or peeling of lead paint, or
lead-contaminated dust. New York Presbyterian Hospital owned and leased at least twenty-nine
housing units to families of physicians at their facility in White Plains, New York. Region 2
suggested possible activities that could be undertaken as Supplemental Environmental Projects,
and New York Presbyterian Hospital submitted a proposal for a SEP that involved exterior
maintenance and repair, but the parties were unable to reach agreement on an appropriate SEP.
New York Presbyterian Hospital entered into a cash settlement with EPA for $248,000, which is
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Healthcare Industry Compliance and Enforcement History
the largest monetary settlement in the history of the Lead-based Paint Disclosure Program. On
July 10, 2003, the Regional Administrator signed the Final Order memorializing the settlement
in the Consent Agreement and Final Order. (T. Bourbon/L. Livingston)
EPA FINES ATLANTIC HEALTH SYSTEMS INC. FOR FAILURE TO PROPERLY
MANAGE HAZARDOUS WASTE
FOR RELEASE: Tuesday, November 25, 2003
New York, N.Y. — The U.S. Environmental Protection Agency (EPA) announced
today that it will seek $64,349 in penalties from Atlantic Health System Inc., owner and operator
of Mountainside Hospital in Montclair, New Jersey. The Agency cited the company for violating
numerous hazardous waste management requirements under the Resource Conservation and
Recovery Act (RCRA).
"Hospitals and healthcare facilities should consider the proper handling of
hazardous waste as an integral part of their mandates to protect people's health," said Jane M.
Kenny, EPA Regional Administrator."We are pleased that Mountainside Hospital has recognized
its responsibility to its patients, employees and neighbors, and is taking action to correct the
violations."
EPA discovered the violations at Mountainside Hospital during an April 2003
inspection. The violations included improper storage or disposal of several types of solid waste,
and failure to determine whether they were hazardous wastes. In addition, the hospital did not
have a permit to store hazardous waste and did not meet the protective management
requirements needed to be exempt from a permit. Hazardous waste containers were not clearly
identified with the required markings or inspected regularly, and emergency response
information was not posted. Mountainside is working to correct the violations. Its parent
company, Atlantic Health, has 30 days to respond to the complaint.
In 2002, EPA started the Hospital and Healthcare Initiative to help hospitals and
healthcare facilities comply with environmental regulations as part of a larger EPA voluntary
audit policy. The Agency established the policy to encourage prompt disclosure and correction
of environmental violations, safeguarding people's health and the environment. Many hospitals
and healthcare facilities were not aware of their responsibilities under various environmental
laws or had failed to implement effective compliance strategies. As part of the initiative, EPA
sent letters to 480 facilities in New Jersey, New York, Puerto Rico and the U.S. Virgin Islands
and held free workshops to help hospitals comply. In addition, the Agency established a web site
that provides information about their duties under the law, and warned hospitals that EPA
inspections of their facilities - with risk of financial penalties - were imminent.
Hospitals that wish to take advantage of the Agency's voluntary self-audit
program can investigate and disclose environmental violations to EPA and, if certain conditions
are met, receive a partial or complete reduction in financial penalties. To date, eleven hospitals
have entered into voluntary self-audit disclosure agreements with EPA. The Agency is
continuing to conduct inspections.
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Healthcare Industry Compliance and Enforcement History
YALE-NEW HAVEN HOSPITAL ACCEPTS EPA PLAN FOR ENVIRONMENTAL
AUDIT
Yale-New Haven Hospital and EPA say they have reached an agreement under
which the hospital will voluntarily carry out a comprehensive environmental audit. The
agreement between EPA Region I and the hospital in New Haven, Conn., is the first of its kind to
be signed in New England and is part of an agency effort to improve hospital compliance with
environmental laws. EPA Region I launched its hospital initiative earlier this year, citing the
experience of EPA's New York/New Jersey regional office, which took enforcement actions
against several hospitals after significant noncompliance was found during inspections of
hospital facilities.
Source: http://t>ubs.bna.com/w/BNA/den.nsf/is/aObOd4kld7
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Healthcare Industry Compliance Activities and Initiatives
VIII. COMPLIANCE ACTIVITIES AND INITIATIVES
This section highlights organizations, resources, and the voluntary activities being
undertaken by the healthcare sector, public agencies, and nongovernmental organizations to
improve the sector's environmental performance. These activities include those independently
initiated by industrial trade associations.
VIII.A. Healthcare Related Programs and Activities
Healthcare Environmental Resource Center (Compliance Assistance Center)
Using an EPA grant the National Center for Manufacturing Sciences with the
cooperation of the American Hospital Association, the American Nurses Association, and EPA,
via the Hospitals for a Health Environment (H2E) program and other stakeholders, is creating an
on-line compliance assistance center (or Healthcare Environmental Resource Center - HERC)
serving the healthcare industry. The HERC will address issues relevant to hospitals, ambulatory
clinics, and other specialized medical facilities. It will serve as a first stop for environmental
compliance and pollution prevention information for the healthcare industry. Among its many
compliance assistance and pollution prevention features, the HERC will include plain language
explanations of applicable regulations and feature links to state and local permitting agencies
where users can find information on local regulations and contacts. Look for the Healthcare
Environmental Resource Center at www.HERCenter. org.
Hospitals for a Healthy Environment (H2E)
Hospitals for a Healthy Environment (H2E) is a voluntary program jointly
sponsored by the EPA, the American Hospital Association, the American Nurses Association,
and Health Care Without Harm. The primary goal of the H2E effort is to educate healthcare
professionals about pollution prevention opportunities in hospitals and healthcare systems and
make significant reductions in mercury-containing healthcare waste, and waste volume overall.
Through activities such as the development of best practices, model plans for total waste
management, resource directories, and case studies, the project hopes to provide hospitals and
healthcare systems with enhanced tools for minimizing the volumes of waste generated and the
use of persistent, bioaccumulative, and toxic chemicals. Such reductions are beneficial to the
environment and health of our communities. Furthermore, improved waste management
practices will reduce the waste disposal costs incurred by the healthcare industry. For more
information, see the web site at http://www.h2e-online. org/.
Resource Conservation Challenge (RCC)
EPA's Resource Conservation Challenge (www.epa.gov/rcc) is a voluntary, joint
effort between EPA, businesses, and communities. RCC aims to find flexible, yet more
protective ways of improving waste reduction, public health, and the environment. As part of the
Resource Conservation Challenge, EPA is asking the hospital industry to develop projects for the
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Healthcare Industry Compliance Activities and Initiatives
reuse and recycling of hospital items and the reduction of waste. For more information, see the
web site at http://www. epa. gov/epaoswer/osw'/conserve/clusters/hospital, htm.
Lead needed to protect healthcare workers from CatScan radiation, mercury in
ultraviolet lamps, and residual or expired pharmaceuticals are just a few examples of the hospital
waste that can harm the environment if disposed of improperly. EPA's RCC is committed to
supporting projects that:
• Reduce the volume of nonhazardous solid waste, including paper,
packaging, yard waste, food waste, and electronic equipment, from the
healthcare industry and promote its recycling and safe reuse;
• Virtually eliminate all mercury waste from the healthcare industry waste
stream;
• Reduce the volume of other toxic chemicals; and
• Improve the management of pharmaceutical waste by reducing the amount
of expired/unused pharmaceuticals that are disposed of in landfills.
Performance Track
Performance Track is a public/private partnership recognizing top environmental
performance among participating U.S. facilities of all types, sizes, and complexity, public and
private. Program partners are providing leadership in many areas, including preventing pollution
at its source and implementing environmental management systems. Currently, the program has
approximately 300 members and welcomes all qualifying facilities. Applications are accepted
twice a year: February 1-April 30 and August 1-October 31. For more information, contact the
Performance Track hotline at (888) 339-PTRK or visit the web site at
www. epa.gov/performancetrack.
EPA Audit Policy
EPA encourages companies with multiple facilities to take advantage of the
Agency's Audit Policy (Incentives for Self-Policing: Discovery, Disclosure, Correction and
Prevention of Violations, 65 Fed. Reg. 19618 (April 11, 2000)) to conduct audits and develop
environmental compliance systems. The Audit Policy eliminates gravity-based penalties for
companies that voluntarily discover, promptly disclose, and expeditiously correct violations of
federal environmental law. More information on EPA's Audit Policy can be obtained from the
web site at http://www. epa. gov/compliance/resources/policies/incentives/auditing/index. html.
EPA Region 2 (NY, NJ, PR, VI) has been actively promoting use of the policy; see voluntary
audit policy at http://www.epa.gov/region02/healthcare/.
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Healthcare Industry Compliance Activities and Initiatives
Office of Solid Waste and Emergency Response (OSWER) Innovations Pilot
The Office of Solid Waste and Emergency Response (OSWER) initiated a series
of innovative pilots to test new ideas and strategies for environmental and public health
protection to find creative approaches to waste minimization. For additional information on
OSWER Innovations Pilots, visit the EPA OSWER Innovations web site at
www. epa.gov/oswer/iwg.
Expanding Pharmaceutical Waste Management in Hospitals
Hospitals for a Healthy Environment is partnering with EPA Region 1,
Dartmouth-Hitchcock Medical Center, New Hampshire Department of Environmental Services,
New Hampshire Hospital Association, and H2E Champion, PharmEcology Associates, to
pioneer pharmaceutical management techniques that ensure regulatory compliance, implement
best management practices, and identify and implement waste minimization opportunities.
Baseline data on costs and quantities of end-of-life pharmaceuticals will be compiled and
evaluated. This information will be used to assess where pharmaceuticals are being discarded,
how much is being wasted, and how wasting can be minimized. Based on the results of the
baseline assessment, the pilot will develop best management practices incorporating waste
reduction activities. A blueprint will be developed providing a step-by-step approach to program
implementation and lessons learned. For more detailed information on the pharmaceutical pilot,
visit H2E's web site at www.h2e-online.org.
Collaborative Partnership to Improve Environmental Performance in the
Healthcare Sector
The overall goal of this project is to institutionalize regulatory compliance and
pollution prevention practices in the healthcare sector. To achieve this goal, the objective of the
project is to establish a formal lasting partnership with multiple healthcare and regulatory
organizations and JCAHO to maximize EPA compliance assistance and pollution prevention
resources, improve the environmental performance of the healthcare sector, and create incentives
for continuous improvement. The final product will be a set of matrices for JCAHO surveyors
and hospital personnel that align environmental regulations and environmental improvement
with the JCAHO standards. The matrices will be available electronically on EPA's forthcoming
Healthcare Environmental Resource Center's web site at www.HERCenter.org. For more
detailed information on the JCAHO project, visit H2E's web site at: www.h2e-online.org.
National Strategies for Healthcare Providers: Pesticide Initiative
The Pesticide Initiative is an initiative created by EPA and the National
Environmental Education & Training Foundation (NEETF) in collaboration with the U.S.
Departments of Health and Human Services, Agriculture, and Labor. It is aimed at incorporating
pesticide information into the education and practice of healthcare providers. The goal is to
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Healthcare Industry Compliance Activities and Initiatives
improve the recognition, diagnosis, management, and prevention of adverse health effects from
pesticide exposures. This initiative also serves as a model for broader efforts to educate
healthcare providers about the spectrum of environmental health issues. Seven federal agencies
and 16 professional associations of healthcare providers were involved in launching this
initiative. For additional information, visit the EPA Pesticide Initiative web site at
http://www.epa.gov/oppfeadl/safety/healthcare/healthcare. htm
EPA and Veterans Health Administration (VHA) Cooperative Environmental
Partnership
Stemming from EPA inspections of VA medical centers in 2002 that revealed
repeated violations of environmental regulations, particularly those involving federal hazardous
waste management regulations, EPA and VHA are conducting environmental management
reviews (EMRs) at select VA medical centers. EMRs evaluate the current status of the
management system and identify steps to establish a comprehensive management system for
environmental compliance as well as continual improvement beyond compliance. The
partnership has fostered environmental training through both EPA Headquarters and the
Regions, and assisted in the development of the VA's Green Environmental Management
Systems (GEMS). These efforts and others are underway to improve environmental compliance
and performance at VA medical centers. For additional information visit
http://www. epa.gov/compliance/assistance/sectors/federal/epavha.html.
The Green Suppliers Network (GSN)
The Green Suppliers Network (GSN) is a collaborative venture between industry,
EPA, and 360vu, the national accounts organization of the Department of Commerce's National
Institute of Standards and Technology Manufacturing Extension Partnership (NIST MEP). GSN
provides expert technical assistance to small and medium-sized suppliers, through 360vu's
national network of technical assistance centers. This assistance provided in a GSN Review
enables suppliers to optimize processes and products, eliminate waste, reduce their
environmental impacts, identify cost-saving opportunities, and remain competitive. GSN
engages both original equipment manufacturers and their suppliers to achieve environmental and
economic benefits throughout the supply chain. GSN has launched a pharmaceutical/healthcare
initiative piloted in Puerto Rico. For additional information on the program, contact Kristin
Pierre atpierre.kristin(q),epa.gov or (202) 564-8837.
WasteWi$e Program
The WasteWi$e Program was started in 1994 by EPA's Office of Solid Waste and
Emergency Response. The program is aimed at reducing municipal solid wastes by promoting
waste minimization, recycling collection, and the manufacturing and purchase of recycled
products. As of February 17, 2004, WasteWise has 1,377 partners (including alumni) spanning
more than 54 industry sectors. Members agree to identify and implement actions to reduce their
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Healthcare Industry Compliance Activities and Initiatives
solid wastes and must provide EPA with their waste reduction goals along with yearly progress
reports. EPA in turn provides technical assistance to member companies and allows the use of
the WasteWi$e logo for promotional purposes. Sixty-one medical services companies are
partners. For more information, contact the Hotline at (800) EPA-WISE (372-9473) or the web
site at www. epa.gov/wastewise.
Energy Star®
In 1991, EPA introduced Green Lights®, a program designed for businesses and
organizations to proactively combat pollution by installing energy efficient lighting technologies
in their commercial and industrial buildings. In April 1995, Green Lights® expanded into
Energy Star® Buildings — a strategy that optimizes whole-building energy-efficiency
opportunities. The energy needed to run commercial and industrial buildings in the United
States produces 19 percent of U.S. carbon dioxide emissions, 12 percent of nitrogen oxides, and
25 percent of sulfur dioxide, at a cost of $110 billion a year. If implemented in every U.S.
commercial and industrial building, the Energy Star® Buildings upgrade approach could prevent
up to 35 percent of the emissions associated with these buildings and cut the nation's energy bill
by up to $25 billion annually.
The more than 7,000 participants include corporations, small businesses,
universities, healthcare facilities, nonprofit organizations, school districts, and federal and local
governments. Energy Star® has successfully delivered energy and cost savings across the
country, saving businesses, organizations, and consumers more than $7 billion a year. Over the
past decade, Energy Star® has been a driving force behind the more widespread use of such
technological innovations as LED traffic lights, efficient fluorescent lighting, power
management systems for office equipment, and low standby energy use. For more information,
contact the Energy Star Hotline, (888) STAR-YES ((888) 782-7937) or the web site at
http://www.energystar.gov/healthcare.
Small Business Compliance Policy
The Small Business Compliance Policy promotes environmental compliance
among small businesses (those with 100 or fewer employees) by providing incentives to discover
and correct environmental problems. EPA will eliminate or significantly reduce penalties for
small businesses that voluntarily discover violations of environmental law and promptly disclose
and correct them. A wide range of resources are available to help small businesses learn about
environmental compliance and take advantage of the Small Business Compliance Policy. These
resources include training, checklists, compliance guides, mentoring programs, and other
activities. Businesses can find more information through links on the web site at
http://www.epa.ffov/smallbusmess/.
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Healthy Building Network (HBN)
Healthcare institutions are increasingly embracing green building goals driven by
several important factors: public health, market competitiveness, operation costs, and social
responsibility. HBN is a national network of green building professionals, environmental and
health activists, socially responsible investment advocates, and others who are interested in
promoting healthier building materials as a means of improving public health and preserving the
global environment. For more information, contact HBN at (202) 898-1610 or the web site at
http://www.healthybuilding. net/healthcare/index. html.
Health Care Without Harm (HCWH)
HCWH is an international coalition of hospitals and healthcare systems, medical
professionals, community groups, health-affected constituencies, labor unions, environmental
and environmental health organizations, and religious groups.
In 1994, EPA's draft Dioxin Reassessment identified medical waste incineration
as the single largest source of dioxin air pollution. The HCWH campaign was formed in 1996 to
respond to this serious problem. Since then, the campaign has grown from an initial 28 founding
organizations into a broad-based international coalition. The mission of HCWH is to transform
the healthcare industry worldwide, without compromising patient safety or care, so that it is
ecologically sustainable and no longer a source of harm to public health and the environment.
For more information, contact the HCWH web site at http://www.noharm.org/.
The Sustainable Hospitals Project (SHP)
SHP's mission is to provide technical support to the healthcare industry for
selecting products and work practices that reduce occupational and environmental hazards. The
SHP is based at the University of Massachusetts Lowell Center for Sustainable Production
(LCSP). The project includes in-hospital research on implementing new products and practices,
using SHP's Pollution Prevention and Occupational Safety and Health (P2OSH) model.
Additionally the SHP web site, http://www.sustamablehospitals.org, provides a list of alternative
products to help hospitals identify and evaluate more benign alternatives to existing products.
SHP also provides technical support by email (shp(a),uml.edu} or phone ((978) 934-3386). For
more information, contact the web site at http://www.sustainablehospitals. org.
Nightingale Institute for Health and the Environment (NIHE)
NIHE assists healthcare professionals recognize the inextricable link between
human and environmental health and their role in changing practices to improve the health of
humans and the environment. There are three initiatives associated with this program: the
Trustees Initiative, the Clinicians Initiative, and the Environmental Procurement Initiative. Each
initiative is designed to educate the target audience on the environmental impact of the
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healthcare industry, and to offer resources that enable them to improve the environmental
performance of their organizations or processes and minimize the adverse ecological impact in
the communities they serve. Inherent in this project is an emphasis on sustainability, resource
conservation, and life cycle thinking. For more information, contact the web site at
http://www.nihe. org/.
Canadian Centre for Pollution Prevention (Healthcare EnviroNet)
Healthcare EnviroNet provides the healthcare community with access to
environmental information, products, and services that support a commitment to quality
healthcare, protection of the environment, and sustainability. Healthcare EnviroNet delivers a
unique collection of Canadian-based information including:
• Green alternatives for healthcare facilities;
• Regulatory updates and government initiatives; and
• Canadian case studies.
Healthcare EnviroNet was established with funding from Environment Canada
and is developed and maintained by the Canadian Centre for Pollution Prevention in consultation
and partnership with healthcare and nongovernment organizations. For more information, go to
the web site at http://www. c2p2online. com/main.php3 ?section=83&doc id= 169.
Recovered Medical Equipment for the Developing World (REMEDY)
Founded in 1991 at Yale University School of Medicine, REMEDY is a group of
healthcare professionals and others promoting the nationwide practice of recovery of open-but-
unused surgical supplies with the goal of providing international medical relief while reducing
solid medical waste from U.S. hospitals. For more information, go to the web site at
http://www.remedyinc.org/about us.cfm.
Public Entity Environmental Resource (PEER) Center
The PEER Center is the Public Entity Environmental Management System
Resource Center. A virtual clearinghouse, it is specifically designed to aid local, county, and
state governments that are considering implementing or have implemented an environmental
management system (EMS) and want to access the knowledge and field experience of other
public entities that have done so. For more information, go to the web site at
httt>://www.peercenter. net/.
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ISO 14000
ISO 14000 is a series of internationally accepted standards for environmental
management. The series includes standards for EMS, guidelines on conducting EMS audits,
standards for auditor qualifications, and standards and guidance for conducting product lifecycle
analysis. Standards for auditing and EMS were adopted in September 1996, while other
elements of the ISO 14000 series are currently in draft form. While regulations and levels of
environmental control vary from country to country, ISO 14000 attempts to provide a common
standard for environmental management. The governing body for ISO 14000 is the International
Organization for Standardization (ISO), a worldwide federation of over 110 country members
based in Geneva, Switzerland. The American National Standards Institute (ANSI) is the United
States representative to ISO. Information on ISO is available at the following Internet site:
http://www.iso.ch/iso/en/ISOOnline.openerpage.
VIII.B. Summary of Trade Organizations and Industry Organizations
There are dozens of trade organizations associated with the healthcare industry.
The following list is meant to act as a representative sample, not a comprehensive list.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
JCAHO is an independent nonprofit organization whose mission is to improve the
safety and quality of care through its accreditation process. JCAHO standards promote patient
safety and care and good operational practices in all aspects of healthcare organizations. Nearly
17,000 healthcare organizations worldwide are accredited by JCAHO. Extensive on-site reviews
are conducted at least once every three years. The reviews currently only cover environmental
issues in a limited manner. See Collaborative Partnership to Improve Environmental
Performance in the Healthcare Sector in Section VIII. A of this Notebook to see how H2E is
working with JCAHO to help healthcare facilities improve their environmental performance.
Contact Information: One Renaissance Blvd, Oakbrook Terrace, IL 60181, Phone: (630) 792-
5000, Fax: (630) 792-5005, web site: http://www.icaho.ore/.
American Hospital Association (AHA)
The AHA provides education for healthcare leaders and is a source of information
on healthcare issues and trends. Through its representation and advocacy activities, AHA
ensures that members' perspectives and needs are heard and addressed in national health policy
development, legislative and regulatory debates, and judicial matters. AHA advocacy efforts
include the legislative and executive branches and the legislative and regulatory arenas. Contact
Information: One North Franklin, Chicago, IL 60606-3421, Phone: (312) 422-3000, web site:
http://www.aha. ors/.
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American Medical Association (AMA)
The AMA serves as the steward of medicine and leader of the medical profession.
The AMA is the national professional organization for all physicians and the leading advocate
for physicians and their patients. The AMA's envisioned future is to be an essential part of the
professional life of every physician and an essential force for progress in improving the nation's
health. Contact Information: 515 N. State Street, Chicago, IL 60610, Phone: (800) 621-8335,
web site: http://www.ama-assn.org/.
American Dental Association (ADA)
The ADA is the professional association of dentists committed to the public's oral
health, ethics, science and professional advancement and leading a unified profession through
initiatives in advocacy, education, research and the development of standards. Contact
Information: 211 East Chicago Ave., Chicago, IL 60611-2678, Phone: (312) 440-2500, web site:
http://www.ada. org/.
American Nurses Association (ANA)
ANA focuses its work on core issues of vital concern to the nation's registered
nurses - nursing shortage, appropriate staffing, health and safety, workplace rights, and patient
safety/advocacy - in addition to its cornerstone work, ethics and standards.
The ANA, composed of professional nurses dedicated to the promotion of health
and the care of the sick, has served as the forum in which the nation's critical health issues have
been discussed throughout the last century.
Functioning as a democracy, the ANA provided the structure in which views were
expressed, ideas were debated and evaluated, and positions and goals were formulated. Because
it represented the views of administrators, clinical practitioners in institutions and community
agencies, educators, and researchers, it has served for 100 years as the public voice for the
diversity of America's professional nurses. Contact Information: 600 Maryland Ave. SW., Suite
100W, Washington D.C. 20024, Phone: (202) 651-7000, Fax: (202) 651-7001, web site:
http://www. ana, org/.
American Veterinary Medical Association (AVMA)
The AVMA, established in 1863, is a not-for-profit association representing more
than 69,000 veterinarians working in private and corporate practice, government, industry,
academia, and uniformed services. Structured to work for its members, the AVMA acts as a
collective voice for its membership and for the profession.
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The AVMA provides a number of tangible benefits to its members, including
information resources, continuing education opportunities, quality publications, and discounts on
personal and professional products, programs and services. Contact Information: 1931 North
Meacham Road - Suite 100, Schaumburg, IL 60173, Phone: (847) 925-8070, Fax: (847) 925-
1329, web site: http://www.avma.org/.
American Health Care Association (AHCA)
The AHCA is a nonprofit federation of affiliated state health organizations,
together representing nearly 12,000 nonprofit and for-profit assisted living, nursing facility,
developmentally disabled, and subacute care providers that care for more than 1.5 million elderly
and disabled individuals nationally.
AHCA represents the long-term care community to the nation at large - to
government, business leaders, and the general public. It also serves as a force for change within
the long-term care field, providing information, education, and administrative tools that enhance
quality at every level.
At its Washington, D.C. headquarters, the association maintains legislative,
regulatory and public affairs, as well as member services staffs that work both internally and
externally to assist the interests of government and the general public, as well as member
providers. In that respect, AHCA represents its membership to all publics, and national
leadership to its members. Contact Information: 1201 L Street, N.W., Washington, D.C. 20005,
Phone: (202) 842-4444, Fax: (202) 842-3860, web site: http://www.ahca.org/.
American Society for Healthcare Environmental Services (ASHES)
Setting the standard for environmental excellence, ASHES advances healthcare
environmental services, textile care professions and related disciplines. ASHES leads, represents
and serves our members by promoting excellence, best practices, innovation, and leadership
through advocacy, education and certification. Web site: http://www.ashes.org/.
American Society for Healthcare Engineers (ASHE)
ASHE is the advocate and resource for continuous improvement in the healthcare
engineering and facilities management professions. Web site: http://www.ashe.org/.
College of American Pathologists (CAP)
The CAP, the principal organization of board-certified pathologists, serves and
represents the interest of patients, pathologists, and the public by fostering excellence in the
practice of pathology and laboratory medicine.
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The CAP's Strategic Plan is intended to help ensure that the College fulfills its
mission in a thoughtful and effective manner. The plan contains 13 specific directions that the
College will follow in carrying out its commitment to members, their patients, and the public.
CAP members can download a copy of the Strategic Plan; log in to access the file. Contact
Information: 325 Waukegan Road, Northfield, IL 60093-2750, Phone: (847) 832-7000, Fax:
(847) 832-8000, web site: http://www.cap.ors/.
National Indian Health Board (NIHB)
The NIHB represents Tribal Governments operating their own healthcare delivery
systems through contracting and compacting, as well as those receiving healthcare directly from
the Indian Health Service (IHS). Contact Information: 101 Constitution Ave. N.W., Suite 8-B02,
Washington, D.C. 20001, Phone: (202) 742-4262, Fax: (202) 742-4285, web site: www.nihb.ors.
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Contacts and References
IX.
CONTACTS/ACKNOWLEDGMENTS/RESOURCE MATERIALS/
BIBLIOGRAPHY
For further information on selected topics within the healthcare industry, a list of
publications and contacts is provided below:
IX.A.
Contacts/Document Reviewers11
Name
Seth Heminway
Anuj K. Goel, Esq.
Charlotte A. Smith,
R. Ph., M.S., HEM
Laura Brannen
Jeffrey Keohane
Eydie Pines
Fawzi M. Awad,
M.S.,E.H.S. II
Catherine Galligan
Kathleen Malone
Organization
EPA, Office of
Compliance
Director, Regulatory
Compliance,
Massachusetts
Hospital Association
President,
PharmEcology
Associates, LLC
Hospitals for a
Healthy Environment
Karshmer &
Associates (P.C.)
Hospitals for a
Healthy Environment
Saint Paul-Ramsey
County Department of
Public Health,
Environmental Health
Section
Sustainable Hospitals
Project Clearinghouse
Manager
EPA, Region 2
Telephone/Email
(202)564-70177
heminway.seth(q),epamail. epa.gov
(781) 272-8000, ext. 140 /
asoel(a),mhalink. ors
(262)814-26357
info&pharmecolosv. com
(603) 643-6700 /
laura. brannen(a)h2e-online. ors
(510)841-50567
keohane&karshmerindianlaw. com
(603)643-67107
eydie. pines(a)h2e-online. ors
(651)773-44597
fawzi.awad(a),co.ramsev.mn.us
(978) 934-3386 7
shp(S>,uml.edu
(212) 637-4083 7
malone. kathleen(a),epa.sov
Subject
Overall Notebook
Content and General
Format
Characterization of the
Healthcare Industry
Activity Descriptions
Hospital Wastes
Environmental
Regulations on Indian
Country
Pharmaceutical Waste
Minnesota Pollution
Control Agency Fact
Sheets
Healthcare Wastes and
Sustainable Hospitals
Project Fact Sheets
Federal Statutes and
Regulations
11 Many of the contacts listed in this section have provided valuable background information and comments during
the development of this document. EPA appreciates this support and acknowledges that the individuals listed do not
necessarily endorse all statements made within this Notebook.
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Healthcare Industry
Contacts and References
Name
Susan A. Moak,
CHSP
Linda Longo
Linda Martin
Michelle Yaras
Marvin Stillman
Glenn McRae
Hollie Schaner, RN,
FAAN
Dale Woodin
Cathy Knox
Chen Wen
John Gorman
Diane Buxbaum,
M.P.H.
Diane Lynne
Organization
Director of
Occupational and
Environmental Safety,
Long Island Jewish
Medical Center
Regional Compliance
Assistance
Coordinator
EPA Region 2
Veterans Health
Administration
EPA, Office of
Compliance -
Agriculture Division
Manager of
Environmental
Compliance
University of
Rochester Strong
Memorial Hospital
CGH Environmental
Strategies, Inc.
CGH Environmental
Strategies, Inc.
Deputy Executive
Director, American
Society of Healthcare
Engineering (ASHE)
Director, EHS Parker
Hughes Cancer Clinic
(PHCC)
EPA, Office of
Pollution Prevention
and Toxics
EPA, Region 2
EPA, Region 2
EPA, Federal
Facilities Enforcement
Office
Telephone/Email
(718)470-47847
Smoak(a),lij. edu
(212)637-35657
lonzo. linda(a),epa.£ov
(314)543-67197
linda.martinS&rned.va.sov
(202) 564-4153 7
varas. michelle(S>,epa.sov
mstillman(q)facilities.rochester.edu
(802) 658-5863 7
cshenviro(q),aol. com
(802) 658-5863 7
czhenviro&,aol. com
(312)422-38137
dwoodin(q),aha. ors
cknox(a),ih.ors
(202) 564-8849 7
wen.chen(ai,epa.gov
(212) 637-4008 7
sorman. iohn(q),epa.£ov
(212)637-39197
buxbaum. diane(a),epa.sov
(202) 564-2587 7
diane. lynne(q),epa.gov
Subject
Overall Notebook
Content
Federal Statutes and
Regulations
Overall Notebook
Content
FIFRA Information
Overall Notebook
Content
Overall Notebook
Content
Overall Notebook
Content
Healthcare Wastes
Healthcare Wastes
H2E
Hazardous Waste
Compliance
Industry Specific
Environmental
Requirements
EPA- Veterans Health
Administration (VHA)
Compliance Assistance
Programs
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February 2005
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Healthcare Industry
Contacts and References
Name
Linda Martin
Michael Pagan
Jan Pickrel
Daniel Schultheisz
Carey Johnston
Kristina Meson
Organization
Veterans Health
Administration
EPA, Region 10 H2E
Coordinator
EPA, Water Permits
Division, Industrial
Branch
EPA, Radiation
Division
EPA, Office of Water
EPA, Office of Solid
Waste
Telephone/Email
(314)543-67197
linda.martinS&rned.va.sov
(206) 553-6646 /
fascm.michael(a),epa.sov
(202) 564-7904 /
pickrel.ian(a)epa. sov
(202) 343-9349 /
schultheisz. daniel(a),epa.sov
(202)566-10147
Johnston, carev(a),epa. sov
(703) 308-8488 /
meson. kristina(a),epa.sov
Subject
EPA- Veterans Health
Administration (VHA)
Compliance Assistance
Programs
Web Site Information
Healthcare Wastewater
Mixed Waste
Healthcare Wastewater
Hazardous Waste
IX.B.
Bibliography
Below is a list of references used in compiling this Sector Notebook, by section.
The Healthcare Environmental Resource Center contains additional details on most of the
subjects touched on in this Notebook and is an excellent follow-up reference for locating
information on state and local requirements. For your convenience, the Center maintains
current URLs for all of the sites mentioned in this document at www.HERCenter. org.
Section II - Introduction to the Healthcare Industry
American Hospital Association, http://www.hospitalconnect.com/aha/resource center/
fastfacts/fastj'acts_UShospitals.html
The Centers for Medicare & Medicaid Services (CMS), http://www.cms.hhs.gov/.
The MedPAC reports, http://www. medpac. gov/.
U.S. Census Bureau, http://www.census.gov/prod/ec97/97s62-sz.pdf.
Webster's Medical Dictionary, http://www.abms.org/Downloads/Which%2OMed%2OSpec.pdf.
The American Veterinary Medical Association, http://www.avma. org/membshp/marketstats/
usvets.asp. Note: veterinary market statistics 2003 Economic Report on Veterinarians &
Veterinary Practices is available for purchase
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February 2005
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Healthcare Industry Contacts and References
The TrendWatch report by the Lewin Group released at the 2004 AHA Annual Meeting in
Washington, •www.hospitalconnect.com/aha/pressj-oom-info/specialstudies.html.
Section III - Activity Descriptions
Centers for Disease Control and Prevention, http://www.cdc.gov/ncidod/hip/sterile/sterilgp.htm
Hospitals for a Healthy Environment (H2E),
http:V/www..h2e-onlme.org/pubs/chemmm/master.pdf
http://www.h2e-onlme.org/pubs/wrgmde/wappe.pdf.
Occupational Health and Safety Administration,
http://www. osha. gov/SL TC/e tools/hospital/index, html.
PRO ACT, http://www. afcee. brooks, af.mil/pro-act/pro-acthome. asp.
U.S. EPA Region 2 presentation. Identification and Management of Regulated Hazardous
Waste, A Workshop Geared Toward Healthcare Facilities, February 2004.
U.S. EPA Region 2, Draft Healthcare Hazardous Waste Management, February 2004.
U.S. EPA Region 3, http://www.epa.gov/reg3artd/airregulations/ap22/incin2.htm.
World Healthcare Organization,
http://www.who.int/water sanitation health/medicalwaste/en/guide2.pdf.
Emmanuel, Jorge,Ph.D., CHMM, REP, PE. Non-Incineration Medical Waste Treatment
Technologies. Health Care Without Harm, August 2001,
http://www.noharm.org/nonincineration.
Hospitals for a Healthy Environment (H2E). Managing Healthcare's Waste: Developing a
Pollution Prevention Model, http://www.h2e-online.org/.
Shaner, H.G., C.L. Bisson, G. McRae. An Ounce of Prevention: Waste Reduction Strategies for
Health Care Facilities. American Society of Healthcare Environmental Services,
Chicago, 1993.
Shaner, HG, G. McRae. Guidebook for Hospital Waste Reduction Planning and Program
Implementation. American Society of Healthcare Environmental Services. Chicago,
1996.
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Healthcare Industry Contacts and References
Smith, Charlotte A. Identifying and Managing Hazardous Pharmaceutical Waste.
PharmEcology Associates, LLC. H2E Teleconference, September 12, 2003,
http://www.h2e-online. org/tools/chem-pharm.htm.
University of Iowa Virtual Hospital Site, http://www.vh. org/welcome/aboutus/index. html.
U.S. Department of Labor Program Highlights Fact Sheet No. OSHA 91-38. Waste Anesthetic
Gases., http://www.osha.gov/pls/oshaweb/owadisp.show document?
p table=FACT SHEETS&p id=128.
Section IV - Waste and Emissions Profile
EPA's Hospital/Medical/Infectious Waste Incinerators,
http://www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html.
Health Care Without Harm, http://www.noharm.org/library/docs /SHEA Proceedings_Waste_
Management White Paper.pdf;
http://www.noharm.org/library/docs/Going Green 4-1 Waste Minimization
Segregation.pdf;
http://www.noharm.org/nonincineration;
http://www.noharm.org/details. cfm?type =document&id=599; and
http://www.noharm.org/library/docs/Going Green The^Mercury Problem - Fast Fact
s.pdf.
Hospitals for a Healthy Environment, http://www.h2e-online.org/tools/chemplan.htm.
U.S. EPA FRN 40 CFR Part 60 Standards of Performance for New Stationary Sources and
Emission Guidelines for Existing Sources: Hospital/Medical/Infectious Waste
Incinerators; Final Rule September 15, 1997,
http://www.epa.gov/ttn/atw/129/hmiwi/fr91597.pdf.
U.S. EPA Region 2 presentation. Identification and Management of Regulated Hazardous
Waste, A Workshop Geared Toward Healthcare Facilities, February 2004.
U.S. EPA Region 2. Draft Healthcare Hazardous Waste Management, February 2004.
Western Regional Pollution Prevention Network,
http://www. w estp2ne t. org/hospital/pdf/Minimizing%2 ORed%2 OBag%2 0 Waste.ppt.
World Health Organization, http://www.who. int/inf-fs/en/fact253.html.
Environmentally Conscious Manufacturing Strategic Initiative Group. Hospitals and Health
Care Impacts, Risks and Regulations, http://ecm. ncms. org/eri/new/IRRhosp. htm.
www. her center, org/links 140 February 2005
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Healthcare Industry Contacts and References
Kentucky Cancer Registry Online Abstractor Manual, Appendix H,
http://www. her, uky. e dii/manuals/abstractor/appendix h.pdf.
Section V - Pollution Prevention Opportunities
California Integrated Waste Management Board. Fact Sheet: Waste Reduction Activities for
Hospitals, December 2003.
Davis, Stephanie C. 10 Ways to Reduce Regulated Medical Wastes (RMW). Waste Reduction
Remedies, June 2002.
Health Care Without Harm. Non-Incineration Medical Waste Treatment Technologies, August
2001.
Shaner, H.G., C.L. Bission, G. McRae. An Ounce of Prevention: Waste Reduction Strategies
for Health Care Facilities. American Society of Healthcare Environmental Services,
Chicago, 1993.
Shapiro, Karen, et.al. Healthy Hospitals: Environmental Improvements Through Environmental
Accounting. Tellus Institute, Submitted to U.S. EPA's Office of Prevention, Pesticides
and Toxic Substances, Boston, MA, July 2000.
Sustainable Hospitals Project Fact Sheets: These are available online at
http://www.sustainablehospitals. org. Over two dozen short, informative summaries
address EPP, Glutaraldehyde, Laboratory Practices, Latex & Medical Gloves, Mercury,
Microfiber Mopping, and Safe Sharps Devices. (Note: A list of SHP fact sheets follows
this table). Contact: Catherine Galligan, SHP Clearinghouse Manager, phone (978) 934-
3386 or shp(q)uml.edu.
Minnesota Pollution Control Agency Health Care Fact Sheets: These are available online at
http://www.pca. state.mn. us/industry/healthcare, html. Over three dozen short,
informative summaries covering all aspects of the healthcare industry.
Section VI - Summary of Federal Statutes and Regulations
U.S. Army Center for Health Promotion and Preventive Medicine. Management of Unused
Pharmaceutical Nitroglycerin, http://chppm-www.apgea.army.mil/documents/FACT/37-
019-702.pdf.
U.S. EPA Monthly Hotline Report December 1994 RCRA/UST, Superfund, and EPCRA.
Notification Requirements for Exported Wastes,
htty://www.eva.sov/eyaoswer/hotline/94reyort/12 94. txt.
www. her center, org/links 141 February 2005
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Healthcare Industry _ Contacts and References
U.S. EPA Region 2 presentation dated February 2004. Identification and Management of
Regulated Hazardous Waste, A Workshop Geared Toward Healthcare Facilities.
U.S. EPA Region 2. Draft Healthcare Hazardous Waste Management, February 2004.
Kentucky Pollution Prevention Center. Healthcare Guide to Pollution Prevention
Implementation through Environmental Management Systems.,
http://www. kppc. org/Publications/Print%2 OMaterials/Healthcare %2 OGuide/index. cfm .
Electronic Code of Federal Regulations (e-CFR) BETA TEST SITE for 40 CFR:
http://ecfr.gpoaccess.gOV/cgi/t/text/text-idx? &c=ecfr&tpl=/ecfrbrowse/Title40/40tab 02.
The Office of Wastewater Management, NPDES Stormwater Program web site:
http://www.epa.gov/npdes/stormwater.
EPA's Office of Solid Waste and Emergency Response web site:
http://www. epa. gov/epaoswer/osw/laws-reg. htm .
EPA's Oil Program web site: http://www. epa. gov/oilspill/ .
EPA' s Poly chlorinated Biphenyl (PCB) Homepage, http://www. epa.gov/pcb/.
EPA's Air Program Mobile Sources web site:
http://www. epa. gov/ebtpages/airmobile sources, html.
EPA's Asbestos Management and Regulatory Requirements web site:
http://www. eya.sov/fedsite/cd/asbestos. html.
www. her center, org/links 142 February 2005
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Healthcare Guide
to
Pollution Prevention Implementation
through
Environmental Management Systems
i i
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Acknowledgements
This manual was developed under funding from a U.S. Environmental Protection
Agency Pollution Prevention Incentives for States grant (contract #NP-9849-7100-1).
Authors
Shannon-Melissa Dunlop Tim Piero Marcie Wingfield
St. Mary's General Hospital Kentucky Pollution Kentucky Pollution
Kitchener, ON Canada Prevention Center Prevention Center
Mention of trade names, products, or services does not constitute, and should not be
interpreted as constituting, an actual or implied endorsement or recommendation for
use by U.S. EPA, the authors, the Kentucky Pollution Prevention Center, St. Mary's
General Hospital, Cambridge Memorial Hospital, or any other organization(s) affiliated
with or mentioned in this manual.
Considerable effort has been taken to ensure the accuracy of information in this manual.
Regulatory requirements can vary based on locale. Please verify your requirements with
applicable federal, state, and local authorities.
September, 2002
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Table of Contents
Section 1: Introduction
Section 2: What is an Environmental Management
System (EMS)? What do they mean for Healthcare?
What is an Environmental Management System? 7
Benefits of an EMS 18
Cost Savings through EMS Implementation 18
Accountability 19
Consistent, Reliable Results 19
Measurement 19
Due Diligence and Improved Compliance 20
From Putting out Fires to Planning Ahead 20
Greater Staff Environmental Awareness and
Commitment 20
Continual Improvement 20
Managerial Points to Ponder 23
One size does not fit all 23
Pay attention to culture 23
Be open to new participants in the
environmental program 23
Think effective planning and
project management 24
Build on what s in place 24
Approach to Implementing and EMS 24
Section 3: Getting Support and Getting Started
Overview of Hospital Corporate Structure and
EMS Roles and Responsibilities 25
Board of Trustees 25
Senior Management 25
Middle Management 26
Hospital Employees 27
Getting Support and Buy-In for and EMS 27
Senior Management 27
Hospital Staff 29
Choosing your EMS Representative(s) 31
EMS Management Representative 31
Environmental Coordinator/ EMS Specialist 34
Choosing your EMS Team 34
Green Team Expectations 36
Meeting Structure 37
Education 38
Facilitating Open Communication 38
Reporting Structure 38
Legal and Other Requirements 38
Audits 44
Types of audits 44
Effective Auditing tips and techniques 45
Corrective and Preventive Action Systems 47
Section 4: General Pollution Prevention
General Pollution Prevention Opportunities 61
Solid Waste 61
Purchasing, Packaging and Solid Waste 64
EPP Options 65
Regulated Medical Waste 66
Persistent Bioaccumulative Toxins 68
Mercury 68
Mercury Spill Case Study 71
Source Reduction Opportunities for Mercury ... 72
Material Substitution 72
Recycling Opportunities for Mercury 73
Polyvinyl Chloride (PVC) and Dioxin 74
Polychlorinated Biphenyls (PCBs) 76
Common Areas for Hospital Pollution Prevention....76
Energy Efficiency 76
Pharmacy 77
Source Reduction Opportunities 78
Hazardous Wastes 78
Inventory Control for Hazardous Wastes 78
Secondary Containment for Hazardous Wastes. 79
Cleaning and Common Laboratory Chemicals . 80
Source Reduction Opportunities 80
Materials Substitution 80
Work Practices 82
Chemotherapy and Antineoplastics Waste 86
Source Reduction Opportunities 86
Formaldehyde 86
Source Reduction Opportunities 86
Procedure Modifications 87
Dialyzers 87
Recycling and Reuse 87
Radiation Therapy 87
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Section 4: General Pollution Prevention (cont.)
Source Reduction Opportunities 88
Radiology 88
Source Reduction Opportunities 88
Recycling Opportunities 89
Xylene 89
Source Reduction Opportunities 89
Materials Substitution 89
Procedure Modification 90
Inventory Control 90
Recycling Opportunities for Xylene 90
Fluorescent Lights 91
Source Reduction Opportunities 91
Maintenance Wastes and Recyclables 91
Aerosols 91
Source Reduction Opportunities 91
Inventory Control 91
Recycling Opportunities 92
Batteries 92
Source Reduction Opportunities 92
Recycling Opportunities 92
Laundry and Laundry Detergents 93
Source Reduction Opportunities 93
Training and Technology Modification 93
Paints 93
Source Reduction Opportunities 93
Material Substitution 93
Inventory Control 94
Training 94
Recycling 94
Pesticides and Landscaping 95
Source Reduction Opportunities 95
Section 5: Planning and Managing the EMS
Environmental Aspects & Impacts and
Determining Significance 99
Introduction 99
Roles and Responsibilities in
Identifying Aspects and Impacts 103
Determining Significance 104
Change Management and
Continual Improvement 105
Helpful Hints for Getting Started 106
Objectives and Targets 107
Setting Performance-Based Objectives
and Targets 107
Implementation Tips 108
Environmental Management Programs 109
Biomedical Waste Reduction BMP 110
Recycling and Reuse BMP 112
Spill Response and Emergency
Preparedness BMP 113
Landscaping Practice BMP 114
Environmental Policy 116
Developing the Policy 116
Things to Consider When Writing the Policy ..117
Communicating the Environmental Policy 118
Hospital Staff 118
Patients, Visitors, and Community 119
Contractors and Suppliers 120
Operational Controls 122
Hospital Considerations 122
Contractors and Suppliers 122
Monitoring and Measuring 123
EMS Auditing 124
Auditing Program Components 124
Audit Program Tips 126
Emergency Preparedness and Response 126
Overview of Requirements 126
Implementation Tips 127
Training 128
Types of Training 128
Getting Started 133
Frequency of Training 133
Lessons Learned 133
Communication 134
External Communication 134
Internal Communication 135
Documentation/Document Control 135
Recordkeeping 135
Management Review 139
Additional System Examples 140
Section 6: Continual Improvement
Section 7: Resources
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Introduction
"Health care has an ethical duty to do no harm to human health. The reality is that, as a
significant economic sector, its operations inadvertently cause harm to the environment
and thus to human health. In short, health care has a significant ecological footprint,
which has important implications for the health of this and future generations." Source:
Green Hospitals: Success Stories of Environmentally-Responsible Health Care", The
Canadian Coalition for Green Health Care, October, 2001 pg. 1
"It is incompatible with the mission of the institutions devoted to healing to be
significant consumers of resources and sources of environmental harm through air and
wastewater emissions, hazardous and solid waste generation, greenhouse gas emissions,
and toxic chemical usage." Source: Canadian Centre for Pollution Prevention, 2001
Medical waste incineration, persistent bio-accumulative toxins (PBT) such as
mercury, and hazardous material use and waste disposal have all heightened public and
political scrutiny of the healthcare industry's impacts on the environment as well as on
the health of hospital visitors, patients, staff and the surrounding community. Given
healthcare's mission to promote health and wellness, hospitals need to continue
proactively managing activities, products, and services to minimize these significant
impacts.
While many organizations, including hospitals, strive to take on voluntary
environmental initiatives such as pollution prevention, these efforts often fail to take root
over extended periods of time due to the lack of an organizational, systematic
environmental management framework. This can result in an environmental compliance
focus only, missed cost savings that can help the bottom line, and the missed opportunity
to boost morale by involving employees in something they generally feel good about—
helping the environment. These are opportunities few hospitals can afford to miss in the
industries' rigorous, if not exacting, competitive climate.
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Environmental management systems (EMS) represent a new way of doing
business. The EMS approach takes proven business principles and applies them to
environmental performance. EMSs promote continual improvement by challenging your
hospital to identify all of its environmental impacts, determine which are most important,
and set performance-based objectives and targets to minimize these impacts on an
ongoing basis. This prioritization is a tremendous benefit.
There are many additional EMS benefits. Foremost among these is improved
hospital reputation and image. EMSs open up environmental communication between
the hospital and key stakeholders including employees and the community. An EMS will
challenge you to seek community input when determining which environmental impacts
to address first. This communication puts you on the road to improved community
relations, enhanced reputation and image, and ultimately to healthier patients, visitors,
staff, and neighbors.
This manual was prepared to provide Kentucky hospitals with guidelines for the
reduction of PBTs and pollution prevention through an EMS approach. Our intent is to
provide you with this information in a clear, concise fashion consistent with the needs of
the healthcare industry.
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What are Environmental Management Systems?
What Do They Mean for Healthcare?
What is an Environmental Management System (EMS)?
EMSs are business systems that allow you to manage your hospital's
environmental issues in a systematic, organized fashion based on continual improvement-
just like any other business area such as quality, accounting and payroll, inventory
management, and cash flow. Like these other areas, EMSs focus on top management
support and commitment, accountability/responsibility, employee involvement and
training, documentation, operational controls, and periodic checking and review with
corrective action. You likely have environmental policies, procedures, pollution
prevention (P2) initiatives, and regulatory tracking and compliance efforts already in
place. An EMS simply formalizes, builds on, and consolidates these into a more easily
managed system that can result in a number of benefits for you and your company.
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EMS Component Descriptions
ENVIRONMENTAL
POLICY
PLANNING
IMPLEMENTATION & OPERATION
CHECKING &
CORRECTIVE
ACTION
Environmental
Aspects and
Impacts
Legal and Other
Requirements
Environmental
Objectives and
Targets
Environmental
Management
Programs
Structure and
Responsibility
Training,
Awareness and
Competence
Communication
EMS
Documentation
Document
Control
Operational
Control
Emergency
Preparedness and
Response
Monitoring and
Measurement
Nonconformance
and Corrective
and Preventative
Action
Records
EMS Audits
MANAGEMENT REVIEW
A statement of a facility's environmental
intentions.
An analysis of the hospital's activities, products,
services to identify those that may have a
"significant" impact on the environment.
Providing a method for identifying, applying and
updating all environmental compliance
requirements.
Setting achievable goals based on the hospital's
"significant" aspects or issues, legal requirements,
financial capabilities, etc.
Developing specific actions, designating resources
and timelines for the completion of your
environmental objectives and targets.
Determine responsibilities under the EMS
(ensuring that adequate resources are allocated) .
Ensure that hospital staff receives training
(relating to their environmental responsibilities).
Establish methods for relaying and documenting
environmental communications with staff,
patients, visitors, contractors, etc.
Maintain all EMS related documentation to
ensure that they are available, up-to-date, and
obsolete documents are promptly removed.
Ensure that all documentation (policies,
procedures, etc.) are controlled, dated, approved,
and reviewed.
Review operating procedures relate to
positions/processes so that significant
environmental impacts are addressed. Train staff
on the importance of conforming to the
procedures.
Establish procedures for addressing
environmental disasters and accidental releases to
air, land and water.
Track key components of your environmental
performance.
Provide a means for documenting environmental
issues/hazards. Identify corrective and/or
preventative actions to prevent reoccurrence.
Maintain records that relate to environmental
performance, compliance, inspections, etc.
Perform periodic audits to ensure that all
components of your EMS are working properly.
Provide EMS-related information to senior
management for periodic review and/or approval
to ensure continual improvement of your system.
Similar to a hospital's mission statement, health and
safety policy, etc.
Examples: use, handling and proper disposal of
radioactive materials, use of significant amounts of
energy and water in facilities management, etc.
Also include voluntary or industry specific codes,
(Accreditation Standards), memorandums of
understanding, codes of practice, etc.
Can be hospital-wide (ex- reducing energy use) or
department-specific (ex. implementing an organics-
recycling program in Food Services.)
Use as a way to determine budgetary requirements for
implementation of an objective.
Include the roles of Senior Management, management,
front-line staff, patients, contractors, etc.
Some training may require general awareness (ex.
overall knowledge of environmental policy) and others
may require competence (ex. spill training) .
Use existing modes of internal communications when
possible (i.e. hospital newsletters, emails, displays,
posters, staff meetings, etc.)
Think about computerizing your EMS manual (if you
have a hospital-wide system that is available to all
staff) . Updating and editing a computerized system
requires much less time than using a number of paper
manuals) .
Utilize existing hospital formats/templates of
procedure/policy documentation.
Example: ensure all staff handling chemicals (especially
Laboratory, Diagnostic, Housekeeping, and
Maintenance staff) are aware of, and utilize proper
chemical handling, transport and disposal procedures.
Hospitals commonly use universal "Emergency Codes"
(i.e. Code Red- Fire, Code Brown- Chemical Spills,
etc.)
Track the progress of your objectives, occurrence of
regulatory inspections, calibration records, etc.)
Tap into existing means for reporting hazards and
incidents (i.e. Employee Incident Reporting Forms,
departmental inspections, etc.)
Keep in a centralized location (if possible the EMS
Administrator's office/work area)
Example: Form an EMS Audit team of a few keen staff
members.
Tap into existing reporting structures (i.e. monthly
reports, annual reviews, management meetings, etc.)
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You will see the term ISO 14001 throughout this manual. ISO 14001 is the international
benchmark against which most EMSs are compared for registration purposes. Registration
means that independent third party auditors come to your hospital and assess your system
against the standard for completeness. You can achieve many of the same benefits of
having an EMS whether or not you pursue registration. This manual follows the ISO
14001 standard as the template for implementing an EMS.
EMSs and healthcare is a very new concept. Currently, only two hospitals in
North America are ISO 14001 registered: Cambridge Memorial Hospital, and St. Mary's
General Hospital in Ontario, Canada.
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CAMBRIDGE MEMORIAL HOSPITAL
700 Coronation Blvd.
Cambridge, ON N1R 3G2
1.0 Background Information
Cambridge Memorial Hospital is a 277-bed facility providing the 120,000 residents of
Cambridge and North Dumfries with acute, ambulatory, and long-term care services. This
health care facility was the first hospital in North America to implement an EMS and
obtain ISO 14001 registration.
2.0 Why did CMH implement an EMS?
During recent years, the Board of Directors established a new vision, moving from a
model of "curing the sick" to one focused on improving the health of the community and
the local environment. Implementing an EMS was seen as a milestone in achieving this
vision.
3.0 How did CMH implement its EMS
In June 1998, CMH's Board of Directors approved an environmental policy for the
hospital, marking the beginning of EMS implementation. Work on the EMS
implementation continued through year 2000.
4.0 What has Cambridge achieved through the EMS?
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Cambridge Memorial achieved a 20% reduction in biomedical waste in each of the
first two years of EMS operation. Cambridge implemented an integrated pest
management program, eliminating the use of chemical pesticides and herbicides, and
added criteria for energy conservation to consider in selecting new products and
equipment. As part of its chemical substitution program, Cambridge Memorial Hospital
has initiated a mercury-free medicine campaign to phase out mercury-containing products
and eliminate the release of mercury to the environment. Just prior to EMS inception in
May 1998, the hospital shut down the 25-year old incinerator, eliminating its contribution
to local air pollution and reducing greenhouse gas and energy consumption. Staff training
and community awareness has been key to meeting the hospital's environmental goals.
CMH actively pursues green team initiatives to promote environmentally friendlier and
healthier alternatives to transportation such as car-pooling, public transportation, biking,
walking, etc. Sustainable building design is a key element used in planning a new
115,000 square foot addition to the hospital, which has participated in the Commercial
Building Incentive Program (CBIP) and C-2000 Advanced Commercial Building
Program through the Office of Energy Efficiency in Natural Resources Canada. CBIP
buildings must use less than half the energy of conventionally designed buildings.
Highlights:
Initiated a Mercury Free Medicine Campaign
The Cambridge GREEN Team made a formal pledge to develop a comprehensive
program to eliminate the release of mercury to the environment. A mercury audit was
completed to identify all mercury sources. Twenty-one staff, encompassing hospital 3
areas, received education in-service sessions to alert the staff about mercury spills
response procedures as well as the environmental and health consequences of the use of
mercury. Measures continue to be implemented to phase out mercury-containing
products such as blood pressure measuring devices. A final SWEEP throughout CMH
was completed to verify that all Hg blood pressure cuffs and thermometers have been
properly removed and replaced.
Pollution Prevention Pledge Project
CMH pledged a 30% reduction in biomedical waste as part of the Ministry of the
Environment P2 Pledge Program (P4). The P4 program is a voluntary initiative that
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encourages companies and organizations to commit to reducing pollutant releases,
hazardous or liquid industrial waste or toxic chemicals. Cambridge's reduction in
biomedical waste in 1999 earned the P3 Reduction Achievement Award. CMH continued
its track record with a 20% reduction in 2000.
4.0 Lessons Learned
Creating a green team helps implement initiatives faster. Staff training and
persistence are key to success.
5.0 Contact:
Mary Jane Hanley,
Environmental Specialist,
Cambridge Memorial Hospital
Tel: 519-621-2333 ext.1720
Fax: 519-740-4928
Email: mhanley@cmh.org
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ST. MARY'S GENERAL HOSPITAL
911 Queens Boulevard.
Kitchener, ON, Canada
N2M 1B2
1.0 Background Information
St. Mary's General Hospital is a 168-bed facility serving nearly 500,000 people in
southern Ontario. St. Mary's was recently designated the region's Cardiac Care Center.
The hospital began developing its EMS under a university-planned venture between
St. Mary's, Cambridge Memorial Hospital, Cambridge, Ontario and the University of
Waterloo, Waterloo Ontario. In October 2001, St. Mary's became ISO 14001-registered,
the second North American hospital to achieve this distinction. As a result of the
hospital's EMS, St. Mary's has been the honored recipient of a number of provincial and
regional awards.
2.0 Why did St. Mary's implement an EMS?
Board of Trustee environmental concerns about chemical usage spearheaded an initial
investigation of how the hospital managed its environmental affairs. Investigation results
lead to additional Board and Senior Management-level discussions concerning other
environmental issues and identified the need for the hospital to proactively address its
internal and external environment.
3.0 How did St. Mary's implement its EMS?
After reviewing recommendations outlined in reports from a local university
environmental class, the hospital's Director of Facilities Services brought the idea of an
EMS to the Senior Management Team and Board of Trustees. The Board hired a recent
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graduate to implement the EMS. Through this joint-hospital effort with Cambridge
Memorial, St. Mary's planned, developed and implemented its EMS using the ISO 14001
standard as a guide.
St. Mary's is committed to promoting "Health care for a Healthy Environment" and
through continual environmental education, promotion and awareness, all levels of
hospital staff and volunteers become aware and participate in the hospital's
environmental pledge.
4.0 What has St. Mary's achieved through its EMS?
The principle EMS accomplishments to date include the following.
Waste Management
Improved biomedical waste segregation and establishment of comprehensive
recycling programs are two key achievements. Since 1998, St. Mary's has reduced
biomedical waste by 38% (by weight) implemented programs to recycle the
following.
• Glass, cans (aluminum & steel), plastic, newspaper, cardboard, boxboard,
paper (all grades), alkaline and nickel-cadmium batteries, all-types of metal,
photocopier cartridges, cold packs, Styrofoam boxes.
• Fluorescent tubes. St. Mary's recycled the mercury, glass, aluminum, and
phosphor powder in over 2000 florescent tubes.
• Cardboard through a take-back program with its suppliers.
• Unused patient and cafeteria food through a local organics composting
company.
• Biomedical waste containers through newly selected medical waste hauler.
Energy Conservation
St. Mary's "energy plan" addresses new construction and renovation projects;
equipment (lighting, powerhouse equipment, etc.); and internal energy education/
communication of hospital staff. The hospital formed a multi-disciplinary team of
energy conservation consultant, architects, mechanical and electrical engineers to
design an energy-friendly addition to house its new Cardiac Care Center. Design
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plans will allow St Mary's to reduce energy usage 30% compared to conventionally
designed buildings.
In addition, St. Mary's:
• Purchased a hydro usage software program to identify and target energy usage
patterns;
• Performed a steam trap survey and implemented resulting recommendations;
• Replaced all T12 fixtures with more energy-efficient T8s;
• Developed an energy education program with a mascot that provides energy tips
and reminders;
• Formed an "Energy Team" to standardize purchases of energy-conserving office
equipment and small appliances;
• Plans to upgrade to more energy-efficient windows.
Landscape Management
In 2000, St. Mary's was among the first hospitals in Ontario to eliminate chemical
pesticide and herbicide usage on hospital grounds. By working with the hospital's
current landscaping company and landscaping professionals, St. Mary's has
maintained a healthy, chemical free landscape. St. Mary's no longer mows on smog-
alert days. Newly designed landscape plans will incorporate, where possible, drought
resistant/salt tolerant/native plants, ground covers, and other environmentally
conscious options.
Alternative Transportation
To promote green transportation St. Mary's has:
• Circulated an "Employee Alternative Transportation Survey" for staff to evaluate
transportation habits and identify future initiatives that the hospital staff would
like to see;
• Purchased additional bike racks;
• Implemented a "Share-a-Ride" program on the hospital's internal email system
that allows staff wishing to carpool to find another individual in their area;
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This goal is ongoing and future plans have been developed to provide staff with
discounted bus passes, safe biking lessons, and improved showering facilities.
Chemical Recycling & Wastewater Discharges
St. Mary's is a member of the Health Care Without Harm's Mercury Medicine
campaign. To date, the hospital has eliminated all mercury containing devices in
patient care areas. The hospital is working to identify alternatives for pressure and
floating switches in powerhouse equipment and to find a replacement for the mercury
thermometer standard for calibrating medical equipment.
Through a regional business water quality program, St. Mary's has identified and
re-mediated many water-polluting processes. In particular, St. Mary's installed
xylene and formalin recycling equipment and eliminated related discharges.
5.0 Lessons Learned
Senior Management Approval and Support
Senior Management support and buy-in is critical and needs communicated to all
staff prior to starting the process. A letter of support circulated throughout the hospital is
one way to communicate this support.
Staff Involvement
Everyone has responsibilities under the EMS- not just the EMS Representative.
Ensure that you ask staff (front line, nursing, physicians and management) to participate
in the EMS wherever and whenever possible (i.e. Green Team, hospital auditing team,
implementing objectives and targets, fun initiatives, etc.).
Integration of Documentation
Designing an EMS involves the development of policies, procedures and work
instructions by the EMS Representative and Department Managers/Supervisors. Ensure
you integrate all document formats with the hospital's existing systems.
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Recognize the Efforts of Individuals and Departments
To maintain momentum, formally recognize individuals and departments that
demonstrate enthusiasm, participation and involvement in the EMS.
Be Creative
Come up with fun ideas and initiatives to get your staff involved. Use existing
national holidays such as Earth Day to organize fun events.
6.0 Contact:
Shannon-Melissa Dunlop
Environment, Health and Safety Specialist
St. Mary's General Hospital
Tel: (519) 749-6406
Fax: (519)749-6426
Email: sdunlop@stmaryshosp.on.ca
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Benefits of an EMS
Cost Savings through EMS Implementation
Hospitals have a wide variety of activities, products, and services including
emergency care facilities, laboratories, diagnostic clinics, offices, operating suites,
pharmacies, warehouses, sterilization services, restaurants, and massive power
plants. These areas use tremendous resources and can generate biomedical,
hazardous and solid waste. All have opportunities that can help your bottom line
and free money for new projects. In general, it is difficult to estimate how much
money an EMS can save you, but having an EMS systemizes the search for,
review, and implementation of cost saving opportunities through the setting of Pi-
oriented objectives and targets. There are a number of hospital-specific EMS
objectives that can provide this outcome.
1. Energy conservation. A well-designed and researched energy conservation
strategy can provide significant immediate, short and long-term cost saving
benefits. Saint Joseph's Medical Center in Yonkers, New York achieved
savings of "more than $250,000 a year" through energy conservation efforts.
(Source: Dunn, Philip, Hospitals and Health Network). When planning an
energy program, look at a performance based contracts. Contractors earn a
percentage of their total costs back if they meet a minimum overall energy
savings level for your hospital.
2. Solid Waste Reduction. You may find that 70-80% of your biomedical waste
stream is actually daily waste such as paper towels, disposable packaging, and
coffee cups. You can reduce red bag fees by keeping these wastes separate.
3. Environmentally Preferable Purchasing, or EPP. Hospitals are relatively new
to the "green" products market but are large consumers of good and services.
For example, purchasing mercury-free products helps the environment by not
putting toxic chemicals into the supply chain. Contact your supplier(s) and
ask to be a hospital "test site" for environmentally preferred products. If your
management agrees, a company can use your product trial data to approach
other health care facilities and earn more business. In turn, your hospital may
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be able to negotiate a decreased cost for buying the product. This can be a
valuable hospital strategy, particularly if you are in search for environmentally
friendly substitutes.
By investigating environmental opportunities for your hospital you may
come across environmental funding prospects through local business, local
government or state funded programs. Look to local P2 centers and state
authorities for information on any of these programs in your area (see the
National Pollution Prevention Roundtable yellow pages at www.nppr.org for
contacts).
Accountability
Traditionally, environmental affairs have been delegated from upper management
to environmental specialists and away from the rest of a hospital's operations. When an
EMS is in place, all employees, including upper management, have responsibility for
overseeing and ensuring environmental performance. All are accountable for compliance
with standards and requirements. Upper management is responsible for providing
resources needed for the EMS and ensuring that performance, evaluation, and
disciplinary procedures are in place to support the EMS performance-based objectives
and targets.
Consistent, Reliable Results
What would happen if an environmental inspector showed up while you or other
environmental staff were out of the office? What would happen if the environmental
manager moved on to new work? Would your hospital stay environmentally focused?
An EMS helps ensure consistent environmental performance even when there are key
personnel changes. There are others delegated in the organization, knowledgeable on the
EMS and environmental performance.
Measurement
What gets measured gets done. It's that simple. An EMS focuses on setting
measurable goals and objectives and measuring performance and progress against them.
Two measurable performance aspects in an EMS are regulatory compliance and P2.
Focusing on these, for example, helps you avoid unnecessary paperwork and costs
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associated with excess raw material use and waste generation. These help another
measurable item-your bottom line: profitability.
Due Diligence and Improved Compliance
Compliance benefits are a common question for many contemplating an EMS.
While compliance is not 100% guaranteed, an EMS puts procedures in place to help you
stay current on compliance issues, check performance against these requirements, and
implement corrective actions if performance falls short of these requirements. This, in
turn, demonstrates due diligence and reduces environmental risk and the possibility of
regulatory fines.
Less Day-to-Day 'Putting Out Fires'
Enhanced compliance is just one of the additional benefits. As one Kentucky
environmental manager recently stated: "The benefits of an EMS go way beyond
compliance. It has helped us identify significant cost areas we previously overlooked and
has helped with the day-to-day managing of our environmental efforts." In other words,
less cost and fewer headaches.
Greater Staff Environmental Awareness and Commitment
At St. Mary's General Hospital in Ontario, Canada, staff within the Pharmacy
department identified possible reuse opportunities for Styrofoam containers and cold
packs delivered weekly to the department. Products that were once thrown in the garbage
are now taken home by staff to reuse. While department specific efforts like this may
have only minimal dollar savings, the savings can quickly add up when applied across the
whole hospital. This is just one example of how employees become more
environmentally aware. An EMS will ask employees to know the environmental impacts
of the their work and how they can do their work in an environmentally-aware manner.
Continual Improvement
The overall objective of an EMS is to promote continual improvement in
environmental performance and change an often prevailing culture from one of simply
reacting to environmental concerns and opportunities to a more proactive, anticipatory
approach. This is often summed up in the "Plan, Do, Check, Act" cycle. The focus of an
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effective EMS is not simply developing, reviewing, and improving processes and
procedures, but more importantly, improving actual environmental performance and
results. The processes and procedure are a means to an end, not the end itself. Refer to
the Standard EMS Implementation Cycle Diagram below for an overall understanding of
the process that helps ensure the EMS stays results-oriented.
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Standard EMS Implementation
Cycle
1. Environmental Policy
A statement
environmental
of the facilities
intentions.
ACT
5. Management
Review
Periodically reporting overall
EMS progress and other related
information to your senior
management for review,
approval, and to ensure the
continual improvement of the
overall system.
4. Checking &
Corrective Actions
Tracking key environmental performance
indicators, identifying and remediating non-
conformances, maintaining records, and
performing regular EMS audits.
PLAN
DO
2. Planning
Identifying compliance
requirements, and the
significant environmental
issues associated with a
"^facilities activities and
operations. Developing
documented objectives,
targets and management
programs to address these
areas
3. Implementation &
Operation
Identification of EMS responsibilities, training
requirements, communication methods,
documentation control, operational control &
emergency response.
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Managerial Points to Ponder
One size does not fit all: EMSs are highly individualized and must mesh with your
organization's culture and administrative framework to be fully effective. In particular,
your environmental issues and opportunities may be different from the next hospital.
Your processes and procedures may differ. When possible, we offer multiple examples
so you can pick what works for your hospital and then develop the procedure that works
best. We include at least one example procedure for you to look at in the immediate text;
extra example procedures and documentation can be found at section's end. These
procedures are examples only; please feel free to modify them to fit your hospital.
Pay attention to culture: Experience shows that the technical aspects of an EMS such as
writing procedures, organizing documentation, and maintaining a list of compliance
obligations are less a challenge than obtaining and maintaining top management support
and initiating the cultural changes needed for the EMS to take root initially and be
sustainable over the long-term. Building on how things are done and improving them
when needed, respects the established culture and enhances the EMSs chance of success.
Be open to new participants in the environmental program: EMS implementation
challenges many environmental managers to take a broader look at what they do on a
day-to-day basis. Many environmental managers are comfortable with the compliance-
based approach to environmental management: filling out and submitting regulatory
paperwork, policing work areas to make sure people are doing things right, and
personally handling the details of getting things done, often in isolation from the rest of
the organization's priorities. A manager that continues to function with only the skills
used to get these tasks done will have a difficult time implementing an EMS. EMS
implementation requires sharing control and responsibility for environmental tasks,
delegating tasks, and effective facilitation skills. In short, the environmental manager
should not always automatically be selected as the EMS management representative.
Respect from coworkers, willingness to delegate, and ability to share power/control are
key attributes of a successful EMS representative.
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Think effective planning and project management: Simply stated, implementing an
EMS is simply completing series of smaller, manageable projects over time. The more
effectively these projects are planned out in advanced and then managed, the more
effectively EMS implementation occurs. Consequentially, effective planning and project
management are among the most important skills to implementing an EMS cost-
effectively and with the least disruption to hospital operations. These are skills to look
for when you select your hospital's EMS representative.
Build on what's in place: The components of an EMS build on one another. Integrating
EMS components into your existing hospital structure not only saves time in
development and training, but aids in the facilitation of the overall success of the system.
For example, hospitals tend to have many existing procedures for reporting incidents and
addressing various types of emergencies. EMS representatives can build on these for
identifying, communicating, and following up on environmental incidents.
Approach to Implementing an EMS
Some organizations implement their EMS following the order in which the ISO
14001 standard presents the components as shown in the "Plan, Do, Check, Act"
diagram. For example, many organizations write the environmental policy first. The
policy states an organization's environmental commitment and can serve as a first
communication from top management to all employees on the importance of the EMS.
There are drawbacks to following the order in the standard. Necessity often drives what
sections of the ISO 14001 standard organizations implement first. Many EMS
organizations appoint the EMS management representative as a first step instead of
writing the policy so people have a point of contact for the EMS. This manual follows a
performance-based approach to EMS implementation, attempting to cover
implementation in the order most commonly observed in practice.
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Getting Support and Getting Started
Overview of Hospital Corporate Structure and EMS Roles and Responsibilities
The Internal Responsibility System (IRS) is a health and safety philosophy based on the
principle that every individual in the workplace is responsible for health and safety. That
includes the CEO, executives, management and workers. SOURCE: Workplace Safety
and Insurance Board (WSIB), Ontario, 2001
While internal management structures may vary somewhat from hospital to
hospital all operate with distinct levels of senior management, middle management, and
associates. All levels have a role in environmental management.
Board of Trustees
This governing body is often comprised of hospital staff and community and health
care professionals. Board members are hospital "stewards" with responsibility for the
overall direction and planning of the hospital. Trustees approve corporate-wide
programs, make significant hospital decisions, and discuss current and future hospital
initiatives. The Board's EMS responsibilities can include the following.
• Establishing the environment as a priority by approving and abiding by the
environmental policy; and
• Supporting cost effective environmental initiatives that protect the hospital from
legal and financial liability and promote environmental health in the community.
Senior Management
The Senior Management team comprised of the President, Chief Executive Officer,
Vice-Presidents/Directors/Program Managers from various functional centers throughout
the hospital, often plan present and future hospital programs/operations and ensure they
remain efficient, effective and fiscally responsible. Senior Management's EMS
responsibilities include the following.
• Approve the overall EMS and ensure that EMS remains suitable, adequate, and
effective;
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• Appoint EMS Representative(s). Define EMS Management Representative and
EMS Administrative Representative positions as job functions (either one person
with dual role or two separate positions) This is further discussed in the
"Choosing your EMS Representatives" section of this guide;
• Establish the environment as a priority by approving and abiding by the
environmental policy;
• Support cost effective environmental initiatives that protect the hospital from
legal and financial liability;
• Ensure that the resources (i.e. human, physical and financial) essential to the
implementation and continuation of the EMS are available;
• Conduct management review of the EMS.
Unlike many other efforts that start at the grass-roots level and work their way up,
EMS implementation is a top-down process. Without Senior Management support, the
EMS will very likely fail.
Middle Management
Hospital middle management includes Program/Department Managers, Supervisors,
and Coordinators that oversee the day-to-day management of hospital programs including
patient services, support services, and facility management. Middle Management plays a
significant role in the EMS, particularly in the follow-through stages associated with staff
environmental training, awareness activities, and standard operating procedures. Middle
Management EMS responsibilities include the following.
• Implement, comply with, and maintain the EMS within the scope of their
functional roles.
• Comply with all applicable environmental requirements, policies, and procedures;
• Attend at least EMS general awareness training; and
• Ensure employees are given the time and opportunity to attend EMS training,
participate as auditees and auditors (as interested or chosen) and assist in writing
effective work instructions for their respective work areas.
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Hospital Employees
Excluding management, hospital employees include physicians/doctors, nurses,
specialists, technologists, support staff, and all other union and non-union staff. Hospital
employees' responsibilities include the following.
• Implement, comply with, and maintain the environmental management system
within the scope of their functional roles;
• Comply with all applicable environmental requirements, policies, and procedures;
and
• Attend EMS training, participate as auditees and auditors (as interested or
chosen), and assist in writing effective work instructions for their respective work
areas.
Recruiting keen front-line staff to assist with aspects identification and communication will
prove to be of great value. Ask each department to designate one employee as an EMS contact
or delegate. Use this person to transfer environmental information to and from the department.
Getting Support and Buy-In for an EMS
Senior Management and Board
Gaining Senior Management and Board support and then working your way down
the hospital's corporate structure is key. Consider scheduling a meeting with your Senior
Management Team to discuss and provide the following.
1. A description of what an EMS is and why it would benefit your hospital;
2. The environmental issues, particularly compliance-related, that the hospital
currently faces (highlight environmental legal concerns and due diligence
issues such as incineration, biomedical waste, hazardous waste,
PVC/Mercury, spill response, etc., if these areas apply to your hospital);
3. The expected resources and time requirements for initially developing and
implementing an EMS; and
4. Top management's roles and responsibilities in implementing and
maintaining the EMS.
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You may wish to have an EMS gap analysis completed at your hospital and
SOME OF THE POSSIBLE BENEFITS OF
DEVELOPING AN EMS AT YOUR HOSPITAL
1. Cost savings;
2. Better patient care;
3. Improved reputation among peers in the health care
sector;
4. Improved waste segregation and waste minimization
programs;
5. Heightened staff knowledge and involvement in
environmental programs and issues;
6. Improved health and safety relating to environmental
issues (i.e. chemical management, emergency
preparedness);
7. Improved pollution prevention programs decreasing the
facilities negative impact on the local environment;
8. Due diligence through improved compliance;
9. Decreased risk and liability;
10. Improved environmental record keeping and document
control (especially for legal documents requiring
present the results during this
initial meeting with your Senior
Management team. In some
organizations, Senior
Management prefers to conduct
the gap analysis prior to
deciding whether to implement
an EMS.
A gap analysis simply
identifies the elements of an
EMS that your facility has in
place and areas of needed
improvements. An example
gap audit tool developed by the
Kentucky Pollution Prevention Center can be found in the Resources Section of this
manual. A more comprehensive gap analysis may also include sections on environmental
compliance and risk. You can conduct the audit in-house or contact a representative from
your local pollution prevention center that provides this service. Keep in mind, it is
highly probable that your hospital has many of the required EMS components in place
already, and other provisions may require only mere edits to exiting procedures. The
utilization of existing hospital processes in all stages of the system is an EMS best
management practice.
The decision to implement an EMS should first be presented to and approved at
the Senior Management level prior to going to the Board for comments and approval.
They are the first communication link to the Board of Trustees and often a source of
agenda items and topics to be reviewed at monthly Board meetings. Your hospital's
Senior Management team also approves and allocates funds for the hospital's upcoming
operating budget.
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Look to your Board members as potential environmental allies. Board members
may live in the local community and have the same environmental concerns of your staff
and local residents. Ask around and tap into these influential and professional resources
at your hospital for support. For example, in 1998 at St. Mary's General Hospital in
Ontario, Canada, a concerned Board member was one of the first hospital staff to
question hospital practices (i.e. chemical usage on the hospital grounds) with the
environment in mind. From this inquiry, St. Mary's investigated ways to address such
environmental issues that ultimately resulted in the implementation of an ISO 14001-
aligned EMS. St. Mary's is the second hospital in North America to implement an EMS.
Hospital Staff
Once you have obtained approval to go forward with EMS development, you must
sell the idea to your hospital staff. This can be done through a number of communication
tools. Here are a few tips.
1. Work with your Communications and Public Relations personnel to create a letter
of support from your CEO/President to all hospital staff (you can use this letter to
reinforce your Senior Management's commitment to the project when staff ask
the question "why are we doing this?"). If you choose to write your
environmental policy first, the policy can be a part of the first communication of
the EMS.
2. Develop department specific training sessions on what EMS is and why the
hospital is proceeding with its development (essentially you will be performing an
EMS "road show" - remember, if you can, bring sweets- it'll get their attention!)
3. Develop displays, table cards, emails, and articles in your hospital's newsletter to
get the word out. Focus on the environmental issues faced by the health care
industry and how the EMS will encourage and support the statement's set forth in
your hospital's mission statement.
4. Ask for involvement and input from your staff at all times. Include them
throughout the process. You would be surprised by the great ideas and programs
staff are doing in their own homes!
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5. Plan an environmental fair. Include information on: local recycling programs,
composting programs, hazardous waste depots, healthy landscaping ideas for your
home, mercury take-back programs, local environmental not-for-profit groups,
environmentally-friendly hospital products, energy conservation and efficiency,
alternative transportation methods (busing, biking, carpooling to and from work),
and water conservation initiatives. Give your staff a taste of the possible
environmental opportunities available to the hospital.
6. Always be enthusiastic - enthusiasm is contagious and makes sessions fun!
Ideally your staff will embrace the idea of "green health care" as it goes hand-in-hand
with the overall mission of the healthcare industry. However, you may get resistance
due to the fact that people see the EMS as a make-work project. Initially, any new
program will require additional work and time by staff, but the key is finding how the
EMS will make their work easier, make the workplace safer, and/or address problem(s) in
their area. Here are some keys to success.
• Look for ways within your hospital's culture to show how the EMS
advances the hospital's mission. If cost cutting is a key factor that
motivates people, show how the EMS will save costs. If patient care and
staff safety is key, show how you see the EMS accomplishing this.
• Ask resistors for possible environmental problems in their area(s) and use
the EMS as a way to fix these problems. Once you start working on these
issues, they're no longer problems but rather opportunities for changing
attitudes and winning people over.
• Listen to vocal resistors but be even more aware of those who say nothing
or agree very easily. Generally, vocal resistors will vent, get on board
and exceed what you ask of them. Silent resistors or those who agree
very easily tend to fall short of expectations.
• Whenever possible, recognize those individuals that make success
possible. Use your hospital's newsletter and any other form of staff
appreciation that your hospital has to acknowledge these individuals.
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• There is no question that changing people's attitudes is difficult and can
take a long time. Communicate success back. Success changes attitudes.
Organizational culture evolves over long periods of time. But remember,
"If you don't succeed, try and try again!"
Choosing your EMS Representative(s)
Depending on your management structure there are a number of ways of
delegating responsibility for developing your EMS. In some organizations, there are two
individuals coordinating all aspects of the EMS, usually an existing hospital management
representative (at the Director or VP level) functioning as the EMS Management
Representative and an Environmental Coordinator/EMS Specialist (at middle
management or specialist level). The Environmental Coordinator/EMS Specialist
performs the majority of EMS procedure development and hospital communications. In
turn, the EMS Management Representative, with the ability to allocate funds, approves
all resulting EMS related procedures and programs. This structure ensures there is a
hospital management representative with knowledge of EMS overseeing the performance
of the Environmental Coordinator/EMS Specialist and the overall system performance.
In contrast, examples have shown that many industries designate one position within the
facility to perform all EMS functions and directly report back to the company's Senior
Management. Choose what is right for your organizational structure.
EMS Management Representative
At two EMS hospitals, the Senior Management position responsible for materials
management and support services (i.e. housekeeping, maintenance, nutrition, purchasing,
sterilization, waste, health and safety, etc.) was appointed as the EMS Management
Representative. The reason behind this was that many of the perceived "high risk" or
environmentally "significant" issues fell within these departments.
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The responsibilities of the EMS Management Representative are:
• Provide leadership in environmental management and environmental
performance.
• Ensure that the resources (i.e. human, physical and financial) essential to the
implementations and continuation of the EMS are available.
• Review and define employee roles and responsibilities as they relate to the EMS.
• Provide feedback and sign off on EMS Team requests.
• Report on the performance of the environmental management system to top
management for review and as a basis for improvement.
Do you have someone at your hospital that fits into this role?
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INTEROFFICE MEMO
TO: Hospital Staff CC:
FROM: President CONCUR:
DATE: 8/13/98 REPLY: NO
SUBJECT: ISO MANAGEMENT REPRESENTATIVE
APPOINTMENT/APPROVAL
As President at [insert hospital name and location] I appoint [insert name] to assume the
responsibilities as the ISO 14001 EMS Management Representative and [insert name] to assume
the responsibilities as the ISO 14001 EMS Management Representative Alternate.
Responsibilities and reporting functions will be consistent with those outlined in [insert hospital
name] EMS Policies and Procedures.
[signature]
President
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Environmental Coordinator/ EMS Specialist
When selecting your Environmental Coordinator/EMS Specialist, consider three
main things:
1. Knowledge of environmental programs and issues,
2. Knowledge of the ISO 14001 standard, and
3. Experience in developing and leading training sessions.
If you have existing ability or interest in-house, the role of Environmental
Coordinator/EMS Specialist could be given to a staff member (possibly someone in your
health and safety department with environmental interest). If not, you will have to hire
someone to fulfill the role (which is often the case). With EMSs being so new in the
health care sector, it would be rare to find an individual with both hospital knowledge and
EMS experience. Most likely, you will need to find someone with environmental
knowledge and teach this individual about the healthcare industry.
Consider hiring a student to develop your EMS, perhaps recruit local college
students with an interest in the environment and knowledge of ISO 14001 to help with
EMS development. You can get an enthusiastic individual with the knowledge and skills
for performing the duty at a reduced cost of hiring a professional. Look to see if one of
your local colleges has an environmental program, then go from there.
Choosing Your EMS Team
In health care, it is a common practice for management to assemble multi-
disciplinary teams of hospital staff, including front-line workers, for development and
implementation of new patient care programs. Likewise, a multi-disciplinary "Green
Team" can be developed to help with developing EMS objectives and targets,
environmental awareness programs, decision-making, research, and staff
communications.
When deciding who will be a member of your hospital's "Green Team" think
through and identify departments where you traditionally have many environmental
issues. From this initial evaluation, you may find it beneficial to have keen individuals
with knowledge and experience in these "significant" areas on the Green Team. For
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example, many facilities take on waste management issues as an initial EMS objectives
or environmental program (considered "low-hanging fruit" with possible substantial cost-
savings and environmental payback). Typically housekeeping has handled waste
management and would be a key participant to involve in meeting the objective.
Secondly, it is essential to have representation from management and from those
departments that affect the decision-making process of environmental programs. A case
in point is the purchasing department. Purchasing is often responsible for products,
services, and equipment brought into your hospital, has close relationships and
communicates with contractors and suppliers on a regular basis, and is closely linked to
your finance department. Furthermore, purchasing can be a key player in "green
procurement" which is critical when working on topics as PVC medical supplies,
mercury thermometers, and disposable vs. reusable products. Likewise, the highest
occupation group at your facility will probably represent medical and/or nursing staff; for
this reason you will also want a nurse-representative on your team.
In planning your EMS you may also want to have a member from your financial
department on your Green Team. The reason being, that when you are determining your
hospitals significant aspects and impacts the member from your financial department can
provide specific cost information for different processes and procedures. This type of
accounting for information related to specific environmental activities is called
Environmental Management Accounting.
Environmental Management Accounting (EMA) serves hospital administration in
making capital investment decisions, process/product design decisions, and performance
evaluations. EMA differs from traditional accounting by including societal and private
costs across the entire life cycle of an activity or use of a product. This accounting
provides a more accurate cost assessment during the significance determination step in
an EMS. Visit www.epa.gov/oppt/acctg/indexold.html for more information.
Last, but definitely not least, it is important that the members of your Green Team
exhibit interest in environmentally related issues and programs and have a willingness to
contribute during meetings. However, keep in mind that like most new committees
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working with relatively new subject matter, it may take a few meetings to get your group
feeling comfortable with one another, the topics, and an open discussion format.
In addition to purchasing, the following are areas from which you should consider
having both management and worker representation for your Green Team.
Nursing (It would be beneficial to choose two nurses as delegates for each other,
representing different key departments such as Emergency, Surgical, and Medical
areas. In the event one nurse can not attend, perhaps the other would be able to stand
in.)
Housekeeping/Environmental Services/Waste Management
Engineering/Maintenance
Physicians
Laboratory and/or Diagnostic Services
Health and Safety
- Educational Services
- Risk and Quality Analysis
Green Team Expectations
The role your Green Team plays in EMS planning and implementation can be
different from site to site. The following is a list of possible responsibilities for your
Green Team:
• Aid in the identification of environmental aspects, associated impacts, and
determination of significant aspects;
• Provide input into the development of environmental objectives and targets;
Environmental Management Program(s), and other related EMS programs (i.e.
members as "champions" of certain objectives);
• Assist in the development and maintenance of EMS documents, particularly work
instructions that may apply to their area;
• Aid in the identification of the training needs of the hospital. Train individuals in
their work areas on the EMS, the environmental policy, objectives and targets
applicable in their work areas, and work instructions that need to be followed to
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meet the objectives and targets or otherwise follow to minimize environmental
impacts;
• Facilitate communication with front line staff concerning environmental issues
and relevant sections of the EMS. Direct questions, issues and any external
communications to the EMS Representative(s);
• Provide input about current or predominate environmental issues that may effect
the hospital;
• Build enthusiasm around the hospital about environmental performance,
programs, and changes; and
• Make recommendations for continual improvement in the hospital's
environmental performance.
These responsibilities should be clearly explained and communicated to all
members during the first few Green Team meetings so as to ensure that everyone is
clear of their role and the focus of the team.
Meeting Structure
The Green Team should meet monthly as various components of an EMS require
input from your team on a fairly regular basis. However, if you are not able to organize
meetings at this frequency, utilize inter-hospital communication modes such as email and
inter-departmental mail for updates and feedback. Set meeting agendas and keep to
them. People get less and less attentive if meetings continue past the allotted time.
Designate a "minutes" taker. These minutes are used as proof of meetings and
discussions when being audited by your Internal Auditing team, (to be discussed later in
this guide) and your EMS external auditor if you plan to become ISO 14001 registered.
Develop a committee "Terms of Reference" or a formal document outlining the roles and
responsibilities of the team. Incorporate input from the individuals on the team and the
requirements of the ISO 14001 standard into the document. Use this document to focus
meetings and to set agenda items. Review this annually with the team to incorporate any
changes that have occurred within the last year to the EMS (this is a requirement for an
ISO 14001 registered facility).
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Education
It is essential to provide extensive EMS-related training to the team, so that they
are aware of EMS requirements and definitions (e.g., environmental aspects and
environmental impacts), and the goals set forth in the hospital's environmental policy.
Provide this education up front at your first few meetings to ensure that all members are
on the right track. Use examples, examples and more examples! If possible, ask your
President/CEO or EMS Management Representative to say a few words at your first
meeting about why the hospital has chosen to commit to this program, and to encourage
your members.
Facilitating Open Communication
Promote open dialogue and communication among members. Possibly start off
your first Green Team meetings with "ice breakers" to introduce the members to one
another. Incorporate short activities into the team's agenda to facilitate members
discussing environmental issues in healthcare, in their communities, in their
neighborhood(s). Open discussion of topics and issues is essential to the progression of
the EMS and the success of the Team's goals. As an EMS administrator (or management
representative) you don't want to be the only person discussing topics at the meetings so,
encourage open communication by providing education, information and an inclusive
environment during meetings.
Reporting Structure
The Green Team should report back to the EMS Management Representative as
often as is required by your facilities reporting structure (i.e. quarterly updates, monthly
reports, and annual reports). When the team is focusing on specific EMS-related
decisions such as recommending/setting environmental objectives and targets, they will
need to report back to Senior Management for budgeting approval.
Legal and Other Requirements
Unlike many other EMS components we'll see, Legal and Other generally stays
under the EHS specialist or EHS committee due largely to the specialized nature of what
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day-to-day environmental compliance (e.g., paperwork, permits, reporting) requires. You
are aware of many federal, state, and local requirements already through your compliance
efforts. Building on this list is key to the success of your EMS and likely only a matter of
consolidating information already at your fingertips. Any current lists of permitted or
otherwise regulated activities and service are good starting points.
Early on, realize that increased compliance assurance may be one of the most
important reasons your administrators have for backing the EMS. Consequentially, it
may be one of the areas they want to see an early return on for the money they are
investing in an EMS. If so, this is an important expectation to recognize and address
through your work; a compliance audit can help. There are other practical reasons to
look at compliance early in the EMS. Compliance is assumed in EMS organizations. It's
the minimal level of environmental performance, and if you're not meeting compliance
requirements, it could mean regulatory fines, penalties, and less-than positive publicity.
Second, addressing any possible compliance concerns at this point prevents them from
arising later and diverting needed resources, time and attention from EMS
implementation; it's tough to get EMS implementation back on track if people lose focus.
Successfully addressing any compliance issues through the EMS builds staff support.
Seeing the system fix compliance problems builds credibility that the system can help
with other environmental problems they would like addressed in their work areas.
Finally, if there is not a specific EHS specialist who does environmental compliance
within your organization, it may bring necessary management attention to the fact and
help make this happen.
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Federal, State, and Local Requirements Commonly Applicable to Hospitals
ASPECT
Material usage
Air emissions
Water discharge
Material usage,
potential spillage
and releases
Solid and liquid
waste generation
POTENTIAL REQUIREMENTS
GENERAL REQUIREMENTS
Hazardous Substances and Reportable Quantities
Hazardous Chemical Reporting (SARA, Title III, PPA)
PCB Management
AIR REQUIREMENTS
Clean Air Act
State Clean Air Act Requirements
Stratospheric Ozone Protection/CFC Containing Equipment
Asbestos Management
Asbestos
Clean Air Act Permitting Requirements
State General Standards of Performance
New Source Performance Standards for
Hospital/Medical/Infectious Waste Incinerators constructed after
June 20, 1996
State Regulations Regarding New Medical Waste Incinerators
Emission Guidelines for Hospital/Medical/Infectious Waste
Incinerators constructed on or before June 20, 1996
Federal Plan Requirements for Hospital/Medical/Infectious Waste
Incinerators constructed on or before June 20, 1996
State Regulations Regarding Existing Medical Waste Incinerators
NESHAP for Commercial Sterilization and Fumigation Operations
WATER/WASTEWATER QUALITY REQUIREMENTS
Wastewater Discharges
EMERGENCY RESPONSE REQUIREMENT
Emergency Planning & Notification
Underground Storage Tanks
WASTE REQUIREMENTS
Hazardous Waste RCRA
Standards Applicable to Generators of Hazardous Waste
Land Disposal Restrictions
Toxic Substances Control Act
Regulations governing disposable waste including sharps, blood,
and blood-containing waste
Universal Waste
PCB Waste Management
CITATION
40 CFR Part 3 02
40 CFR Part 370
40 CFR Part 761
40 CFR Parts 5 0-61
401 KAR Chapters 50,
52
40 CFR 40 CFR Part 82
40 CFR Part 61
401 KAR Chapter 5 8
401 KAR Chapter 52
401 KAR Chapter 63
40 CFR Part 60 Subpart
EC
401 KAR 59:020
40 CFR Part 60 Subpart
Ce
40 CFR Part 62 Subpart
HHH
401KAR61:010
40 CFR Part 60 Subpart
O
40 CFR 403, 401 KAR
5:557, and relevant local
ordinances
40 CFR Part 355
401 KAR Chapter 42
40 CFR 264-265
401 KAR Chapter 32
40 CFR Part 268
40 CFR Part 700
902 KAR 20: 016
40 CFR Part 761
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Although EMSs do not guarantee compliance, they do make it more likely you
will achieve and maintain compliance. An EMS requires your organization to identify
and have access to your environmental legal and other requirements. Most organizations
track this information in a table or matrix, electronically or on paper. Your list should
include the regulatory citation and a plain-English description of what the requirement is.
Once you have this list, you should conduct a compliance audit against the requirements,
identify potential compliance issues, and fix them, ideally through the checking and
corrective action system. Knowing where you go and what resources you use to stay up-
to-date and current is the Legal and Other requirement. Commonly used resources
include the following.
• Legal counsel such as attorneys
• Regulatory field inspectors or HQ
personnel
• Hospital trade association workshops,
newsletter, and publications
• Environmental j ournal s
• Commercial updates and databases
• State or provincial pollution prevention
technical assistance providers
• Environmental consultants
• Web sites
• Contractors and suppliers
'Other' requirements include voluntary requirements, codes of practice, standards, etc. that
relate to the healthcare environment. One example is the Joint Commission on the
Accreditation of Healthcare Organization's (JCAHO's) Management of the Care of the
Environment standard. It provides guidelines on environmental issues such as emergency
planning and preparedness, also covered under the ISO 14001 standard. Are there other
industry codes or programs that apply to your organization?
Legal and other requirements ties to other EMS areas we'll talk about including-
training, compliance auditing (as found under monitoring & measurement), checking and
corrective action, and management review. We'll cover each in turn.
• The legal and other requirements you identify are associated with various
environmental issues, or aspects, at your organization. Consequentially,
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identifying all your environmental legal and other requirements will help greatly
later working on your list of environmental aspects.
Monitoring and measurement's compliance auditing. Compliance is one part of
environmental performance and an EMS requires you check it. There are two
times to think about compliance auditing. The first time is now when you are
starting EMS implementation. Audit your organization against your list of legal
and other requirements. Potential problems you find can then be written down
and fixed as part of your EMS checking and corrective action (see section below).
Generally, once the EMS is in place, you'll want to audit compliance at least once
a year. In both instances, you may choose to use an outside consultant.
Training. You may have various aspects of environmental compliance training in
place now that ensures your staff perform their duties in such a way the hospital
continues to stay in compliance. Your existing environmental training, ensures
people know the "why" of their roles and responsibilities as well the "how-to."
Tying the "why" to environmental benefits such as community and patient health,
which is core and central to the healthcare mission, is apt to receive positive and
long-lasting support.
Example: Employee: Housekeeper transporting Biomedical Waste -
"Why?" Because this person is working with a highly regulated waste
class that if spilled can potentially cause both environmental and health
risks to that individual and those around him/her. "How-to" ensure that
storage containers are leak-proof and appropriately labeled, internal
transport containers are well-maintained, staff wears appropriate PPE and
handles bags with extreme caution, and waste is stored in locked storage
area before transport
• Use your training as an opportunity to provide positive feedback on how
people are doing. At one facility, the production supervisors successfully
worked with people on the production floor to recycle and reuse Styrofoam
wrappers, saving thousands of pounds of waste and saving $100,000 annually -
-critical in its industry where contracts could be won/lost based on 17100th of a
cent differences per bid part. However, the EHS specialist provided no
positive feedback, drawing the rather severe response of the supervisors.
People like to know and need to know if their efforts are paying off! This is
critical with an EMS.
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• Management review. An EMS requires you have management review, which
we'll cover later in more detail. Suffice it to say, that one of the things that's
good to cover is an update on compliance efforts and any upcoming changes in
regulatory requirements you see for your organization, particularly if you see any
significant expenditure or staff time that will be needed.
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Audits
Internal EMS audits and compliance audits are the next key places to start
working on for the EMS. The reason for auditing and a corrective and preventive action
system is two-fold. First, no EMS is perfect. You will have nonconformance's—times
when your system is not performing as you said it would in your documentation and
times when your system is not meeting an EMS requirement in the ISO 14001 standard
(important if you seek ISO 14001 registration). Second, things change in your
organization. You may change operationally, bringing new chemicals, activities,
products or services into your hospital. These can change your environmental impacts.
Auditing helps catch these so you can manage them in your system, keep the system
operating as intended, and continually improve your environmental performance.
Types of audits
There are several different audits when it comes to an EMS: compliance audits,
gap audits, and internal EMS audits. They are frequently confused but, in fact, serve very
different purposes.
Compliance audits compare your performance with a set of environmental
requirements (i.e., your table of legal/other requirements) relying largely on following a
paper trail of permits, sampling data, and reports. EMS audits drive continual
improvement by checking your system's performance against how you said the system
would work in your documentation and, in the case of an ISO 14001-aligned EMS,
against the ISO 14001 standard. While reviewing paperwork also, EMS audits have a
greater focus on interviewing employees from various levels and job functions within the
organization and assessing actual environmental performance.
We cover compliance and compliance auditing now, rather than later in
implementation, for several reasons. First, compliance is considered the baseline, or the
minimally acceptable, level of performance in an EMS organization. Your administrators
may want to know where things stand on compliance before agreeing to take on an EMS.
Alternatively, they may want to implement an EMS because it will put some mechanisms
in place that make environmental compliance more assured. Second, compliance issues
that come up later can divert needed resources, time, and attention from EMS
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implementation that make getting the EMS back on track very difficult. Lastly,
conducting a compliance audit can point to the need for more staff. If there is not a
specific compliance person or group within the organization, it brings necessary
management attention to the importance of maintaining compliance in the face of
frequently changing regulations. Many EMS organizations check compliance annually
once the system is up and running. You may want to communicate compliance audit
findings on a more limited basis than findings form the gap and EMS audits.
Gap audits
Gap audits are done early and simply identify the EMS components your
organization has in place and areas of needed improvements. You may wish to do an
EMS gap audit at your hospital and present the results during your initial meeting with
Senior Management and the Board of Trustees. In some organizations, Senior
Management prefers to conduct the gap audit prior to deciding whether to do implement
an EMS. In either case, an effective gap audit allows you to focus time and attention on
those areas needing the most effort. An example gap audit checklist developed by the
Kentucky Pollution Prevention Center is included for your use in the Resources section
of this manual.
Effective auditing tips and techniques
Setting the right tone with audits off the bat is key if you want to see your audits drive
continual improvement. Audits help your EMS get better and improve environmental
performance. Punitive repercussions from audits should be avoided; audits are about
finding ideas and ways to keep improving. There are many classes covering the technical
aspects of effective auditing techniques (see resources at end of section); however,
effective people skills are just as important and should be considered whether you are
setting up an internal auditor team or selecting an outside contractor to conduct audits.
Your auditors will interact with many in the hospital. The perceptions your auditors
create with people should reflect positively on your EMS efforts. Some things to
consider follow.
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Recognize that auditing may be an imposition on the people you are auditing.
Look around for people in your hospital who have audit experience. Their
familiarity with auditing will be an asset even if you need to provide them with
environmental training to get them up to speed. They will likely be familiar with
how to approach people they audit and put them at ease.
Depending on the size of your hospital and the nature of the auditing, you may
choose to send teams of auditors out into the hospital. Consider putting at least
one experienced auditor on each team. Two to three auditors per team allows for
one person to be asking questions/writing responses and at least one other to be
observing what's going on in the work area. Early in EMS auditing, sending
auditors in teams provides assurance to team members they are not out there "on
their own" and have someone to confer with for if questions come up. Two pairs
of eyes are better of one.
Good listening and effective questioning are key in the auditing process.
"Yes/No" questions make people liars 50% of the time and fail to provide you the
auditor very much more than what you had before you asked the question. Ask
"how" questions. People generally like to talk about what they do in their job.
"How" questions help them do this and help you as an auditor obtain more
information about what's really going on.
Audits are like an "open-book" test; auditees can use resources around them to
answer auditor questions. Information doesn't have to be memorized.
Provide advance notice to areas well in advance of audits. People generally do
not like surprises, particularly when they are in the form of an audit. One EMS
representative set the audit schedule for areas six months in advance and then
would send reminders two weeks and then one week before the audit.
Set an audit schedule and stick to it. Recognize audits are a sample. You won't
be able to look at every record or talk to every employee. Sampling helps you
keep on schedule and on time to areas you are to audit.
Conduct questioning with in your level of knowledge and scope of the audit.
Report in terms of departments or areas you have audited, not in terms of
individuals. Audits are not meant to get people in trouble.
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• Audit findings can be positive. Be positive on people's accomplishments. Pay
compliments when in order.
• Audit teams disagreements should be done outside of the auditee's presence.
During an audit with an ISO 14001 registrar an EMS auditor trainee with a quality
management background began asking quality questions. The lead senior auditor
asked for a "sidebar" with the trainee auditor and stepped out of earshot of the
auditees. When the two returned, the trainee auditor was back on track asking
environmental and not quality, questions.
• Look at the experience of your auditors. If you are hiring an auditor in, look to
see if they have any healthcare experience. Auditor familiarity with healthcare
coming in can mean a more focused audit for your organization.
• Don't let company politics interfere with the audit.
You should feed audit findings (compliance audits, internal, and external (if ISO
14001 registered)) into your corrective and preventive action system to get fixed. This
helps build your system and continually improve it. In both cases, EHS managers
typically find that documenting problems, needed resources including peoples' time, and
roles and responsibilities for implementing solutions helps tremendously in getting things
done. One EHS manager indicated this as the single biggest benefit of implementing an
EMS: things started to get done environmentally through the documented, assigned
accountability. The corrective and preventive action is also the single biggest reason
many environmental regulators support EMSs.
Corrective and preventive action systems
Audits are a good source of continual improvement opportunities. Over time,
however, there will be other sources you can look to for these opportunities including
incident reports, tracking performance against objectives and targets, monitoring and
measurements, hospital employees, visitors, and other hospital stakeholders. Day-to-day
EMS implementation and administrative reviews will reveal other system and
environmental performance opportunities. As your organization changes and grows,
there will be improvement opportunities. While these may be communicated to you
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informally, there should be a formalized way of recording these to ensure they are
considered and then possibly handled in your corrective and preventive action system
also. One facility used the communication form at the end of this section. Completed
forms would then be forwarded to the EHS department for review and to be possibly
written up for corrective action. Audit non-conformances would be written up
automatically for corrective action. The example procedures outline how audit non-
conformances can be handled. Section or work area managers are typically, but not
always, responsible for determining and implementing corrective or preventive action
and reporting back on progress.
Begin implementing your checking and corrective action system early in the EMS
process. An effective checking and corrective and preventive action system requires you
to have a procedure to accomplish the following.
• Investigate actual or potential problems. Initially you may be playing catch-up,
fixing things needing fixed. But eventually as you have your system in place, this
part of your system will hopefully shift to preventing problems, keeping fires
from happening, instead of putting them out. Be sure to look at your non-
conformances for patterns. This should be done in the EMS Management
Review. Knowing these trends will help anticipate and prevent potential future
problems.
• Identify and write down root causes of problems such as non-compliance.
Sometimes getting at the root cause requires digging below the surface to
determine why the problem occurred.
• Identify, track and document corrective and preventive actions. This involves
writing down what resources you need to correct the problem, implementing an
action plan/solution to prevent reoccurrence, defining needed resources, and
indicating what action(s) were ultimately taken that fixed the nonconformance.
Several example corrective and preventive action procedures and forms are
shown.
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Title: EMS-4. 3. 2 PROCEDURE FOR LEGAL AND OTHER REQUIREMENTS
Document No: EMS-4. 3. 2
Date Approved: 06/01/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To ensure that appropriate persons have access to and understand all legal and
other requirements that are applicable to the environmental aspects of [insert
hospital name]'s activities are met.
2. Scope
2.1 This policy governs the operations and programs conducted by [hospital name],
located at [insert hospital address].
3. Responsibility
3.1 It is the responsibility of the EMS Representative and/or designate to ensure that
all legal and other requirements are kept up-to-date and to inform staff of the
legislative, regulatory and other requirements that the hospital must comply with.
3.2 It is the responsibility of the Department Managers/Supervisors to implement new
or to revise existing programs or operations to meet applicable regulation
requirements and to ensure that their employees are aware of the legislation,
guidelines, regulations, etc., that effect their area(s) of operation.
It is the responsibility of all employees of [insert hospital name/ to inform the
EMS Representative and/or designate should they learn of new and changed
legislation and other requirements.
4. Procedure
4.1 The EMS Representative and/or designate is responsible for identifying and
documenting the legislative and other requirements associated with the hospital's
significant aspects.
4.2 The EMS Representative and/or designate is responsible for identifying new or
changed legislation, regulations and by-laws by reviewing the Federal, State and
Municipal legislative web-sites, and any other tools that may be available for
updating compliance, on a regular basis.
4.3 The EMS Representative and/or designate retains copies of applicable
environmental legislation for referral. Copies of legal and other requirements are
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retained in the Environmental Legislation and Regulations Binder. Obsolete
documents are discarded when new changes are made.
4.4 Affected Department Managers must communicate and implement changes that
occur as a result of amendments to legal or other requirements within their
departments.
4.5 The EMS Representative, in collaboration with associated management, will
address legislative or other changes that affect the hospital corporation and/or
non-specific departments.
4.6 In the incidence of non-compliance with changes in regulatory requirements, the
EMS Representative and/or designate, in consultation with Department
Managers/Supervisors, will create a corrective action plan to address the issue(s).
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001 - 96 - Environmental Management System Standard
7. Exhibits
N/A
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(CONFIDENTIAL)
[hospital name]
CLASSIFICATION:
ENVIRONMENTAL
STANDARD
STABDARD
NUMBER:
ENV-001
ISSUE
DATE:
TITLE:
Regulatory Compliance Audits
ISSUE
NUMBER:
1
DRAFTED
BY:
PAGE:
APPROVED
BY:
Regulatory Compliance Audits
1.0 Purpose/Scope
This procedure defines the mechanism for the planning and implementation of
regulatory compliance audits at [hospital name].
2.0 Activities Affected
All areas and departments
3.0 Forms Used
3.1 Audit Checklist
3.2 Corrective and Preventive Action Request (CAR)
3.3 Internal Environmental Audit Summary Report
3.4 Audit Schedule
4.0 References
4.1 Non-conformance and Corrective and Preventive Action
4.2 Environmental Management System Management Review
4.3 ISO 14001:1996, Elements 4.5.1 and 4.5.4
5.0 Definitions
5.1 Auditee: individual audited.
5.2 Auditor: audit team member performing the audit.
5.3 Audit Criteria: policies, practices, procedures or other requirement against
which the auditor compares objective evidence about the subject matter.
5.4 Audit Program Leader: individual responsible for maintaining the
Environmental Audit Program.
5.5 CAR: corrective and preventive action request that identifies observed
non-conformances.
5.6 Finding: an existing condition supported by objective evidence.
5.7 Non-conformance: the non-fulfillment of specified system requirement.
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5.8 Objective Evidence: qualitative or quantitative information, records, or
statements of fact pertaining to the existence and implementation of an
EMS element which is based on measurement or test and which can be
verified.
6.0 Exclusions
None
7.1 Conducting the Compliance Assessment Audit
7.1.1 The EMR or designee is responsible for planning, scheduling and
implementing internal environmental regulatory compliance assessment
audits, including the identification of required resources.
7.1.2 The EMR or designee develops and maintains the environmental
compliance assurance program and issues program support documents,
based on company environmental compliance assurance guidelines, where
available.
7.1.3 During a compliance assessment audit, assessment team members will
record information, such as: items checked, individuals interviewed, any
possible regulatory non-compliance issues. The assessment team shall
promptly notify the Environmental Management Representative or
designee of any possible regulatory non-compliance. Upon verification of
non-compliance, the Environmental Management Representative shall
notify facility management.
7.1.4 The assessment team reviews possible regulatory non-compliance issues
with the responsible and accountable area department representative. The
team also prepares a CAR identifying the issues, corrective and preventive
actions required, and the individuals responsible for completing the
actions. The EMR or designee and area or department manager will
concur with the CAR before its issuance.
7.1.5 Upon completion of the corrective and preventive action, the area or
department manager will acknowledge completion of these actions by
signing the original CAR and returning it to the EMR or designee.
7.1.6 A member of the assessment team will verify corrective and preventive
actions in a timely manner. When full compliance is determined or
corrective and preventive actions accepted, the assessment team member
will sign the original CAR and return it to the EMR or designee for the
closure and filing.
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7.1.7 Each calendar quarter, the EMR or designee will present a summary of
open CAR's that are based on regulatory non-compliance to facility
management for review.
8.0 General Rules
8.1 Records, including CAR's, relating to potential or actual non-compliance
issues will be treated as confidential and will be kept separate from those
relating to internal EMS audits.
8.2 Potential non-conformance issues (Note: a non-compliance is a non-
conformance) must receive prompt attention and timely corrective and
preventive action.
8.3 All audit records shall be marked "Environmental Audit Report:
Privileged Document" (US only) and distributed to individuals with a need
to know their contents in order to assess, respond to or remedy a potential
or actual non-conformance.
9.0 Records
Records shall be retained consistent with Record keeping procedure.
Record of Revisions
Revision Date
Description
Sections Affected
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Title: EMS-4.5.2 PROCEDURE FOR NON-CONFORMANCE, CORRECTIVE AND
PREVENTIVE ACTION
Document No: EMS-4.5.2
Date Approved: 07/25/02
Next Revision Date: 07/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
Purpose
1.1 To ensure that a process is in place to define responsibility and authority for handling
and investigating non-conformances, taking action to mitigate resulting impacts, and
for initiating and completing corrective and preventive action.
Scope
2.1 This procedure applies to the operations and programs conducted by [insert hospital
name], located at [insert hospital address].
Definitions
3.1 Definitions relating to the content of the EMS are contained in the Glossary.
Responsibility
4.1 It is the responsibility of the EMS Representative and/or designate to:
• to lead the Environmental Auditing Team to find hospital non-conformances;
• investigate the occurrence of non-conformances;
• to aid in the development, follow through, and evaluation of
corrective/preventive actions in consultation with the Department
Managers/Supervisors;
• to revise EMS procedures as a result of non-conformances; and
• organize staff re-training, when needed.
4.2 It is the responsibility of the Department Managers/Supervisors to:
• verify the occurrence of non-conformances within their departments;
• to identify and follow through with corrective/preventive actions;
• to evaluate the effectiveness of the corrective/preventive actions taken; and
• to prevent reoccurrence of non-conformances.
Procedure
5.1 Non-conformances can be identified by:
• Internal/external audits (EMS- 4.5.4),
• Compliance audits (EMS-4.5.1),
• Regulatory inspections (EMS-4.3.2)
• Observation by staff members,
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• Internal/External communications (EMS-4.4.3),
• Review of emergency preparedness and response procedures after the
occurrence of a spill or environmentally related accident (EMS-4.4.7), and
• Management review process (EMS-4.6).
5.2 Non-conformances identified not through an EMS Audit are to be recorded on the
hospital's current "Employee Incident Reporting Form" and/or an employee can contact
the EMS Representative to report the non-conformance (will be documented on an
Employee Incident Reporting Form".
5.3 When the EMS Internal Auditing Team uncovers a non-conformance during an audit, the
non-conformance is formalized and documented in the EMS Audit Report. Identified
non-conformances are also documented on the "Non-conformance Corrective Action
Report" and sent to the associated Department Managers/Supervisors for remediation.
1.4 The EMS Representative and/or EMS Internal Auditing Team conducts an initial severity
evaluation of the non-conformances identified to determine if it is a MAJOR or MINOR
non-conformance:
• "MAJOR- a serious, possibly reoccurring deficiency within the EMS that
adversely affects the hospital (i.e. a missing requirement of the ISO 14001
standard, and/or a system is not functioning as it is documented).
- Requires documented corrective and preventive actions.
• MINOR- an isolated deficiency in the functioning of a system that does not
affect the performance of the hospital's overall EMS (i.e. a documented
procedure is not followed consistently, and/or a part of a procedure is
missing).
- May not require documented corrective and preventive actions."
(Taken from St. Mary's General Hospital's EMS, Kitchener, Ontario, Canada, 2001)
1.5 The EMS Representative and/or associated Department Managers/Supervisors addresses
major and minor non-conformances as they occur.
1.6 For Major non-conformances, the associated Department Manager/Supervisor, EMS
Representative, and/or other responsible position identifies and documents corrective
and/or preventive actions in the "Correction" section of the Employee Incident Reporting
Form. Proposed actions, responsibilities, and target dates are to be included in this
corrective and/or preventive action plan.
1.7 The EMS Representative and/or a management representative approves corrective and/or
preventive actions.
1.8 Department Managers/Supervisor and/or delegated departmental staff follow through
with identified corrective/preventive actions.
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1.9 If the non-conformance relates to EMS documentation or legislative and other
requirements, the EMS Representative will proceed with the identified corrective and/or
preventive actions.
5.10 The EMS Representative conducts a follow-up inspection/audit/review to determine is
corrective/preventive action(s) have been completed and are effective.
5.11 If hospital staff identified the non-conformance the EMS Representative will report
progress back to the initiating staff member within two weeks.
References
ISO 14001 - 96 - Environmental Management System Standard
EMS-4.3.2- Procedure for Legal and Other Requirements
EMS-4.4.3- Procedure for Communication
EMS- 4.3.7-Procedure for Emergency Preparedness and Response
EMS- 4.5.1- Procedure for Monitoring and Measurement
EMS-4.5.4 Procedure for Environmental Management System Audits
EMS-4.6 Procedure for Management Review
Exhibits
N/A
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NONCONFORMANCE/RECOMMENDATIONFORM
As per Section 4.5.2-Nonconformance, Corrective and Preventative Action of the hospital's
Environmental Management System (ISO 14001), all *major nonconformances identified
through the process of internal inspections (performed by the EMS Internal Auditing Teams)
must be documented, have corrective/preventative actions identified, responsibilities designated
and timelines set for remediation.
Department: ENGINEERING SERVICES/LABORATORY
Manager/Supervisor: BILL JONES
Return Form To: EMS REPRESENT A TIVE
weeks from Audit Date) APRIL 15, 2002
Audit Team: SALLY WILSON, JOE PALMER,
1, 2002
MELISSA LEVIGNE, PAUL TAIT
Program
By Date: (2_
Audit Date: APRIL
Nonconformance
(Site section of Standard/
EMS in
contravention)
4.3.1- Aspects and
Impacts
- Manager audited were
unaware of their
responsibilities to update
the aspects list annually.
4.3.1- Aspects and
Impacts
- Managers were unaware
of their responsibilities to
inform the EMS
Representative of any new
products/equipment that
may have a significant
impact on the
environment.
Recommendation(s)
Increase awareness
through education
(managers meetings
and emails).
Increase awareness
through education
o
(managers meetings
and emails).
Corrective /
Preventative Actions
- Attended Manager 's
Meeting on May 23,
2002 to discuss
Aspects updating
process. Managers
were given a copy of
their department and
are to respond with
any changes by June
30, 2002.
- Same as above
Dates of Completion
- May 23, 2002
- Managers
Meeting
June 30,
2002-
Receive all
updated
aspects list
- July 19, 2002
(have aspects
list updated).
- Same as
Above
* Major Nonconformance: a serious, possibly reoccurring deficiency that adversely affects the Hospital, a missing
requirement of the CAN/CSA ISO 14001: 1996 Standard, a system is not functioning as it is documented. Requires
documented corrective or preventative actions.
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Problem Identified: June 2001
Problem Identified By; Laboratory Supervisor
Resolution Due Date: July 2001
Problem (described existing or anticipated problem): EMS Management Team failed to
conduct a cost-benefit analysis on implementation of new chemical tracking and
inventory system, which was identified as an action item during the first quarter EMS
steering committee meeting. Original due date for analysis was May 1, 2001.
Most Likely Cause(s):
• EMS Management Team focused on preparing for regulatory compliance audit during
June 2000.
• Laboratory did not follow-up with EMS Management Team.
• Lack of information to estimate costs of implementing system above.
Possible Solution(s):
• Schedule working meeting between laboratory staff and EMS cost-benefit
analysis team.
• Research chemical tracking and inventory systems (assign to laboratory staff)
and report to EMS Management Team.
Implemented Solution(s):
Due Date: July 2001
Completed: July 2001
• Laboratory staff researched existing chemical tracking and inventory systems
and reported to EMS Management Team on June 30, 2001.
• Laboratory and EMS cost-benefit team met on July 7, 2001 to discuss
findings.
• EMS Management Team completed cost-benefit analysis on July 15, 2001 and plans
to implement new systems are being determined cooperatively between laboratory
staff and EMS team.
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Resolution (confirm effectiveness of implemented solutions):
Responsible Person
Effective Date
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Problem Identified: May 25, 2001
Resolution Due Date:
May 30, 2001
Problem Identified By: Hazardous Waste Management Staff
Problem (described existing or anticipated problem) Requires Corrective Action:
Four of 17 drums of hazardous waste stored in storage area B behind the Maintenance
Building were improperly labeled; one had no waste accumulation start date, two had no
waste description, and one had no label.
Most Likely Cause(s):
• New employee in Maintenance Building started at the beginning of May and didn't
receive training during first week of work.
• Laboratory where new employee works didn't receive phone number for waste
management department to receive support in handling and storing waste.
• Supply of labels was low and existing labels were old and ineffective.
Possible Solution(s):
• Schedule and complete training for new employee(s).
• Meet with all laboratory managers in Maintenance Building to review hazardous
waste management procedures.
• Provide new supply of labels and phone number magnets.
Implemented Solution(s):
Due Date: May 30
Completed: May 30
1) Trained new employee May 28
2) Conducted meeting with laboratory manager
May 28
3) Re-supplied labels and magnets May 30
Resolution (confirm effectiveness of implemented solutions): Maintenance Building
staff has been trained/briefed on hazardous waste handling procedures and no further
deficiencies have been noted for 3 months. (Dates September 1, 2001)
Responsible Person
Effective Date
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Pollution Prevention Opportunities
For the Healthcare Industry
General Pollution Prevention Opportunities
Pollution prevention makes bottom line sense as these hospital learned.
• P2 efforts at Staten Island University Hospital reduced waste management costs
by $500,000 per year.
• Mercy Healthcare of Sacramento purchases reusable liquid-proof surgical gowns
and towels at six facilities, saving $60,000 per year and preventing 50,000 pounds
of waste per year.
• Legacy Good Samaritan Hospital purchased several hundred permanent
waterproof mattresses to replace 95 percent of disposable egg crate foam
mattresses. The initial purchase was significant but the decision paid for itself in
just one year. The savings in purchasing costs per year were $80,710. The
disposal savings per year were $817 and prevented 16,350 pounds of waste
annually.
• The Legacy Health System switched from paper/plastic blend disposable coffee
cups to an all-plastic recyclable cup. Employees were encouraged to bring their
own mug to the cafeteria for a discount. Savings in purchasing costs per year
were $24,000. Savings in disposal cost per year were $1,417. Waste reduced was
28,333 pounds.
Solid Waste
A recent study found that hospitals generate close to two millions tons of waste
per year. Seventy to eighty percent of this amount is solid waste, nearly half of which is
paper and cardboard. The rest of the solid waste is primarily plastics (15 percent) and
food (10 percent). Only 15-20 percent of a hospital's total waste generation is considered
hazardous. However, non-hazardous waste is often placed in "red bag" or medical waste
containers, unnecessarily increasing the cost of disposal and level of treatment needed for
the waste.
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Choosing to design solid waste reduction programs as one of your hospital's
environmental objectives and environmental management programs is a great way to
focus your efforts on proper waste segregation and minimization. Source reduction is
preferred before you resort to implementing recycling options.
Source reduction is any practice, which reduces the amount of any hazardous substance,
pollutant, or contaminant entering any waste stream or released into the environment prior
to recycling, treatment, or disposal. Examples include environmentally preferable
purchasing, raw material substitution, process or procedure modification, improvement in
inventory control, training, maintenance, and housekeeping.
If you cannot eliminate the generation of waste, then evaluate recovery,
reclamation, reuse, and recycling of wastes. Generally, recycling is the most common
of all the available solid waste reduction options for hospitals. In order to have a
successful recycling program, education is essential. Staff should be educated about
proper waste segregation practices as soon as they enter the organization, in the hospital's
orientation session, to ensure that they are aware of the hospital's recycling programs and
the costs and liabilities associated with improper disposal of other hospital waste streams.
For example, in many of the hospital's fast-paced departments (Emergency,
Operating Rooms, etc.) solid waste articles such as plastic packaging, cups, paper towels,
boxes, gloves, etc., find their way into biomedical red bag waste containers. This costly
practice can be avoided. To reinforce the need for solid waste reduction, look at
strategically locating recycling bins in common solid waste generating areas and ensure
that signage is large and visible. Here are a few areas you should consider for recycling
bins.
Administrative and office areas - office paper, corrugated cardboard, other paper, cans,
bottles.
Foodservice areas - glass, metal, cans, plastic containers, corrugated cardboard.
Public areas - newspaper, magazines, bottles, cans. Make sure that bins in public areas
are well marked. Also if possible bins with specialized openings. Such as holes big
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enough only for aluminum cans, slots for newspapers instead of large openings where
it might look like a trash can.
Due to the such large quantities of paper and cardboard, many hospitals look to
reusable totes. Reusable totes are most cost-effective when used to replace a constant
cardboard need, such as distribution from central supply to satellite locations. Using
color-coded, stackable containers makes this option much more feasible.
The Nightingale Institute estimated that approximately 19 percent of waste stream
generated by surgical services is blue sterile wrap. Other hospital areas that typically
generate considerable quantities of this waste include central distribution, purchasing,
pharmacy, and labor/delivery rooms. This makes collection within the a hospital
relatively easy. Because of the relatively low value of this material, attention must be
given to keeping costs as low as possible especially once the material is collected
internally. Identifying a local market for polypropylene or #5 plastics is key to minimize
transportation distances. Establishing a low-cost collection and transport system and
generating a significant quantity to warrant vendor cooperation are also important.
Another area in hospitals often overlooked is kitchen and food service operations.
Although food waste itself represents only 10 percent of the hospital's waste stream,
nearly 15 pounds of associated waste glass, cans, and cardboard are typically generated
per patient tray of food. One option for food waste is to divert organic food waste to
composting. When considering this option, look at space limitations and fitting the size
of your composting to the amount of food waste generated. Obtaining management buy-
in for employee support and properly running the composting bin both help overcome
misconceptions associated with this recycling program. Case study examples suggest
that properly-administered food composting systems can handle 100-300 pounds of food
waste daily.
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General Recycling Success Story
Thomas Jefferson University Hospital in Philadelphia has cut in half the amount of trash it
sends to the landfill since implementing its program to recycle paper, glass, metal and
plastic. This resulted in a savings of $150,000 a year in waste disposal costs. To educate
and motivate staff, Support Services manager Ed Barr takes representatives of various
departments on monthly visits to the landfill, where they sort through and audit the
hospital's trash.
If source reduction and recycling are not feasible or possible, proper treatment
and disposal is the next option. Neutralizing acids and bases and diluting alcohols for
publicly owned treatment works (POTW) disposal are examples of waste treatment. The
focus of this section is preventing waste.
Purchasing, Packaging and Solid Waste
Solid waste in hospitals often relates directly to purchasing practices. In these
cases, implementing environmentally preferable purchasing (EPP) can greatly reduce
solid waste. EPP is the purchase of products or services that have a lesser or reduced
effect on human health and the environment when compared with competing products or
services that serve the same purpose. EPP includes the total effect of the product
including packaging, disposal, quality and cost.
Visit Hospitals for a Healthy Environment website for a How To Guide on Hospital EPP
at http://www.geocities.com/EPP how to guide/. The Massachusetts Office of
Technical Assistance has an online copy of their EPP newsletter at
www.state.ma.us/ota/otapubs.htm#eppnet. The Nightingale Institute for Health and the
Environment has a new environmentally preferable purchasing tool at www.nihe.org.
HealthCare Purchasing News Online at www.hpnonline.com has additional tips.
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Environmental Purchasing Success Story
The University of Texas-Houston Health Science Center has made great advancements in
using EPP. They provided The Natural Step (TNS) workshops to vendors and brought
the vendors into partnerships to discover ways to help preserve the environment. The
Health Science Center arranged with its office supplier to deliver supplies in reusable
organic cotton bags instead of cardboard boxes. This step saved the University recycling
and waste disposal costs. The Health Science center also replaced all mercury
thermometers with alcohol thermometers and have worked to purchase radioactive
chemicals with shorter half-lives. From Health Care EPP Network Information
Exchange Vol. 2 No. 1 January 2000
EPP Options
Switching to bulk containers is an option and may require negotiating with your
suppliers. One option is to join a Group Purchasing Organization (GPO). GPO's buy in
volume for their member hospitals to achieve discounts on pricing. GPO's have
significant buying power and can therefore be very instrumental in influencing
environmentally preferred purchasing practices. Benefits of GPO membership for
hospitals include reduced supply costs, product, standardization, and market leverage.
If you are a member of a GPO, raise packaging waste as an issue. Packaging
costs the supplier also. In one instance, a medical supply distributor saved $22,500
annually in purchase of new cardboard boxes by saving and reusing boxes from its
suppliers to ship its customer orders. Other benefits included reducing staff time to
flatten boxes for recycling and assembling boxes for new orders.
Another way to improve purchasing is to create a Preferred Vendor Program. Any
list of preferred products or vendors should have clear criteria so as not to raise unfair
trade or liability issues. There are many ways to create a preferred vendor program.
Some businesses require suppliers to do one or more of the following: be ISO 14001-
registered, have an environmental management program in place, maintain and provide a
current list of environmentally preferable products, or complete environmental impact
questionnaire(s) for total operations or on each product line. Additional EPP practices
follow.
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• Purchase products in bulk.
• Purchase products with less packaging or reuse packaging.
• Take care in ordering "custom packs." While there is less waste on individual
item packaging, waste from unused supplies can generate more waste. Negotiate
through a purchasing alliance to exclude certain items in patient care kits that are
repeatedly not used in patient procedures and become unused waste.
• Monitor requests for chemicals and implement policies to reduce over-purchasing
that result in waste generation.
• Procure chemicals through a central department or person.
• Purchase smaller quantities of chemicals and supplies not frequently used.
• Purchase chemicals in totes or in recyclable containers.
• Control acquisition and use reagents that have limited shelf life. These supplies
should be ordered in smallest practical container (e.g. ethyl ether and its formation
of explosive peroxides).
• Avoid over-purchase of supplies. Order reagents and chemicals in exact amount
to be used. Be careful when ordering extra quantities to take advantage of unit
cost savings. You can lose the net savings by paying to dispose of unused
chemicals.
• Encourage suppliers to become responsible partners by providing quick delivery
of small orders and accepting the return of unopened stock such as sealed bottles
of stable chemicals.
• Require an on-going relationship involving waste reduction with suppliers and
purchasing alliance representatives.
Regulated Medical Waste (RMW)
Hospitals send millions of pounds of regulated medical waste ("red bag waste")
off-site for incineration. Regulated medical waste presents human health hazards such as
dioxin and is costly. Providing training on what constitutes red bag waste is key. By
definition (RCRA Title 42 Chapter 82 Subchapter X Sec 6992a), medical waste includes:
(1) Cultures and stocks of infectious agents and associated biologicals, including
cultures from medical and pathological laboratories, cultures and stocks of infectious
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agents from research and industrial laboratories, wastes from the production of
biologicals, discarded live and attenuated vaccines, and culture dishes and devices
used to transfer, inoculate, and mix cultures.
(2) Pathological wastes, including tissues, organs, and body parts that are removed
during surgery or autopsy.
(3) Waste human blood and products of blood, including serum, plasma, and other
blood components.
(4) Sharps that have been used in patient care or in medical, research, or industrial
laboratories, including hypodermic needles, syringes, pasteur pipettes, broken glass,
and scalpel blades.
(5) Contaminated animal carcasses, body parts, and bedding of animals that were
exposed to infectious agents during research, production of biologicals, or testing of
Pharmaceuticals.
(6) Wastes from surgery or autopsy that were in contact with infectious agents,
including soiled dressings, sponges, drapes, lavage tubes, drainage sets, under pads,
and surgical gloves.
(7) Laboratory wastes from medical, pathological, pharmaceutical, or other research,
commercial, or industrial laboratories that were in contact with infectious agents,
including slides and cover slips, disposable gloves, laboratory coats, and aprons.
(8) Dialysis wastes that were in contact with the blood of patients undergoing
hemodialysis, including contaminated disposable equipment and supplies such as
tubing, filters, disposable sheets, towels, gloves, aprons, and laboratory coats.
(9) Discarded medical equipment and parts that were in contact with infectious
agents.
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(10) Biological waste and discarded materials contaminated with blood, excretion,
excudates or secretion from human beings or animals, who are isolated to protect
others from communicable diseases.
Persistent Bioaccumulative Toxins (PBTs)
The Environmental Protection Agency (EPA) designated 12 chemicals as PBTs.
PBTs are highly toxic carcinogens that can adversely impact the nervous system; cause
reproductive and developmental problems; and cause genetic defects in small children,
fetuses, and women in their child bearing years. PBTs do not degrade easily in the
environment, can be transported long distances in the environment, and build up in the
food chain over time.
Mercury is the PBT most commonly found in various hospital waste streams.
Dioxins from the combustion of polyvinyl chloride (PVC) found in red bag waste are a
second common hospital-related PBT. "Doing no harm" to human health is a hospital
mission. Given the potential impacts of PBTs on human health and the environment,
hospitals should strongly consider including these areas in planning and implementing an
EMS.
Mercury
Mercury is probably the most common PBT in hospitals. Ten to twenty percent
of mercury released to the environment nationwide comes from the health care industry;
in fact, medical waste incinerators are the fourth-largest point source. Many local
wastewater treatment plants have identified hospitals as industrial pollution sources and
have imposed strict wastewater limits for mercury (hospitals are known to contribute 4-5
percent of the total wastewater mercury load). Mercury releases impact human health as
well as the environment. In a survey conducted by the National Institute for
Occupational Safety and Health, researchers estimated that 70,000 American workers are
potentially exposed to mercury vapors on the job, including nurses, lab technicians, and
others working in health care facilities. In addition, families of these workers were
identified to be at risk of exposure from mercury contaminated work clothes brought
home by workers. Identifying starting points for mercury reduction is easy. The
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California Department of Health Services found that sphygmomanometers and
gastroenterology accounted for 89 percent of the mercury in seven surveyed hospitals.
When attempting to identify sources of mercury in your facility, start with items your
purchase. Also consider joining voluntary programs. Over 240 hospitals nation-wide
have already taken the "Hospitals for a Healthy Environment Pledge" at www.h2e-
online.org. Hospitals are committing to becoming mercury free for several reasons
including an ethical obligation to protect human health and the environment consistent
with the healthcare mission; regulatory requirements; and voluntary agreements between
the U.S. EPA and the American Hospitals Association (AHA).
Sphygmomanometers
Each mercury sphygmomanometers (sphygs) contains between 70 to 90 grams of
mercury. Coupled with the fact that most sphygs are located in patient rooms, waiting
areas, triage centers, and offices and the potential for patient or health care worker
exposure to mercury is high, particularly through breakage of these devices. Cleanup
costs associated with a mercury sphyg spill cleanup can range from $600 to over $10,000.
The accuracy of readings from mercury-based sphygs is also in question. A recent study
concluded that "the majority of the mercury sphygs.. .had serious problems which would
give rise to major errors in blood pressure measurement." Many of these error readings
result from lack of proper equipment maintenance and training.
Gastroenterology
Various tubes used to clear the gastrointestinal passages, such as Cantor tubes,
Blackmore tubes, bougie tubes, and Miller-Abbot tubes accounted for the second largest
volume of mercury in the hospitals inventoried in California. A single set of bougie tubes
can contain up to 454 grams of mercury. Internal breakage can occur. FDA knows of
over 58 incidents reported from 1991 to 2000 in which such mercury-containing tubes
broke inside patients, releasing mercury internally.
The good news is that non-mercury substitutes are available for all of these tubes.
Some substitutes can be weighted with air, water, or mercury while others are pre-
weighted with tungsten. Because the mercury in GI tubes functions as a weight, rather
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than a measurement device, the performance of alternatives is less questionable, and
tungsten-weighted alternatives have the advantage of being opaque in X-rays, allowing
detection of the dilator as it moves through the body.
Thermometry
Although fever and lab thermometers accounted for less than 1 percent of the
mercury sources identified at the seven Californian facilities audited, they are important
sources of mercury contamination of non-hazardous waste streams because they are often
disposed of improperly in red bag waste which is incinerated, releasing mercury into the
air.
Non-Clinical Mercury
Non-clinical mercury was generally found in sphyg repair kits as elemental
mercury and in barometers, which contain around 800 grams of mercury. The
elimination of mercury sphygs from a hospital makes the mercury in sphyg repair kit
obsolete, potentially reducing a facility's non-clinical mercury load by approximately 40
percent. Additionally, because aneroid units often do not require calibration using a
mercury barometer, the barometer can usually be eliminated. If other devices require
calibration, consider replacing the mercury barometer with a 1-millibar precision aneroid
(these can cost less than $250). Another option is to simply call the local airport or
weather station for a mercury column reading.
There are many viable mercury-free products for hospitals pursuing a mercury-
free environment. Other common sources of mercury can be found at the end of this
chapter. The Sustainable Hospitals web site (www.sustainablehospitals.org) is perhaps
the most comprehensive resource available for finding alternatives. The following case
study demonstrates the value of mercury-free alternatives.
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Mercury Spill Case Study
Source: Northwest Guide to Pollution Prevention by the Healthcare Sector.
On March 6, 2001, a mercury barometer used to calibrate instruments fell and
broke in a 60 square foot office in a Medical Center. An emergency call was placed and
personnel arrived on the scene to evaluate, secure and clean up the spill.
In the early afternoon, a Manager in the Department overheard that the mercury
spill occurred in a carpeted area. The Manager called the Safety Officer and they both
arrived on the scene. Using flashlights they found that there still was mercury on the top
surface of the carpet and under the mercury vacuum on the shelf of the spill cart. They
asked the staff working in the office to leave and secured the area. Staff were again
dispatched to clean the cart shelf area.
An environmental cleanup company arrived and was eventually required to
complete the cleanup. Vapor monitoring was done in the office. The portion of
contaminated carpet was removed and additional mercury was found below on the
substrate. The office was sealed and not reopened until the following day when further
air monitoring was done.
On March 7, cleanup personnel returned to the spill site and conducted further air
monitoring. The air vapor levels were well within safe ranges and the office was returned
to service. Cleanup personnel returned on March 8 to the Spill Cart Storage Room to
decontaminate the spill cart. During cleanup, air vapor levels exceeded safe levels. Once
all visible mercury was removed, vapor levels began to diminish. The Spill Cart Storage
Room was shut down for further monitoring the next day. On March 9, air vapor levels
in the Room and the cart had returned to safe levels. Both were deemed operational at
that time. The following are the costs associated with the mitigation of the spilled
mercury in this 60 square foot office area.
Outside Vendor Cleanup Company - Time, Materials and Labor: $ 4,094.00
Replacement of Mercury Spill Vacuum: $ 3,200.00
Medical Follow up for Hospital Staff: $260.00
Mercury Disposal Costs: $1,600.00
Labor Hours Cost for Hospital Personnel Involved Est: $ 1,000.00
Total Costs for Spill Mitigation: $ 10,054.00
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Lessons Learned
Source Reduction Opportunities for Mercury
Material Substitution
Eliminate, reduce, or recycle mercury containing products or waste wherever possible.
You may choose to accomplish this by establishing a mercury environmental
management program (described later) in your EMS.
• Conduct an inventory/preliminary assessment of mercury in equipment, materials
(also chemicals and pharmaceuticals), in storage, and in waste streams. Be sure to
look at cleaning supplies for mercury-content.
• Gather life-cycle cost of purchasing/using mercury-containing products versus
mercury-free products. Consider potential risk of mercury spills and regulatory
fines/penalties associated with unintentional releases.
• Switch to mercury-free products (e.g., thermometers, blood pressure cuffs, lab
reagents). This may require establishing an environmentally preferable
purchasing procedure as part of your EMS and communicating with the vendor.
The purchase of mercury-free products meets this definition. Replacing mercury-
formalin tissue fixatives with zinc-formalin fixatives is one example of EPP. Zinc
fixatives are substitutes and can reduce or eliminate mercury chloride precipitates
that require costly hazardous waste disposal.
• Segregate mercury-containing products before they get into incinerator waste
stream (conduct training for proper disposal).
• Use T8 fluorescent lighting. T8 lighting are more energy efficient than
incandescent of T12 bulbs.
• Eliminate purchase of mercury-containing products through environmentally
preferable purchasing and purchase contracts with vendors/suppliers. Create and
enforce agreements with vendors to supply only mercury-free products.
Communicating and involving employees in mercury elimination is absolutely critical to
success. Here are some options.
• Include articles devoted to mercury reduction, handling, and proper disposal in
staff newsletters.
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• Include specific information about the proper handling of mercury in new-
employee orientation and "Right-to-Know" training.
• Ensure that all personnel—including temporary workers—are familiar with the
facility's mercury handling procedures and protocols to prevent mercury from
being disposed of in sharps containers, red bags, or solid waste containers.
• Include information about waste reduction and pollution prevention in in-service
training sessions.
• Encourage personnel to be label readers.
• Place placard or labels on or above red bags, sharps containers, and solid waste
containers that state "No Mercury."
• Make sure you have mercury spill kits available in all labs, nursing stations,
ICU/ER/Surgery rooms, patient rooms and storage/maintenance facilities (Train
on proper usage of the kits).
Recycling Opportunities for Mercury
Mercury recyclers may provide airtight, steel containers that the facility can use
for collecting and shipping waste without additional packaging. Training, worker
understanding and involvement is key in successful mercury handling and reduction. At
one hospital, a worker reported that broken thermometers are sharp and disposed of them
in "sharps" containers used for waste hypodermic needles. In other instances, workers
reported throwing away materials used to clean up mercury spills in infectious "red bag"
waste, bound for incineration. The contents of these containers were later incinerated,
resulting in an otherwise preventable release of mercury to the environment.
Visit Health Care Without Harm's website at www.noharm.org and investigate the
"Mercury Free Medicine Campaign" supported by the National Wildlife Federation. This
program has led hundreds of American hospitals to take a pledge to eventually eliminate
all mercury within their facility. Look for the many valuable resources on mercury
equipment identification and elimination at this website.
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Mercury Success Story
Newton Wellesly Hospital in Massachusetts significantly reduced its use of mercury
compounds by identifying mercury-containing compounds in use and requiring department
managers using these products to develop a time frame for their elimination. Where
elimination is not possible, the manager must present an acceptable rationale for to the
hospital safety committee. The safety committee in turn is required to maintain a readily
retrievable log of mercury-containing products and processes in use, the rationale for
continued use, and a time frame for the reconsideration of available alternatives.
Polyvinyl Chloride (PVC) and Dioxin
Polyvinyl chloride is a commonly used polymer in the production of plastic
hospital products because of its low cost, flexibility, and optical properties. Twenty-five
percent of all health care products such as IV bags, blood bags, and tubing are made with
PVC. Other PVC hospital products include: basins, hemodialysis equipment, patient
identification bracelets, bedpans, inflatable splints, respiratory therapy products,
stationary supplies, catheters, lab equipment, drip chambers, medical gloves, thermal
blankets, enteral feeding devices, and packaging. Hospitals also have basic construction
materials and furnishings such as water pipes and wall coverings that may contain PVC.
When burned, PVC releases dioxin, a PBT and probable EPA carcinogen.
Hospital PVC incineration accounts for nearly half of all dioxin released into the
environment in the United States. This is almost completely avoidable considering that
only 1-2% of a hospital's waste stream needs incineration. The first step a hospital can
take is to gather information through audits and letters to vendors to find out what
products contain PVC. Then, identify alternatives and develop and implement a PVC
reduction plan as part of your EMS.
The reduction of PVC's can be driven based on the potential for patient exposure
to DEHP (a softener added to PVC plastics); potential for the PVC product to be
incinerated upon disposal; volume of PVC use; and availability of substitute products. In
establishing an organization-wide PVC reduction plan make sure to include the following
priorities.
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• Target disposable PVC health care products especially within neonatal
intensive care units, maternity departments, and pediatrics.
• Phase out the purchase of PVC-containing office supplies, furnishings,
furniture products, and construction products. Specify PVC-free
purchases.
Polyvinyl Chloride (PVC) Products in Hospitals
Disposable Health Care Products
Blood Products and Transfusions: apheresis circuits, blood bags and tubing, extracorporeal
membrane oxygenation ciruits
Collection of Bodily Fluids: dialysis, peritoneal: drainage bags, urinary collection bags,
urological catheters, and irrigation sets, wound drainage systems
Enteral Feeding Products: enteral feeding sets, nasogastric tubes, tubing for breast pumps
Gloves
Intravenous (IV) Therapy Products: catheters, solution bags, tubing
Kidney (Renal Disease) Therapy Products: hemodialysis: blood lines and catheters,
peritoneal dialysis
Packaging, Medical Products: film wrap, thermoformed trays for admission and
diagnostic kits, and medical devices
Patient Products: bedpans, cold and heat packs and heating pads, inflatable splints and
injury support packs, patient ID cards and bracelets, sequential compression devices
Respiratory Therapy Products: aerosol and oxygen masks, tents, and tubing, endotracheal
and tracheostomy tubes, humidifiers, sterile water bags and tubing, nasal cannulas and
catheters, resuscitator bags, suction catheters.
Office Supplies: notebook binders, plastic dividers in patient charts
Durable Medical Products: testing and diagnostic equipment, including instrument
housings
Furniture Products and Furnishings: bed casters, rails and wheels, floor coverings,
furniture upholstery, inflatable mattresses and pads, mattress covers, pillowcase covers,
shower curtains, thermal blankets, wallpaper, window blinds and shades
Construction Products: doors, electrical wire sheathing, water and vent pipes, roofing
membranes, and windows
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Polychlorinated Biphenyls (PCS)
PCBs do not break down in the environment and can build up in the food chain.
They are generally found as oily liquids or solids that are colorless to light yellow. They
have no smell or taste and can exist as a vapor in air and soil and as a liquid in water.
PCBs have been used in many industrial applications because of their insulating
properties, non-flammability, and chemical stability. PCB applications include electrical
capacitors, transformers, surface coatings, inks, adhesives, flame retardants, pesticide
extenders, heat transfer systems, fluorescent lamp ballasts, television sets, rubber
products, pigments, and carbonless copy paper. In addition, PCB's can also be found in
hospitals in lab samples, microscopy fluids, standards, electrical equipment, and
hydraulic systems.
Identify materials containing PCB's in your hospital. Take special precautions to
segregate these materials from the other waste streams. It is imperative that PCB's are
not disposed of by incineration, as this process causes the release of dioxins into the air.
For more information on the identification, regulation, and disposal of PCB's, please visit
the EPA's PCB Home Page at www.epa.gov/opptintr/pcb.
Common Areas for Hospital Pollution Prevention
Energy Efficiency
Health care is one of the most energy intensive industries in the United States.
Hospitals run continuously and certain uses such as diagnostic equipment, large air
handling systems, and technical equipment can be particularly energy-intensive. Health
care facilities average 228 kBtu energy usage per square foot per year, more than twice
the energy per square foot as typical office space. Providing education and incentives for
employees to do little things such as turning off computers/monitors, personal heaters and
unused lights at night can really add up in a hospital.
In the long-term picture, the key to gaining control over energy use is in looking
at your facility's historical electric, gas, oil and steam use, as well as your peak demand
periods. Convert energy usage to a standard measure, such as Btu per square foot.
Where possible, use such measures to compare your energy performance against other
hospitals and institutions. This can highlight higher-than-expected usage and allow you
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to take corrective action. A further reason for facility managers to understand energy use
is to guard against major cost swings due to variations in electric and gas rates.
Emerging utility deregulation is creating opportunities to purchase electricity and gas
from the lowest cost supplier. Energy managers who know the most about their energy
use will be able to leverage that knowledge to obtain the best energy contracts.
Health care organizations have the opportunity to increase their attention to
energy conservation as part of their EMS. The US EPA has many programs that foster
this type of activity, providing incentives, rewards, and technical assistance. US EPA's
Green Lights program, Energy Star, and Climate Neutral are programs health care
organizations can adopt and benefit from. Health care organizations can become prudent
consumers of energy and take advantage of opportunities to invest in renewable energy,
thus reducing the adverse impacts on the environment and health. More than 875
hospitals and health systems across the country have partnered with EPA in an effort to
reduce hospitals mounting energy costs while also preventing pollution. Energy Star
Buildings and Green Lights healthcare Partners have experienced an average annual
savings of $0.63 per square foot. To learn more about how your healthcare organization
can benefit from the Energy Star and Green Lights Partnership visit the Web site at
www.epa.gov/buildings or call toll-free Energy Star Hotline at 1-888-Star-Yes.
Energy Efficiency Success Story
Mercy Hospital in Pittsburgh, Pennsylvania participated in Energy Star and instituted a
comprehensive energy plan that resulted in operational and cost savings of more than $1
million. Mercy accomplished this by retrofitting lighting to high efficiency T8 lamps and
electronic ballasts, expanding its energy management system to allow for better monitoring
and control, installing variable speed drives on chilled water pumps, and replacing chillers
and cooling towers with new high efficiency equipment.
Pharmacy
US EPA states that pharmaceutical products do not become waste until the
decision has been made to discard them. If the damaged or outdated products are
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returned to the manufacturer, distributor, or third party processors with the intent to
receive, reclaim, or destroy, they are regarded as products (not waste) at the time they are
shipped. The only requirement for shipping becomes proper DOT labeling.
Source Reduction Opportunities
Open formularies make monitoring patient drug use more difficult and can
significantly contribute to the volume of drugs that must be disposed. Open formularies
allow providers to dispense samples to patients. This dispensing practice encourages the
development of secondary storage areas. Once established, secondary storage areas and
their environments cannot be controlled. When drugs are improperly stored (e.g.
improper cooling requirements), they may become obsolete and require disposal,
increasing disposal costs.
• Monitor outside drug sources.
Medical providers (who may have off-site offices) with hospital privileges
accumulate samples that may become a disposal problem for pharmacies.
Typically, pharmacies dispose of these drugs gratuitously for the provider.
• Track and reduce the distribution of drugs samples.
Hazardous Wastes
Inventory Control for Hazardous Wastes
Effectively managing inventory provides the next best opportunity to reduce
hazardous waste generation. A good inventory control program attempts the following.
• Adopt a first-in, first-out policy-chemicals. For example, purchased first should
be used first. Reduce high volume chemical inventories to an ideal supply level
of four weeks or less.
• Central distribution. For inventory control purposes, chemicals should be
delivered to a central location at the hospital (one common dock area) and
distributed throughout the facility by a designated individual. Ideally, this
individual would be your Shipper/Receiver or a Central Supply/Stores staff
member.
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• Chemical standardization . This promotes sharing of chemicals between common
users.
• Developing and implementing a program involving the reuse of unwanted, but
usable chemicals. A computerized, running inventory of unused reagent
chemicals for reuse in other departments is helpful.
• Tracking waste generation.
- Develop data (chemical inventories) by user groups identifying high
volume user and generators.
Locate caches of unused reagents/chemicals and determine why they are
accumulating.
Monitor reagent/chemicals half-life and expiration dates.
• Ensuring that the identity of all chemicals is clearly marked on all containers. It is
illegal to ship unused reagent chemicals, containers, and solution mixtures and
unidentified wastes for disposal without proper labeling.
Secondary Containment for Hazardous Wastes
Secondary containment collects leaks and spills. It protects your property, water,
resources and employees from hazardous waste spills. It's a minimal investment
compared to the possible clean up cost associated with one spill or accident.
Use secondary containment systems in satellite accumulation areas and final
waste accumulation areas. Secondary containment should:
• Ensure that the storage area keeps out rain, snow and standing water.
• Prevent water, such as storm water from a parking lot, from entering the
containment system. Careful layout, sloping or elevating the containment area
above grade usually works.
• Ensure that the stored wastes cannot penetrate the base or floor of the system.
Sealed concrete and impervious plastic may work well while asphalt generally
does not. Avoid cracks or unsealed joints.
• Make sure the system can hold the entire volume of the largest container.
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Cleaning and Common Laboratory Chemicals
Source Reduction Opportunities
Material Substitution
Environmentally preferable purchasing (EPP) of cleaning supplies and other common
chemicals can positively impact the health of your staff, patients, and visitors. Many
cleaning chemicals are flammable and contain chlorinated solvents. Thus, your choice of
chemicals may also provide an opportunity for reducing and eliminating hazardous
wastes. There are many potential advantages of establishing an EPP program for your
chemicals including the following.
• Creation of a safer environment
• Continued cleaning effectiveness. Many of the new-generation environmentally
friendly cleaning products are high-level disinfectants and include the same
infection control/sterilization capabilities that the old chemicals possessed.
• Reduced concerns about potential chemical incompatibility.
• Environmentally friendly cleaning attributes including biodegradability and
reduced toxicity.
• Potentially fewer cleaning products.
• Potential to streamline purchasing with fewer products.
• Reduce the chance for exposure to dangerous chemicals.
• Environmental stewardship - "Lead the Charge."
Some people may oppose EPP for many of the same reasons they might oppose an EMS.
• It is new - people may not want to cooperate
• It is different - people are unsure of different ideas
• Change is often challenging and can be time consuming
• Training will likely be necessary
EPP helps you evaluate the use of less hazardous materials and cleaning agents in
non-critical requirements. Here are some examples and tips for chemical change-out in a
hospital environment.
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• Using simple alcohols and ketones instead of petroleum hydrocarbons. Toluene
and xylene are examples of compounds to replace. Terpene-based solvents and
naphtha isoparaffinic hydrocarbons may be substituted for xylenes used in slide
cleaning in some applications. Citrus-based alternatives may reduce worker
exposure but may produce hazardous waste due to possible flashpoints less than
140 degrees Fahrenheit.
• Evaluate physical cleaning methods that may replace and reduce chemical
cleaning requirements.
• Evaluate the use of sonic or stream cleaning instead of alcohol-based disinfectants
or other forms of chemical sterilization.
• Evaluate specialty detergents, potassium hydroxide, or sonic baths to replace
chromic and sulfuric acid for cleaning glassware. Sodium or potassium
dichromate dissolves in sulfuric acid and chromic acid cleaning solutions are
common methods of cleaning glassware. However there are alternative cleaning
agents that have proven effective and less hazardous.
• Use biodegradable or aqueous detergents where possible. In some cases,
powerful cleansers are still essential.
Focus on Ethylene Oxide and Glutaraldehyde
Hospitals typically use ethylene oxide (EtO) to sterilize moisture and heat
sensitive instruments and glutaraldehyde as a high-level disinfectant. EtO poses several
health hazards that require special handling and disposal of the chemical and training in
its use. The National Toxicology Program has identified ethylene oxide as a known
human carcinogen. Some of the side effects of EtO are nausea, vomiting, and
neurological disorders from inhalation, eye, skin, and lung irritation when in solution,
and may also cause damage to the central nervous system, liver, and kidneys. A small
selection of hydrogen peroxide and peracetic acid based sterilants can be used to replace
EtO for many applications throughout your hospital.
Hospital employees who commonly use glutaraldehyde range from members of
gastroenterology and cardiology departments to research technicians, researchers, and
pharmacy personnel who prepare alkaline tissue fixative solutions in laboratories.
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Symptoms from glutaraldehyde exposure include asthma, burning eyes, headaches,
hives, nausea, nose bleed, nose irritation, rashes, staining of the hands, and throat and
lung irritation. There are cost-competitive non-glutaraldehyde alternative that exist and
meet infection control standards and reduce risks to patient, visitor, and employee health.
Train people to check labels for the ingredients. Mercury often can show up in
cleaning chemicals at less than 1% content, below the limit which requires the chemical
manufacturer to disclose the content, but high enough to cause water discharge violations.
Consequentially, you may need to contact chemical manufacturer for a chemical analysis,
particularly if you are attempting to eliminate all mercury or have a mercury problem.
The following attributes should be present in some verifiable or demonstrable degree in
an offered product. Suppliers are required to provide a Material Safety Data Sheet
(MSDS), equivalent information, and/or any additional information upon request.
The following are EPP criteria you may use to evaluate cleaning and other
chemicals. Failure of a product to meet any of the criteria listed below should trigger
search for a more environmentally friendly product.
Carcinogen: Try to eliminate the use of products containing known and probable
carcinogens. The following organizations classify known or probable carcinogens.
• American Conference of Governmental Industrial Hygienists (ACGIH);
• International Agency for Research on Cancer (IARC);
• National Institute of Occupational Health and Safety (NIOSH);
• National Toxicology Program (NTP); and,
• Occupational Health and Safety Organization (OSHA).
Flammability/Flash Point: Products that do not ignite easily are favored.
Corrosiveness (pH): Products that have a pH closer to neutral are favored.
Chronic Health Risks: Products that pose no potential for chronic health risks are
favored.
Skin/Eye Irritant: Products that are less irritating to the skin and eyes are favored.
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Volatile Organic Compound (VOC) Content: Products with the lowest VOC levels
possible are favored. Most desirable are products that do not contain VOC's in
concentrations that exceed 10% of the weight of the product.
Ozone-Depleting Compounds: Products that do not contain ozone-depleting compounds
are favored.
Biodegradability: Products that are partially or completely biodegradable are favored.
Product Packaging: Products that are packaged in recyclable or reusable containers (such
as use of refillable product distribution devices and/or concentrates) and containers made
with a percentage of post-consumer recycled materials are favored. Additionally,
products that use no, or only a minimal amount of, polypropylene and/or polystyrene
("Styrofoam") packaging are favored.
Energy Needs: Products that work effectively in cold water, which decreases the amount
of energy consumption necessary, are favored.
No Sealed Aerosol Spray Cans: All chemical cleaning products must be available in
either a liquid form or manual pump action sprays and/or concentrates that can be
dispensed into pump bottles for use.
Dyes and Fragrances: Products that do not contain dyes or fragrances are favored.
Products should be tested for efficacy. A chemical cleaning or recycled content
product that meets the desirable attributes still may be deemed ineffective for its intended
purpose(s) after testing.
Solvents
Solvents are predominantly a waste of lab waste streams. They are used for fixation
and preservation of specimens in histology and pathology and for extractions in
laboratories. Halogenated solvents are generally more toxic and persistent than
nonhalogenated solvents. Halogenated compounds used in hospitals include methylene
chloride, chloroform, tetrachloroethylene, chlorobenzene, trichloroethylene, 1,1,1-
trichloroethane, and refrigerants. Source reduction is the best option for solvents, but if
use of a solvent can't be eliminated, work practice modification may be the next best bet.
• If using solvent, conduct initial cleaning with used solvent and then fresh solvent
for the final cleaning. This is countercurrent cleaning and decreases the amount
of solvent used. When solvent used for the initial cleaning step becomes too
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dirty, eliminate it and replace with solvent from the second cleaning step and so
on.
• Using a wide variety of solvents means there will be a wide variety of waste
streams to manage. Investigate the possibility of using one type of solvent for
equipment and other cleaning. By switching to one type of solvent, it may be
cost-effective to have onsite distillation.
• Before placing lab ware in autoclaves or other cleaning equipment, drain
chemicals out of containers and collect in proper disposal receptacles. This can
significantly reduce the amount of contaminate wastewater entering the POTW
system.
Alternative Mopping Techniques
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 risk of cross-contamination for patients, conventional mopping
techniques require janitors to change the cleaning solution after mopping every two or
three rooms. This means that cleaning solutions are constantly being disposed of and
replenished. There are three drivers for changing the way custodial staff maintain the
floors in patient care areas: to reduce chemical and water use and disposal, to reduce
cleaning times for patient rooms, and to reduce custodial staff injuries and workman's
compensation claims from the repeated motions of mopping and wringing.
Microfiber mop heads, a relatively recent innovation, may help. These mop heads
weigh approximately 5 pounds less than conventional loop mops and are changed after
each room. This benefits the custodial staff by reducing the effort of wringing a
conventional mop and not having to change the water between rooms (provided the mop
head is not put back in the water once it's been used in a room).
Pilot test results indicate a 60 percent lifetime cost savings for mops, a 95 percent
reduction in chemical costs associated with mopping tasks, and a daily 20 percent labor
savings associated with mopping. There were only a few limitations to this option. The
medical center found that it was best to use conventional mops in areas contaminated
with an extraordinary amount of blood or other bodily fluid. It was also found that
microfiber mops are not as effective in greasy, high-traffic kitchen areas. The microfiber
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mop heads can also not be laundered in industrial washers and dryers. Instead a standard
commercial washer and dryer with controlled heat settings and standard laundry
detergent is used.
Cleaning Products Success Story
The City of Santa Monica, California's green cleaning product purchases have eliminated the
purchase of 3,200 pounds of hazardous materials annually. This translates into a savings of
approximately 5 percent of annual spending on cleaning products when compared with the
traditional products it was purchasing.
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Chemotherapy and Antineoplastic Chemicals
Chemotherapy and antineoplastic chemicals are generally handled through a
central clinical laboratory or pharmacy. Administrative controls represent the best
alternative to reducing these wastes.
Source Reduction Opportunities
• Minimize the cleaning frequency and volume of gauze materials used for the
compounding hood. Cleaning frequency depends on drug handling volume and
the amount of spillage that occurs in the hood. Proper handling practices and
techniques should be emphasized to minimize hood cleaning frequency and waste
generation. These teaching points may be added to existing OSHA training
conducted for the hoods.
• Purchase drug volumes according to need. Over-purchasing results in generation
of outdated materials that must be disposed. Reducing waste may be
accomplished by computing daily compounding requirements of each drug and
ordering appropriately sized containers. Work with supplier to return outdated
drugs.
• Centralize the location of chemotherapy compounding areas.
Formaldehyde
Source Reduction Opportunities
Material Substitution
Formalin (formaldehyde and water) is used to disinfect dialysis machines. Check
with your machine vendors to determine if bleach, paracetic acid, or other disinfectants
can be used instead of formalin. Carefully evaluate all substitutes for cleaning
effectiveness and comply with all machine manufacture requirements.
If formaldehyde must be used, use the smallest sized container of formaldehyde
possible. Provide training to staff on the importance of this in reducing waste and costs.
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Procedure Modifications
Determine the minimum effective cleaning formalin concentration. Effective
formalin concentration for disinfecting and cleaning machines and disinfecting dialyzers
are in the Centers for Disease Control Guidelines. Formalin concentrations used to
disinfect dialysis machines vary among machines and hospitals. Formalin is typically
purchased in concentrations that range from 10 to 37 percent. Many machines will dilute
the 37 percent formalin to a 10:1 ratio to achieve a 4 percent disinfecting concentration.
Formalin concentrations of 2 percent are not recognized as effective disinfectants.
However, some machines will requires mixing of formaldehyde and water to
produce formalin that is poured into machines. These machines don't internally dilute
formalin. Therefore, the effective formalin concentration (4 percent) should be measured
accurately and maintained consistently. Using formalin concentrations greater than 4
percent for disinfecting machines may generate unnecessary wastes.
Dialyzers
Formalin usage may be reduced in dialyzers. The use of special incubators to
heat dialyzers in 1.0 percent formalin solution at 40° C for 24 hours may be effective
alternative to using 4 percent formalin at room temperature for 24 hourss.
Recycling (Reuse) Opportunities for formaldehyde
In autopsy and pathology laboratories, it may be possible to reuse formaldehyde
in specimen preservation. These solutions retain their desired properties for periods far
longer than the usual holding times for specimens. In addition, the desired preservation
properties may be effective at concentrations less than the standard 10 percent.
Radiation Therapy
Radioactive wastes are generated in nuclear medicine and clinical testing
laboratory departments. Radioactive wastes cannot be treated or neutralized.
Radioactive wastes are typically retained on site (in areas 100-200 square meters in size)
until their half-life is spent and they are no longer considered hazardous. These low level
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radioactive wastes need to be segregated and properly labeled as isotopes, form, volume,
laboratory origin, activity and chemical composition. Proper labeling and handling are
legally required and make waste management decisions easier. Radioactive and other
hazardous wastes should not be mixed. Try to use suppliers that will accept return of
isotope containers.
Source Reduction Opportunity
• Evaluate processes for substitution of long-lived isotopes with short-lived
isotopes. For example, use iridium-192 or cesium-137 in place of radium-226.
Radiology
Full-service hospitals generally have a radiology department. The main waste
stream is water containing used photographic developing solutions (fixer and developer)
and silver. Silver-containing effluent from the fixer solution is passed through a steel
wool filter or otherwise treated to recover this precious metal.
Source Reduction Opportunities
• Store materials properly. Many chemicals are sensitive to temperature and light.
Chemical containers list the recommended storage conditions. Meeting the
recommended conditions will increase their shelf life.
• Extend processing bath life. Techniques for extending bath life include: 1) adding
ammonium thiosulfate, which doubles the allowable concentration of silver
buildup in the bath; 2) using an acid stop bath prior to the fixing bath; and 3)
adding acetic acid to the fixing bath as needed to keep the pH low. Accurately
adding and monitoring chemical replenishment of process baths will cut down
chemical wastage.
• Use countercurrent washing to replace the commonly used parallel tank system.
This can reduce the amount of wastewater generated. In countercurrent washing,
water from previous rinsing is used in the initial film-washing stage. Fresh water
enters only at the final stage, at which point much of the contamination has
already been rinsed off the film.
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• Implement dry laser film processing. This process reduces the chemicals that are
manually poured into the machine and does not need to be connected to the
sanitary sewer for chemical discharge.
Recycling Opportunities for Radiology
There are four major waste streams associated with electrolytic image processing at
hospital radiology department that must be managed properly. They are:
• Silver that is recovered from recycling units. This silver waste is not a hazardous
waste.
• Discharge wastewater. The wastewater may contain silver. The wastewater is
hazardous if its concentration is greater than 5ppm.
• Spent fixer is hazardous if its silver concentration is greater than 5ppm.
• Discard X-ray film has recoverable amount of silver that is typically removed by
a recycler for processing. The reclaimed silver can be used in other industrial or
commercial applications. If the silver is removed, the remaining X-ray film is
recyclable polyester.
The two most common methods of recovering silver are metallic replacement and
electrolytic replacement. Metallic replacement involves ion exchange between silver and
another metal. The other metal is usually iron (mesh) or steel wool. Electrolytic
replacement involves the accumulation of silver on a negative cathode. The silver is
reclaimed from a 5-10 percent fixer solution.
Xylene
Source Reduction Opportunities
Material Substitution
Xylene is used in processors, stainers, and as a cleaning agent that removes
paraffin from the tissue. There are alternative chemicals that have been used to replace
xylene in the stainers.
Carefully evaluate citrus-based substitutes. Citrus-based alternatives may reduce
worker exposure but may produce a hazardous waste due to flashpoint less than 140°F.
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These citrus-based solvents may process samples slower than xylene and will require
temperature and time modifications. Generally, these products are effective on samples
in the micrometer range. However, thicker samples may be difficult or impossible to
process. Evaluate hazardous waste and quality issues before using xylene alternatives.
Procedure Modification
Do not mix wastes unnecessarily. Sometime wastes are mixed without respect to
characteristic and compatibility at the point of generation. In one hospital, five 16-gallon
drums of formalin (fixation), alcohols (dehydrators), xylene (processors), chronic acid
(glass cleaner), paraffin wax, and water were mixed. In this case, the hospital reduced 75
percent of its RCRA hazardous waste by not mixing formalin waste with alcohol waste.
Inventory Control
Mounting chemicals are used to stabilize the sample on the slide and contain
polymers and solvents such as toluene and xylene. Control the inventories of these
chemicals because they have limited shelf lives.
Evaluate routine laboratory processes or tests such as fixation and extraction to
determine if quantities of reagents are reducible. The evaluation can include using
calibrated solvent dispensers and unitized test kits; reducing volumes of reagents; and
increasing the use of instrumentation in tests and experiments.
Recycling Opportunities for Xylene
There is significant opportunity to reduce hazardous waste generation in hospital
histology laboratories by distilling xylene. You can eliminate hazardous waste that must
be manifested except for an extremely small quantity of sludge (still bottoms) from
distillation, which is an F003 hazardous waste. Other solvent wastes may not have
sufficient generation rates to use distillation. Distillation of xylene will reduce xylene
raw material costs. At a minimum:
• Evaluate the quality of distilled xylene. Laboratory personnel and/or chemical
review board members should agree on recycled xylene quality.
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• Do not mix waste streams because this practice may complicate or negate
distillation opportunities.
• Standardize solvent usage if possible.
Check with your local fire marshal and OSHA field office to determine if there are
location and safety issues that must be addressed. Fire-rated doors and walls,
impermeable floors, designed ventilation, and locations away from patient care areas are
some issues that must be addressed.
Fluorescent Lights
Source Reduction Opportunities
To reduce the mercury waste that is generated when lights are disposed, consider:
• Using T8 lamps instead of T-12 lamps.
• Using timed lights or lights with occupancy switches instead of manual switches.
• Implementing EPA's Green Lights Program
• Recycle fluorescent light bulbs
Maintenance Wastes and Recyclables
Aerosols
Aerosols are present in many areas throughout the hospital, but primarily in the
facility maintenance areas in health care organizations. Aerosols include adhesive
cleaners, electronic solvent cleaners, touch-up paints, and ceiling tile renewers.
Source Reduction Opportunities
Discourage the use of aerosols. If aerosol purchases seem high, investigate which
activities use the most and focus reduction efforts on these.
Inventory Control
An inventory control system can assist in reducing waste. Request products from
the manufacturer in recyclable non-aerosol pump sprays. Order products according to
demand as expired shelf life may require excess inventories to be disposed. Dispense
aerosol cans when an empty can is returned. This process should be controlled through
one person in one location to prevent unnecessary usage.
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Recycling Opportunities
Facilities are available that recycle aerosol containers. If they do not offer pick-
up services, see what options are available to send your aerosol containers to them. If
you generate enough aerosol container waste, investigate the purchase of an on-site
recycling unit.
Batteries
Batteries are used in numerous applications including the following: cameras,
pagers, flashlights, exit signs, alarm systems, backup power sources in medical monitors,
hearing aids, smoke detectors, glycometers, and many others. Some common varieties of
batteries include alkaline magnesium, nickel-cadmium, silver-cadmium mercuric oxide,
lithium, and zinc-air. Check your state regulations regarding how to handle these spent
batteries, as they often must be considered hazardous waste due to the metal content. In
some cases, recycling spent batteries may be possible.
Source Reduction Opportunities
Zinc-air batteries may be used to replace the more hazardous mercuric oxide
batteries in some applications. Carefully consider the use of rechargeable batteries. They
may not be appropriate in all situations, especially those involving life saving equipment
where a partially recharged battery could result in equipment failure and death. While
some batteries such as the nickel-cadmium are rechargeable, they, too, will need eventual
disposal.
Recycling Opportunities
Contact your commercial hazardous waste provider to find out if they will recycle
batteries, and the Hazardous Waste Branch Division of Waste Management at (502) 564-
6716 for local office information.
For rechargeable battery recycling visit Rechargeable Battery Recycling
Corporation at www.rbrc.org/consumer/uslocate.html to find the rechargeable battery
recycling location closest to you or call 1-800-BATTERY. For lithium batteries call
Battery Solutions Inc., 38680 Michigan Avenue, Wayne, MI 48184 (313/467-9110). For
additional resources on other types of batteries visit Recycler's World at
www.recycle.net/battery/index.html.
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Laundry and Laundry Detergents
Source Reduction Opportunities
Educate staff to recognize and separate out hazardous materials before doing the
laundry. Rags used to clean up hazardous spills are also hazardous waste and need to be
disposed of properly. Optimizing the use of laundry chemicals and minimizing
accidental spills is achieved through work training, prepackaged laundry chemicals, or
the use of automated laundry feed. Laundry chemicals are often supplied in 5-gallon
containers; consider receiving chemicals in totes.
Training and Technology Modification
Poor handling of laundry chemicals can lead to accidental spills, underuse, or
overuse of chemicals. Under use of laundry chemicals results in poorly cleaned articles
that must be cleaned again. The overuse of laundry chemicals unnecessarily increases the
volume of chemicals and increase raw material costs.
Optimizing the use of laundry chemicals and minimizing accidental spills is
achieved through worker training, prepackaged laundry chemicals, or the use of an
automated laundry chemical feed system. While laundries might incur capital costs to
install an automated system, the savings from optimal chemical usage and reduction in
labor costs may have long-term benefits.
Paints
Source Reduction Opportunities
Material Substitution
Replace oil-based paints with water-based paints in facility maintenance
operations to eliminate the use of solvents and thinners as cleaners. Using paints without
metal pigments or paints with high solid, low volatile organic compound will also help
reduce hazardous waste.
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Inventory Control
Controlling inventory is important when trying to reduce waste. Three practices that
can help control inventory:
• Adopt first-in, first-out inventory practices for paints to reduce waste associated
with expired shelf life.
• Purchase paints only in needed quantities.
• Do not mix more paint than is needed for a painting job.
• Standardize paint colors in the facility.
Training
Over-spray is the paint that does not reach the part or wall. Over-spray creates waste
and increases raw materials cost. To reduce over spray:
• Use spray system equipment with high transfer efficiency. High volume low
pressure (HVLP) guns provide the highest transfer efficiency. Electrostatic spray
guns also improve transfer efficiency.
• Maintain proper pressure as identified in the operator's manual for specified gun
systems. Higher pressures contribute to over spray.
• Clean spray gun nozzles.
• Replace damaged nozzles.
• Keep spray gun perpendicular to the surface.
• Maintain a fifty percent overlap of spray pattern.
• Maintain gun distance of six to eight inches from work piece.
• Trigger gun at the beginning and end of each stroke.
• Use heaters to reduce paint viscosity instead of adding thinners.
Recycling
If paint guns are cleaned with solvents, consider investing in a gun cleaner system
that re-circulates the solvent. Gun cleaners can save you as much as 30 percent on
disposal and raw materials.
Let paint brushes and rollers used with latex or water-based paints stand in a pail
of water prior to rinsing. This will help reduce the water consumed when cleaning the
brush.
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Pesticides and Landscaping
Source Reduction Opportunities
Reduce generation of pesticide waste generated by grounds maintenance activities by:
Reducing pesticide inventories toward a goal of just-in-time.
Reducing pesticide, herbicide and fertilizer quantities
Preparing and using only the required quantities
Using non-chemical pest control methods such as corn meal gluten a natural
herbicide
Using dry pesticides that are spread on the ground and watered into the ground.
Using this method may eliminate the need for pesticide spraying containers and
the resulting contaminated wastewater from clean up.
Use contract services for insect control, rodent control, and lawn maintenance.
Waste is managed by the contractor and doesn't impact the hospital's generation
rates
If you have contracted off site landscaping services at your hospital facility, work
with your service to eliminate pesticides and herbicides, to use plants that are native to
the area and do not have to be watered as often, as well as using mulching mowers to
eliminate bagging grass wastes.
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Possible Sources of Mercury
Thermometers
Body temperature thermometers
Clerget Sugar test thermometers
Heating and cooling system thermometers
Incubator/water bath thermometers
Minimum/maximum thermometers
National Institute of Standards and
Technology calibration
thermometers
Tapered bulb (armored) thermometers
Sphygomanometers
Lamps
Fluorescent
Germicidal
High-intensity discharge (high pressure
sodium, mercury vapor, metal halide)
Ultraviolet
Dental amalgam
Float control
Septic tanks
Sump pumps
Thermostats (non-digital)
Thermostat probes in electrical equipment
Reed Relays (low voltage, high precision
analytical
equip)
Plunger or displacement relays (high
current/high voltage)
Thermostat probes
Gas Appliances
Flame sensors
Gas safety valves
Tilt switches
Air flow/fan limit control
Building security systems
Chest freezer lids
Fire alarm box switches
Lap top computer screen shut-off
Pressure control (mounted on bourdon tube
or diaphragm)
Silent light switches (single pole and three
way)
Temperature control
Gastrointestinal tubes
Cantor tubes
Esophageal dialators (bougie tubes)
Feeding tubes
Miller Abbott tubes
Pharmaceutical supplies
Contact lens solutions and other
ophthalmic products containing thimerosal,
phenylmercuric nitrate
Diuretics with mersalyl and mercury salts
Early pregnancy tests kits with mercury
containing preservatives
Merbromin/water solution
Nasal spray with thimerosal,
phenylmercuric acetate or
phenylmercuric nitrate
Vaccines with thimerosal (primarily in
hemophilus, hepatitis, rabies, tetanus,
influenza, diphtheria and pertussis
vaccines)
Pressure gauges
Barometers
Manometers
Vacuum gauges
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Chemicals that contain mercury
Acetic Acid
Alum hematoxylin (Solution A)
Ammonium reagent/Stone Analysis kit
Antibody test kits
Antigens
Anti serums
B5 fixative
Buffers
Bleach solutions containing sodium
hypochlorite
Cajal's
Calibration kits
Calibrators
Cameo
Carbol Gentain violet
Chloride
Carnoy-Lebrun solution
Diluents
Enzyme Immunoassay test kits
Enzyme tracers
Ethanol
Extraction enzymes
Fixatives
Gomori's
Golgi's
Gram Iodine
Helly solution
Hematology reagents
Hitergent
Hormones
Immunoelectrophoresis reagents
Immunofixationphoresis reagents
Immun-sal
Mercury chloride
Mercurochrome
Mercurophyline
Mercury iodide
Mercury nitrate
Mercury sulfate
Merthiolate
Million's reagent
Mucolex
Negative control kits
Nessler's solution
Ohlamache
Phenobarbital reageant
Phenol Mercuric Acetate
Phenytoin reagent
Positive control kits
Potassium hydroxide
Pregnancy test kits
Rabbit serum
Shardin Solution
Shigella bacteria
Sodium hypochlorite
Stains
Stabilur Tablets
Standards
Takata' s reagent
Thimerosal
Tracer kits
Urine analysis reagents
Wash solutions
Zenker solution
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Other sources of mercury
Devices, such as personal computers that
utilize a printed wire board
Blood gas analyzer reference electrode
(Radiometer brand)
Cathode-ray oscilloscope
DC watt hour meters (Duncan)
Electron microscope (mercury may be used
as a damper)
Flow meters
Generators
Hitachi Chem Analyzer reagent
Lead analyzer electrode (ESA model
3010B)
Sequential Multi-Channel Autoanalyzer
(SCMA) AU 2000
Vibration Meters
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Planning and Managing the EMS
Environmental Aspects & Impacts and Determining Significance
Introduction
This section focuses on the performance-based components of the EMS and how
they link together. These are the components that most directly drive positive change in
actual environmental performance improvement. It all starts with identifying your
hospital's environmental issues (termed environmental aspects) with the ultimate goal of
determining those aspects that significantly "impact" on the environment. Significant
impacts are considered in setting objectives and targets. Operational controls such as
work instructions will help minimize the significant impacts and help your organization
meet its objectives and targets. Monitoring and measurement asks you to track your
progress against both of these.
The end of the section covers topics including training, communication,
documentation/document control and other EMS "support" components without which
the EMS (or for that matter, any organization) can not fully or effectively function.
Environmental Aspect: "An element of an organization's activities, products or
services, that can interact with the environment" (ISO 14001 Standard)
Example: Environmental aspects for landscaping practices may include air
emissions natural resource consumption (i.e. water, fuel), chemical usage, and
possible chemical spillage.
Environmental Impact: "Any change to the environment, whether adverse or
beneficial, wholly or partially resulting from an organization's activities,
products or services." (ISO 14001)
Example: The environmental impact(s) associated with landscaping chemical
usage may include: air pollution, human health affects, groundwater and/or
storm sewer contamination, and flora and fauna (plant and animal) health
affects.
Environmental aspects drive the EMS. An EMS encourages healthcare organizations
to systematically address the environmental aspects and impacts associated with its
activities, products, and services. This is a perfect opportunity for pollution prevention.
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Pollution prevention can often eliminate or greatly reduce many environmental aspects.
For those aspects that can not be eliminated upfront, other pollution prevention
alternatives can be used to manage them in a more environmentally-friendly manner.
Environmental aspects can include waste generation, resource utilization and depletion,
energy utilization, and noise/light pollution.
Identifying all of your aspects and impacts can be a big job. One manufacturing
facility had 550 aspects. Ultimately, this facility determined that 50 of its 550 aspects
were 'significant' according to its criteria and eventually set objectives and targets for 10
of its most significant aspects. The key point is that you will have many aspects; but not
all of your aspects will be significant and not all significant aspects need to have an
objective and target.
The first step in identifying your aspects is setting the scope of your EMS. Do you
want to include the whole hospital in the EMS, select hospital buildings on-site or just
selected departments? You may wish to implement an EMS in one part of the hospital on
a pilot project basis and then take the advantage of "lessons learned" to implementing the
EMS hospital-wide. Also, a positive experience on the pilot can build momentum as you
approach other departments; conversely, a less-than-positive experience can thwart your
efforts as you approach other areas to start the EMS. Next, identify activities and
services within the scope of your EMS. These are starting points for the next step:
identifying aspects and impacts. Identify aspects and impacts associated with each
activity or service. Techniques you may choose to use to identify aspects include process
mapping (charting a materials flows from entry into your hospital, through use, and
disposal/recycling); interviewing; benchmarking against other hospitals and healthcare
organizations; and inspections and audits.
Next, identify the impacts associated with each aspect. Impacts are the changes in
the environment that occur as a result of the aspect. Examples of impacts can include
increases in ground level ozone (air pollution); degradation of water quality or drinking
water supplies; conservation of natural resources (through recycling, for example); and
soil pollution (from accidental spills). Ask whether you have control or influence over
each aspect. Your hospital's degree of control or influence over different aspects will
vary. For example, energy usage is an aspect. Your hospital may not have control over
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what kind of fuel your utility burns to provide power, but your hospital does have
considerable control over how much energy it uses and requires from its utility.
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Training for workers
whose work may
impact the environment
Structure and
responsibilityfiEMR)
k
' - - m
Identify aspects
and impacts
Develop and apply
to im pacts (aspects)
k
• m
Set objectives
and targets .
(o & fs)
EMPsas
action plans
Identify & Implement
operational controls
for o&f sof
sign VI can t aspects
Monitor and measure
progress toward o & f s
for sign VI cant as pacts
-compliance audit
- calibration
Preventive
» actions
(emergency planning
preparedness)
Man agement review
E fats system
audit
Compliance out of
control
N on -eonf or man ce
and
corrective action
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Table 1 and Table 2 at the end of this section show example aspects and impacts for a
health care facility. Key information to write down includes the following.
1. The name of the activity, product or service with a short description of process in
question.
2. The environmental aspect(s) associated with each activity, product, or service.
3. Legal Requirements: Is the environmental aspect(s) of the activity, product or
service legislated and/or regulated?
4. Actual/potential impacts associated with each aspect
5. Significance rating. This may be based on the example shown. In the example,
frequency, consequence, and degree of control are each independently rated then
combined for a Total Significance score. More on determining significance is
presented later in this section.
You may find the examples in this manual do not cover all the functions and activities
performed at your hospital. Use them as a guide to help you conduct a thorough analysis
of the activities within your facility.
You may choose to use environmental regulations as one approach to identifying your
aspects and impacts. Be sure, though, not to limit yourself to only regulated aspects and
impacts when developing your aspects/impacts inventory. This is an easy trap to fall
into. Many environmental managers gained their environmental work experience from a
compliance-based perspective and think in media-based terms-air, water, and solid or
hazardous waste. This can lead to an emphasis on "end-of-pipe" treatment technologies
and missed cost savings opportunities. For example, how much energy and water your
hospital uses is not regulated (in most U.S. locations) and would likely not be examined
in a compliance-based EMS; however, these areas often present significant cost-savings
opportunities.
Roles and Responsibilities in Identifying Aspects and Impacts
When identifying your environmental aspects and impacts you can do it
individually or by enlisting the help of your Green Team. Involving your Green Team
divides the workload and gives the members more of a hands-on involvement earlier in
EMS implementation. You may need to provide aspects/impacts training to the Team
and review and monitor the departments' work outcomes to ensure continuity between
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the department's lists, but the approach is an effective way to build rapport with
department managers and personnel.
Alternatively, you may choose to develop your aspects inventory as an individual.
This approach allows you greater control and continuity of the aspects lists and requires
less coordination. However, it may take longer to complete and you may find you have
to regularly update your Green Team on progress.
Either way, it is beneficial to actively involve front-line staff and departmental
managers in the initial completion and maintenance of the aspects inventory. Employees
may be aware of environmental issues and opportunities unknown to management and
have ideas on how to address them. Second, involving employees begins to build buy-in
and understanding in a way that is real to their work area and their experience. This in
turn builds employee ownership in and understanding of the EMS which is key when you
will need employees to develop work instructions addressing significant aspects in their
work areas, measure environmental performance, and otherwise do things
environmentally they might not normally do. Finally, this is also a good opportunity to
train employees on how important it will be to keep aspect/impact information up-to-date
and to report environmental changes to you or department managers.
Determining Significance
Once you know your aspects and impacts, the next step is to determine which are
most significant. You may choose any criteria. While there are no hard and fast rules or
requirements, commonly used significance criteria include cost, volume/toxicity of waste,
frequency of the environmental aspect, and whether the aspect is regulated or has
compliance concerns. These criteria become the filter by which you tell which aspects
are most important.
Environmental Management Accounting (EMA) goes hand and hand with
identifying costs associated with environmental impacts. EMA identifies, collects, and
considers costs over the entire product/chemical life cycle as well as those traditionally
"hidden" in overhead. These are often not considered in traditional business decision
models. In short, using EMA program can help you be more fully aware of the cost of
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alternatives, bringing greater clarity to which projects you should focus on in your EMS
through your significance determination.
Determining significance is the perfect area to apply any environmental
management accounting information to your aspects and impacts. You should ask your
financial representative from your green team for any financial information on existing
environmental projects currently in the hospital, and also compile any cost information
on perspective options as you go along. Your financial representative may not be the
only person who has cost information on these projects, so don't forget to look to other
departments as well. Also make sure to consider any costs that might get labeled as
overhead cost and assign these to their respective areas. This information will be
particularly useful to administration in supporting your EMS, and furthering projects.
Table 3 Significant Evaluation Criteria for Environmental Impacts shows one
approach on how to determine significance. The significance ranking method used is
based on a scale of one through five. Each of the numbers selected for a given impact in
each of the three categories (consequence, frequency, and degree of control) is multiplied
to give an overall significance rating. At this particular hospital, any impact that ranked
at or above 27, or had legal requirements associated with it, was considered significant.
Change Management and Continual Improvement
When you implement your system, you'll have an initial list of aspects. Not all
aspects will be significant, but keep the list as a record nonetheless. As you address your
most significant aspects, you'll be able to go on and address the remaining aspects later
as part of continual improvement.
Keeping your aspects list current is important. As your activities, products, and
services change at your hospital, update your aspects and impacts list. This helps your
environmental programs change and stay current. In one case, an automotive
manufacturer changed from a lead-based electro-coat material to a lead-free alternative.
During the 6-month surveillance audit to maintain its ISO 14001 registration, the facility
proudly showed this to its auditors as an example of continual improvement. The auditor
congratulated the facility and promptly asked the facility if it had updated its list of
aspects to reflect the new waste stream coming out of the modified process.
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Train your departmental managers to evaluate any new or future processes,
activities, or services for new aspects and impacts and to communicate this information to
the EMS representative. Involving and providing training to purchasing staff is
especially important. Purchasing often has first-hand knowledge of new equipment and
processes and can notify the EMS Representative of new significant environmental
issues. New pieces of equipment may be acquired during your hospital's capital
budgeting process. Work with your Finance department to identify opportunities to
evaluate the environmental impacts of equipment prior to their approval. Such
notifications also allow the EMS Representative to identify any potential new regulatory
requirements.
Helpful Hints for Getting Started
1. Keep your categories of aspects and impacts general. While your technical
proficiency an environmental specialist may allow you to be more detailed, consider
that most people in a hospital may not have an environmental/technical background
and experience. Keeping categories general helps people more easily understand and
brings them on board as participants in aspect identification.
2. When developing your list, you may find that certain activities and thus their resulting
aspects and impacts are continuously repeated [ex: waste generation (biomedical,
garbage, recycling), operation of office equipment, energy usage, general
housekeeping, etc.]. You may choose to combine these activities together under a
title such as "General Hospital Operations" to help simplify your inventory.
3. Not all aspects and impacts are negative or detrimental to the environmental.
Recycling programs, household hazardous waste collection days the hospital sponsors,
and other environmental improvement efforts will have positive aspects you should
include when identifying aspects and impact. Recycling, for example, reduces raw
material and energy usage and the associated pollution these cause. When you
identify these, be sure to include the activity in your inventory and designate the
outcome as a positive impact (+).
4. Impacts can relate to the immediate changes to the environment (i.e. vapors from
chemical use affecting human health) or eventual changes to the environment (i.e. the
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generation of garbage will eventually impact natural resources as a landfill utilizes
land space).
Click here to see example healthcare aspects, impacts, and significance
determination. Page 140
Objectives and Targets
Setting Performance-Based Objectives and Targets
An EMS requires setting performance-based objectives and targets. Objectives are
overall environmental goals. Targets are detailed performance requirements, quantifiable
where possible, set to achieve the objectives.
Consider using your cross-functional Green Team to help brainstorm possible
objectives and targets. It is up to you and the hospital to decide on how many objectives
and targets to pursue; however, you should consider the following in setting objectives
and targets.
• Significant environmental aspects. Some of your environmental aspects rated
most significant. Are there any you want to set objectives and targets for? For
example, you may wish to set an objective of "reduce mercury waste" in hospital
with a target reduction of 10% per year.
• Legal & other requirements. You may choose to set compliance-based
requirements as an EMS objective and target. For example, you may wish to set
an EMS objective as "maintain compliance with applicable environmental
regulations" and a related target as "submit all required paperwork on time" or
"no written notices of violation."
• Views of external parties. This is key for hospitals. Input from your patients,
visitors, and community neighbors is especially important particularly considering
hospitals' mission to protect the health.
• Technological options. If technology is not available, you may not be able to
pursue certain objectives and targets. At one EMS facility disassembling office
copy machines, toner from ink cartridges could not be recycled because cost-
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effective technology was not available. At some point, cost-effective technology
could become available but until then the toner requires land filling.
• Financial requirements. You're not required to pursue objectives and targets that
do not make financial sense.
• Operational & business requirements. Many EMS organizations are including
their environmental objectives and targets in the annual business plan, ensuring
that they are in line with overall hospital requirements and receive needed
resources. Are there objectives and targets that can operate in line with or
otherwise complement other hospital objectives and targets?
Implementation Tips
In addition, you may wish to consider the following tips.
• Make sure your objectives and targets are attainable within reasonable limits.
• Choose a manageable number of objectives for the resources, time and personnel that
are available. Narrow your search down by considering the financial and physical
resources needed for each objective. Based on available resources, initially, you may
only be able to implement those plans that have high payback and low costs.
• Your objectives and targets should be S.M.A.R.T. (Specific, Measurable, Achievable,
Results-oriented, and Time-dependant.)
• Don't try to address all environmental issues your first time around. Pace yourself!
• Objectives can focus on individual activities or processes, be department-specific or
hospital-wide. The scale of each objective is up to you.
• Develop performance indicators (i.e. how will you measure how well you have done)
for each objective and target that can be used as a basis for the overall evaluation of
your objectives progress.
• Objective and targets should be periodically reviewed and where necessary revised to
incorporate any changes.
• Regular updates of objectives and targets should be given to your Green Team,
management and Senior Management Teams.
• Be sure to write down your objectives and targets and train people on what they need
to do to help meet objectives and targets that can apply to their work. Various ways
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to do this include posting a display and writing an article for your hospital newsletter,
etc.
Environmental Management Programs
Environmental Management Programs, or EMPs, are the plans laid out to achieve
your objectives and targets. In short, an EMP spells out roles/responsibilities, the action
plans, deadlines, and resources needed to accomplish objectives and targets. This
information should be documented. The process of setting objectives/targets and EMPs
is closely linked; it helps to have an idea of how you will accomplish an objective and
target before you set it as a program in your system
How you structure your EMPs is up to you. One automotive manufacturer had an
EMP for each major initiative at the facility: one EMP for energy usage, one EMP for
solid waste, one EMS for all regulated aspects, and one EMP for PCB elimination.
Another facility set the EMPs at the department level, resulting in many more EMPs, but
allowing for greater employee ownership and buy-in. However you choose to set your
EMPs, you will need to measure your progress. Some measurements are quantitative
while others will be more qualitative and subjective. In either case, measure your
progress.
You may already have programs similar to EMPs in place at your hospital. If so
consider using the same format and approach for your environmental programs. For
example, many facilities have already developed formal action plans to decrease
biomedical waste to reduce haulage costs, risk and improve health and safety. Even
though this goal may not be formally documented, an individual has researched available
options and set achievable targets and developed actions to fulfill this goal. This is very
similar to what an EMP requires. Key things to consider when working on EMPs include
the following.
• Ensure that actions have responsibilities, timelines, and resources for each action item
identified.
• Spread responsibility for tasks around to associate managers, members of the Green
Team, staff, etc. "Many hands make light work!"
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• Don't "invent the wheel" if you don't have to. Ask around and see how other
hospitals are addressing the issues you have identified.
• Look to the resources and pollution prevention programs highlighted in this manual.
• Not all objectives are to be completed in a one-year time period (i.e. energy
consumption can be a multi-year objective that requires substantial financial
budgeting).
• EMPs should be periodically reviewed and where necessary revised to incorporate
any changes. As you accomplish objectives and targets and set new ones, your EMPs
should correspondingly come into and go out of existence.
• Regular updates of the environmental management programs should be given to the
Green Team.
At St. Mary's General Hospital, the Environmental Management Team (Green Team)
began implementing achieving its objectives and targets through the following EMPs.
Biomedical Waste Reduction EMP
Biomedical waste management and disposal was one of the hospital's most
significant aspects (i.e. highly regulated, significant disposal costs, health and safety
issues if handled improperly).
The first step in St. Mary's biomedical waste reduction program was to address
the risk, cost and compliance associated with the operation and maintenance of the
hospital's incinerator. A formal review of the incineration equipment and usage resulted
in the incinerator being shut down permanently. St. Mary's contracted the waste disposal
services of a responsible, licensed medical waste hauler who also contractually assisted in
the hospital waste reduction efforts. The hospital performed a biomedical waste audit of
all departments, focusing primarily on the departments that produced the largest amount
of biomedical waste (i.e. Emergency, Operating Rooms, Laboratory). The goal of the
waste audit was to review current proper container usage, review staffs knowledge of
proper disposal methods and to determine possible waste reduction actions for each area.
The audit revealed these findings.
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• 70-80% of all the biomedical waste bags were filled with garbage (gloves,
plastic, cups, paper towel, etc.;)
• Proper signage was not adequate on containers;
• Some rooms only had biomedical (yellow) bags and all garbage was being
disposed in that container;
• Staff were putting objects that could be recycled into red bags and garbage
bags;
• Rooms that produced no biomedical waste had red bags ("Just in case!"),
• Staff were not aware of what went into the red bags and what the definition of
biomedical waste was; and
• Departments often used large containers for red bags and small containers for
garbage. Staff often migrated to the largest, closest container for waste
disposal.
Actions resulting from the audit:
• Red bag containers were removed from rooms that only produced garbage;
• Proper signage was placed above the majority of containers to dispel myths
about what was to be placed in a red bag;
• Biomedical and garbage containers were switched so that the larger containers
contained a black bag;
• Environmental Services (Housekeeping) staff received training on how to
properly segregate biomedical waste to help identify departmental problem
areas in the future; and
• A hospital-wide "Road-show" on waste education was delivered to all floors.
Cookies and treats were brought to each floor to entice the participants
(resulted in great attendance).
In one year the hospital decreased its biomedical waste stream by 22%, in spite of
an 8% increase in surgeries in the hospital's operating rooms (main generators of
biomedical waste). To date, even with substantial hospital growth, the segregation
efforts of the staff resulted in a 38% reduction in biomedical waste weights since 1998.
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It is important to understand that the waste separated out of your biomedical
waste stream will primarily be garbage, and hence your landfill weights will increase. To
counteract this increase you must evaluate the reuse and recycling programs your hospital
has in place.
Recycling and Reuse EMP
When St. Mary's General Hospital first began developing its EMS, the hospital
had implemented a few recycling and reuse programs. Most departments had a "blue
box" used for glass, cans, plastic, cardboard and newspaper. Many of the administration
offices and communication clerk areas had desk side cardboard boxes for paper waste
(colored paper, magazines, envelopes, etc.). The Nutrition Department already collected
food waste from the cafeteria trays and sent it to a local pig farmer for reuse.
When the Environmental Management Team decided to "improve recycling" as
one of its objectives and targets, the hospital had to evaluate current recycling service
providers and investigate a number of non-conventional recycling and reuse
opportunities. St. Mary's joined forces with two other regional hospitals to develop the
"Regional Hospitals Recycling Initiative." By combining negotiations for contracts, the
hospitals were able to increase buying power and receive discounted prices for pick-up
services. The chosen recycling company would be able to perform "milk-runs" to pick-
up the three hospital's glass, cans, plastic, and paper/newsprint recycling containers.
With pick-up service of the "general" recyclables underway, newly purchased
recycling containers were dispersed throughout the hospital to incorporate a "segregated"
recycling system. The "recycling stations" primarily located in kitchenette areas,
lunchrooms, lobby areas and the cafeteria consisted of three slim plastic containers that
contained glass, cans, and plastic. The blue boxes that were previously in place were re-
designated for cardboard and newspaper. Widely distributed plastic desk side recycling
containers replaced the cardboard desk side paper recycling containers. Other recycling
efforts included the following.
• Pagers, personal electronic organizers and other information technology devices
generate a large number of alkaline and nickel-cadmium batteries. Due to the
hazardous nature of this material if disposed (metal and battery acid), the hospital
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decided to ship these materials out for recycling and reuse. Plastic buckets
(reused from the Nutrition and Food Services department) were placed on floors
for battery collection. When the containers are full, Environmental Services staff
personnel transport the buckets to battery disposal drums and return empty
buckets to the floor. The hospital pays for disposal of alkaline batteries while
nickel cadmium batteries are picked-up free of charge.
• Florescent tubes contain mercury vapor, and as "Mercury Free Medicine
Campaign" hospital, St. Mary's needed to dispose of the mercury content
properly. The hospital enlisted the service of a local company that recycles all
fluorescent tube components. When a tube is changed by Engineering Services,
(Maintenance) staff, the spent tube is placed back in its original boxes and
attached to a skid for transport. In 2001, St. Mary's collected 1,414 florescent
tubes resulting in the recycling of 393 kg of glass, 5 kg of aluminum, 6 kg of
phosphor powder and 0.04 kg of mercury.
• The hospital was recycling cardboard, but not boxboard (tissue boxes, glove
boxes, various supply boxes, etc.). The hospital implemented this recycling
alternative and now collects and bails boxboard along with cardboard.
• The Pharmacy department at the hospital also identified re-use opportunities.
Drugs and medications needing refrigeration are always delivered in Styrofoam
containers with cold packs. The Pharmacy department now offers the Styrofoam
containers and cold packs to staff for reuse. The program is widely popular.
Spill Response and Emergency Preparedness EMP
Health care facilities with onsite laboratories utilize a large number of chemicals
on a daily basis. In addition, health care facilities have numerous shipments by trucks
carrying chemicals or hospital supplies. At anytime, either of these situations could
result in a chemical spill, internally or externally. For this reason, one of St. Mary's
objectives focused on spill prevention and response.
First, the hospital performed an emergency preparedness audit of high-risk areas.
Inventory was taken of all equipment and personal protective equipment. One finding
was that all aspects of emergency preparedness and response dealing with fires,
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evacuation, disasters (natural and not), and bomb threats had already been adequately
addressed through the hospitals emergency code system. However, little information was
available on emergency response for internal and/or external chemical spills and handling
chemically contaminated casualties. Personal protective equipment and spill clean-up
equipment was lacking.
In response, the hospital's Environment, Health and Safety Specialist developed a
"Code Brown- Chemical Spill Response Procedure" and assembled a hospital Spill
Response Team. The Code Brown procedure dictates what staff and the hospital's Spill
Response Team should do in a case of a chemical emergency. The hospital also
purchased three hospital spill kits, 4 full-face respirators (in addition to what the hospital
had), and personal protective equipment (chemical resistant gloves, suits, and goggles).
Each member of the hospital's Spill Response Team receives annual comprehensive spill
response training, respirator training, and Code Brown responder training. All new
hospital staff receives Code Brown training during their hospital orientation session and
existing staff receives annual Code Brown training as a part of the hospital's code review
sessions. Since program inception, there have been no reportable chemical spills.
Landscaping Practice EMP
Landscaping provides a variety of environmental challenges including pesticide usage
and lawnmower emissions. Hospitals often have immune-deficient individuals entering
and leaving the hospital's property. For this reason, St. Mary's recognized the
importance of being proactive and eliminating pesticide and herbicide use in current
landscaping practices. St. Mary's worked with its current landscaping company to
investigate the opportunities available to the hospital. Identified options included the
following.
• The hospital developed a "green landscaping policy";
• All spot spraying was stopped;
• Increased aerating, re-seeding and fertilizing are used to reduce herbicide use;
• Shrubbery and other vegetation prone to attacks by pests was promptly removed
and replaced with native, drought- and insect-resistant alternatives;
• St. Mary's uses microbial pest intervention to kill lawn grubs;
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• Future landscaping plans would reduce the amount of grass around the facility to
promote the usage of groundcover, gardens, and other vegetation not requiring
such labor-intensive up-keep;
• Scheduled mowing to avoid smog-alert days;
• Use of a natural fertilizer (corn gluten meal) with inherent herbicidal qualities;
and
• Use of environmentally friendly alternatives to salt for ice removal on walkways.
Your hospital will most likely choose to include mercury reduction as one of your
objectives to establish an EMP. Consider the following ideas in your development.
• Eliminate, reduce, or recycle mercury containing products or waste wherever
possible.
• Inventory/preliminary assessment of mercury in equipment, materials (also
chemicals and pharmaceuticals), in storage, and in waste streams. Be sure to look
at cleaning supplies for mercury-content.
• Gather life-cycle cost of purchasing/using mercury-containing products versus
mercury-free products.
• Switch to mercury-free products (e.g., thermometers, lab reagents).
• Segregate mercury-containing products before they get into incinerator waste
stream (conduct training).
• Use fluorescent lighting. Fluorescent lighting requires four times less energy than
incandescent lighting. This means less mercury emissions at point of power
generation.
• Eliminate purchase of mercury-containing products through environmentally
preferable purchasing and purchase contracts with vendors/suppliers. Create and
enforce agreements with vendors to supply only mercury-free products.
• Develop a broad-based communications program to increase awareness of human
health and environmental dangers of mercury.
• Include articles devoted to mercury reduction, handling, and proper disposal in
staff newsletters.
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• Include specific information about the proper handling of mercury in new-
employee orientation and "Right-to-Know" training.
• Ensure that all personnel—including temporary workers—are familiar with the
facility's mercury handling procedures and protocols to prevent mercury from
being disposed of in sharps containers, red bags, or solid waste containers.
• Include information about waste reduction and pollution prevention in in-service
training sessions.
• Encourage personnel to be label readers.
• Place placard or labels on or above red bags, sharps containers, and solid waste
containers that state "No Mercury."
• Make sure you have mercury spill kits available in all labs, nursing stations,
ICU/ER/Surgery rooms, patient rooms and storage/maintenance facilities.
Click here to see objectives/targets and EMP example procedures. Page 158
Environmental Policy
Developing the Policy
The environmental policy can be created any time during EMS implementation.
In the ISO 14001 standard, the environmental policy is addressed first. Some
organizations draft the policy first and use it as a first communication from top
management to all employees. Other hospitals identify their significant environmental
aspects, legal requirements, and objectives and targets prior to developing the policy in
order to accurately depict the organization's future environmental goals and guiding
principles. Choose whatever process best suits your hospital's needs.
The environmental policy is the cornerstone of your EMS. Like your hospital's
mission statement or policy, the environmental policy should ultimately reflect the
environmental values and senior management's commitment. Some environmental
policies are short and concise; others are more elaborate and detailed. Look at your
hospital policy and procedure process to help identify the context in which you might
develop this document.
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Things to Consider When Writing the Policy
1. Does your policy reflect the values set forth in the hospital's mission statement?
Hospital mission statements often include a commitment to provide quality patient
care services, promote healthy living, and to provide a healthy and safe workplace for
staff and volunteers. Consider supporting statements from your mission when writing
your policy. This helps integrate the policy into the overall management of the
hospital and may help get Senior Management approval.
2. What are the significant aspects and impacts associated with your hospital's
operations, activities, and services? Consider these possible issues when developing
the wording in your policy.
3. Consider including any underlying environmental guiding principles, references
and/or verbiage from existing environmental policies or procedures, and statements of
prior commitment to pollution prevention strategies.
4. Does your policy distinctly include a commitment to continual improvement,
pollution prevention, and compliance with applicable legal and other requirements?
Does it include a guiding statement referring to how your organization will set
environmental objectives and targets? Keep in mind specific reference to these areas
in your policy is a requirement of the ISO 14001 standard.
5. Is the policy clear, concise and understandable? The policy will be a tool for EMS
communication both internally and externally and should therefore be developed with
the end user in mind. One facility implementing an EMS wrote a three-page
environmental policy. This long of a policy made it harder for employees to relate to.
Generally, an environmental policy should be no longer than a page. You may wish
to have an environmental policy statement in addition to the environmental policy.
The policy statement is a condensed version of your policy and consists of a
statement of your hospital's commitment to continual improvement, compliance with
legal and other requirements, and prevention of pollution.
6. Has the environmental policy been signed and dated by your senior most
management? Like any corporate policy, you will want the CEO to sign on behalf of
your senior management team. In some instances, and depending on your policy
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development procedures, you may want your Board Chairperson to sign the policy as
well.
7. Is the policy reviewed on a regular basis by your senior management? By dating the
environmental policy, you have a reference for when your policy was last reviewed
and changes made. Consider reviewing your EMS policy on a yearly basis; however,
if your hospital reviews corporate policies every two or three years, you have the
opportunity to accept this timeline.
Communicating the Environmental Policy
Hospital Staff
Communicate the environmental policy to all hospital staff. The following is an
example of some of the most effective ways to communicate the policy to hospital staff:
1. Post copies of the policy in highly visible, frequently visited locations within
the hospital: cafeteria, near the time clock, front or main lobby area, outside
main elevator landings, within a permanent environmental display board,
outside your CEO's office, on a hospital accomplishment board, and at any
other location that staff frequently visit.
The EHS management representative posted the policy, significant aspects, objectives
and targets, contractor environmental information sheet on a bulletin board in the
hallway between the work and break area. Area supervisors would take their teams to
the bulletin board and review this information at the end of the weekly health and safety
meeting.
2. One facility put a copy of its environmental policy on the back of the
vacation/holiday leave schedule handed out to employees. By hanging onto
the vacation/holiday leave schedule, employees would always have a copy of
the environmental policy.
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3. Many facilities place the environmental policy on a business card-sized insert
that can be slipped into the back of staff/visitor ID badges. Other ways of
communicating the policy include showing it on the hospital TV network, at
hospital entrances/exits, in environmental training, and via email.
4. Post a copy of the policy within your hospital's main policy and procedure
manual (either paper or electronic version).
5. Include the policy in your hospital's newsletter.
6. Post the policy on your hospital's website.
7. Ask to include the policy as an agenda item at each departmental staff
meeting.
8. If you haven't already done so, ask to be included at your hospital's
management meetings. If you get this time, use it wisely. Ask for enough
time to cover the definition of an EMS, the contents of the environmental
policy, and the EMS roles and responsibilities of management staff. This can
be an EMS training opportunity.
9. Educate new staff on the environmental policy during their hospital
orientation training. Attach a copy of the environmental policy to their
orientation package for reference.
Patients, Visitors, Community
Your environmental policy is the only document in your EMS you must provide
externally (if you are pursuing ISO 14001 registration). Posting your policy in a highly
visible location within your hospital or on your hospital's web site are just a few ways to
provide your policy publicly.
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Contractors and Suppliers
Contractors and suppliers should be aware of your hospital's commitment to the
environment and the environmental policy. Contractors and suppliers can have an impact
on your hospital's environmental performance and will need to follow EMS procedures.
There will be times you may need their commitment, particularly on issues such as
reducing product packaging, green procurement, and information on products they supply
to your hospital.
St. Mary's General Hospital sent recent contractors and suppliers (those with
whom the hospital had done business in the prior two years) an environmental awareness
brochure outlining the hospital's environmental commitment. Also included was a
questionnaire asking for input on how they could help the hospital attain certain
environmental goals. Supplier and contractor response was positive and assisted hospital
purchasing in developing a "green" products and services database. In turn, participating
suppliers were able to promote additional product lines to the hospital for future possible
business.
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(Mai)
St.Maryfe
GENERAL HOSPITAL
Environmental Policy
St. Mary's General Hospital is a community-oriented organization, which is committed to the protection of the natural
environment by providing patient and community health care services and operating our facility in an environmentally
responsible manner. We will strive for continual improvement in our environmental performance and the prevention of
pollution through the following goals:
Corporate Commitment
We will comply with all applicable legislation, regulations and other requirements that apply to the hospital's
environmental activities, and, wherever possible, we will exceed requirements as legislated.
Protection of Natural Resources
We will contribute to the conservation of natural resources and minimize the release of pollutants through environmentally
sound decisions and processes.
Reduce, Reuse, Recycle
We will reduce, reuse and recycle waste wherever possible in order to optimize our utilization of available resources.
Waste Disposal
We will dispose of all waste responsibly to protect the health and safety of our employees, the community, and the
environment.
Purchasing Practices
We will continually evaluate our purchasing practices in order to minimize adverse environmental impacts.
Communication and Staff Education
We will ensure that staff, patients, volunteers and physicians are aware of the environmental policies, procedures, and
issues within the hospital, through the use of formal training and communication programs.
Environmental Objectives and Targets
We will set and review measurable environmental objectives and targets, and report on our environmental performance.
Monitoring and Evaluation
We will monitor our progress against program goals, and review training, procedures and resources, in order to continually
improve our environmental performance set forth in this policy.
Administrative Support
We will support the appropriate administrative structure to ensure institutional compliance with this policy.
Bruce M. Antonello,
President & Chief Executive Officer
Cathy Brothers,
Chair, Board of Trustees January 24,2001
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Operational Controls
Hospital Considerations
Operational controls are perhaps the most important part of the EMS in terms of
actually getting things on the floor done. They provide the "how-to" instruction. You
will need operational control(s) in place to address your significant aspects and your
objectives and targets. Generally, operational controls are written work instructions like
the example shown, but also can include training, test results, and 'control points' like
those found in air and water discharge permits. You may choose to have additional work
instructions for other important areas. When determining which of these additional work
instructions should be documented, consider factors such as task frequency and
complexity, personnel turnover, and level of required supervision. Written work
instruction can also be an excellent training aid.
Work instructions also help you achieve your objectives and targets. For
example, one EMS facility set an objective and target to reduce its hazardous waste by
10% over the upcoming year. It generated one hazardous waste stream associated with
lacquer coating copper winding used around electric motors. It implemented three work
instructions, or operational controls, to help get to the 10% reduction. One work
instruction specified that employees chip lacquer off the mix beaters instead of using new
solvent. Another instruction directed the use of used solvent to purge lines and the third
specified cleaning lacquer measuring cylinder at the end of the day instead at the end of
every shift. All of these together helped the facility reduce the lacquer use and
corresponding hazardous waste generation.
Click here to see operational control examples. Pagel73
Contractors and Suppliers
Communicating environmental requirements to contractors/suppliers is often one
of an Environmental Manager's least favorite things to do. However, it can be one area
of tremendous "bang-for-the buck" when it comes to environmental performance,
particularly considering the environmental impacts contractors can have. Contractor
performance can directly impact whether you meet objectives and targets. If, for
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example, you have a solid waste reduction objective and target and construction
personnel leave their worksite waste for you to dispose of, you're going to have a harder
time meeting your waste reduction goal.
You may choose to use a contractor information sheet like the one shown in the
Training section to communicate EMS requirements. Be aware that if you send this to
corporate office addresses, it may not be communicated on their end to the people that
actually come out to your facility and do the work; consequentially, you may need to find
alternate ways to make sure such EMS information gets into worker hands. One way is
to include it in safety/health training you conduct or in contractor handbooks. Another
way is to distribute it at check-in points (e.g., guard gates) at your hospital.
Monitoring and Measurement
An EMS requires you have procedures in place to monitor and measure your
environmental performance against your objectives, targets, and significant impacts; to
record information that allows performance tracking of operational controls and
conformance with objectives and targets; and to evaluate compliance with environmental
regulations. Review the kinds of monitoring and measuring you do for regulatory
compliance and other purposes such as safety and health you may be able to use these in
your EMS. Be sure to think of non-regulated environmental issues such as water and
energy usage. Here are some example measures.
• Number of computers and monitors recycled/diverted from landfill (mercury)
compared to previous, baseline years. There is mercury in the computer relays
and switches in laptop screens and batteries. Computer monitors contain lead.
Recycling or otherwise reusing your computer electronics keep mercury and lead
PBTs out of the environment.
• Number of mercury spills compared to prior years
• Annual or monthly energy usage (electricity, natural gas, other)
• Water use (normalized)
• Pounds red bag waste reduced (normalized)
• Number of mercury products replaced with mercury-free alternatives
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Click here to see an example monitoring and measurement procedure. Page 181
Choose your measures carefully—too many create information overload and an
ineffective system, too few may mean you won't have enough information to make good
decisions. Information gathered through monitoring and measurement should be used
strategically to detect overall performance trends and possible need for corrective and
preventive action. This may allow you to identify gradually declining performance and
to correct it before it becomes a nonconformance in your system.
You need to calibrate and maintain equipment you use to measure environmental
performance. This ensures that readings are true and correct. For example, one facility
set a goal of recycling a set percentage of scrap rubber, collected scrap rubber in Gaylord-
style crates, and fork-lifted the crates onto a scale for measurement; they calibrated the
scale annually and kept records of calibration. In many cases, you may be able to refer to
guidelines in equipment manufacturer manuals, rely on calibration your organization or
utility already performs, or otherwise subcontract out calibration. When calibration is
performed by outside parties, you should still have a record of calibration. Remember to
look around for what you already have in place for monitoring and measurement.
Click here to see an example calibration procedure. Page 186
EMS Auditing
Auditing Program Components
Once your EMS is in place, verifying that it is performing as expected will be
critical. EMS audits actively check to see if your system is performing as you said it
would and, if you are ISO 14001-registered, whether the system is still conforming to the
standard. There are several components of an EMS audit program.
• An EMS audit procedure. Several examples are shown at the end of the
section. They cover audit team selection and training; preparing a written
audit plan; prior notification of audits, audit scope (areas and activities
covered), audit frequency; audit methods; key roles and responsibilities,
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how audit results are reported and followed up on. Audit results should
link to your corrective and preventive action process.
An internal audit team. The size of your internal audit team depends on
the size of your hospital and how many significant impacts your hospital
has. You should have enough auditors so that no auditor is auditing
his/her own work area and that there are enough backup auditors in the
event of illness or turnover. In manufacturing facilities with 200-300
employees, it is common to see anywhere from four to nine internal EMS
auditors. Typical internal auditor training includes in-class instruction as
well as on-the-job auditing. There are commercially available EMS
internal auditor training courses such as those ANSI-RAB offers
(www.rabnet.com). These should cover the components of an EMS and
good auditing techniques. While new auditors may not have the
familiarity with environmental requirements, facility operations, and
environmental science, these can often be learned through on-the-job
training. One specific technique is to pair an experienced auditor with the
trainee. With the right training and on-the-job experience, trainee auditors
can become quite proficient in their auditing and findings. At one
automobile manufacturer, an internal audit team conducted an EMS audit
in the paint booth facility on its own and with the EMS management
representative there only to provide ISO 14001 interpretative guidance.
The employee auditors on the team led the audit, conducted the
questioning, identified findings and presented these findings to the paint
booth facility managers on their own.
Audit frequency and audited areas. Audit frequency should be tied to the
importance of the activity being audited and the results of previous audits
of that area. Generally, organizations conduct internal audits of all areas
at least once or twice a year.
Maintaining audit records. Audit agendas, audit notes and checklists, and
perhaps most importantly, non-conformances written up as a result of the
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internal audits are the most common records demonstrating an EMS audit
program is in place.
EMS audits help maintain management and employee focus on the EMS and
environmental performance, find opportunities to improve the EMS and environmental
performance, and ensure that environmental efforts remain cost-effective and tied to the
overall hospital mission. At the paint booth facility above, the audit team began its audit
in the control room where readings on the incinerator indicated it running at 800 degrees
Fahrenheit; subsequent audit team investigation at the incinerator showed it reading over
1200 degrees Fahrenheit. The manager took great interest upon hearing this finding,
knowing the energy and cost savings that could be had by lowering the operating
temperature.
Click here to see an example EMS audit procedure. Page 188
Audit Program Tips
• Collect objective evidence (e.g., documentation, forms, memos, procedures,
policies, and records) of EMS conformance. Auditing should check management
commitment to EMS conformance and environmental performance and not focus
on why something did or didn't work. Identifying root causes comes later when
writing up the corrective action request.
• Auditors should avoid casting their expectations of what they should see and
instead focus on what they see during the audit and how it may meet a given
requirement.
• Use audit results to identify trends and patterns in EMS deficiencies. These
become opportunities for continual improvement.
Emergency Preparedness and Response
Overview of Requirements
One of the most needed EMS sections covers emergency preparedness and response.
While many organizations can use what they have in place already, this section really
challenges you to review and update (if needed) existing emergency preparedness plans.
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You may have these plans under any of a number of US regulatory requirements such as
RCRA, SPCC, EPCRA, Oil Pollution Act of 1990, and Hazard Communication.
Basically, there are four key points this section requires:
• Assess potential for accidents and emergencies
• Prevent incidents and associated environmental impacts
• Respond to incidents
• Mitigate impacts associated with incidents.
There is a strong emphasis on prevention in an EMS and this applies to emergency
preparedness and response also. One area where some organizations need additional
work is on identifying and addressing the potential for accidents and emergencies. A
good way to start is to ask 'what-if questions related to hazardous materials, activities,
and processes at your site. Consider normal and startup, shutdown, and other abnormal
scenarios for possible emergencies also in your assessment.
You are required to periodically test your emergency response procedures (at least
annually). Second, you need to review and revise your emergency preparedness and
response procedures, particularly after accidents or emergency situations, and to make
any necessary improvements. These are there to help ensure emergency response
remains suitable, adequate, and effective.
Implementation Tips
• Make sure emergency evacuation routes are clearly posted. At one facility,
intricate facility layout diagrams were photocopied down onto an 8 1/2'" by 11"
sheet of paper, making it difficult to read. Some diagrams were actually posted in
nearly hidden areas. In one case, at floor level near an ice machine in the break
area. Make sure your emergency evacuation routes are readable and posted
prominently in each work area.
• Make sure SNAFUs are worked out of your emergency system. At one facility
during an audit, a worker justifiably required to wear hearing protection in a loud
area indicated he could not hear or see emergency lights/sounds during a recent
actual emergency. Nor had anyone been assigned to alert him. Upon evacuation
and headcount, managers realized he was still in the building and went back to get
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him. Learning these kinds of things is an extremely valuable EMS benefit;
address such finding promptly.
• Don't forget about visitors and contractors. Would they know what to do in an
emergency? This is critical in the hospital environment with a continual flux of
visitors.
Click here to see an example EMS emergency preparedness procedure. Page 192
Training
Types of training
Training is key to successfully launching and maintaining any EMS because every
employee can have potential significant impacts on the environment as well as ideas on
how to improve those impacts. Try to tie EMS training into existing environmental,
health, and safety training. There are different kinds of EMS-related training to consider.
1. EMS awareness training provided to all employees covers what the policy is,
objectives and targets that apply hospital-wide (if any), and general roles and
responsibilities (e.g., who the EMS representative is). Good starting questions to
training your employees can be found in KPPC's EMS gap audit tool in the
Resources section of this manual. Ultimately, you want your employees not
simply to rattle off information they need to know, but to understand why the
EMS and related information is important. There are many ways to provide this
training. One company created a bulletin board displaying the company's policy,
significant aspects and impacts, and objectives and targets. During morning
meetings, the line supervisors went with the line team to the bulletin board and
reviewed this information all the way up to the time of their ISO 14001
registration audit. This approach was excellent for several reasons: 1) it built on a
system already in place; 2) the regular meeting established and reinforced the
importance of knowing the information; and 3) the employees knew where to go
when the auditors asked them questions about these areas of the EMS.
2. Work-area training provides task-specific training to employees to understand
what environmental impacts their work may have, how they minimize them, and
what they need to do to help meet objectives and targets that apply to them.
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Consider having written work instructions if not having them documented could
result in deviations from your policy or impede your ability to meet your
objectives and targets. Written work instruction are an excellent training aid to
consider. Employees should also be acquainted with any monitoring and
measurement responsibilities that apply.
3. Compliance training can tie into work-area specific training. Essentially there are
things that employees need to do to follow applicable environmental, health, and
safety requirements.
4. EMS Internal Auditor training for employees who are expected to perform this
function.
5. Top management may need additional training to address their special roles and
responsibilities in the system. In short, top management is there to ensure the
continued suitability, adequacy, and effectiveness of the EMS. They do this
through the following roles and responsibilities.
• Provide resources essential to implementing and controlling the EMS
where resources includes things such as human resources (peoples' time
and skills), technological resources, and money.
• Appoint management representative who 1) ensures EMS requirements
are established, implemented, and maintained; and 2) reports back on
EMS performance and possible need for improvement
• Participate in EMS Management Review.
6. Should your hospital choose to pursue ISO 14001 registration, you should
consider having at least one person attend ISO 14001 Lead Auditor training.
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Mercury Training Example
Workers at some hospitals were not separating mercury wastes properly, unintentionally
disposing of mercury waste in medical waste bound for incinerator. In another instance, a
worker reported that broken thermometers are sharp and disposed of them in a "sharps"
containers used for waste hypodermic needles. In other instances, workers reported
throwing away materials used to clean up mercury spills in infectious "red bag" waste. All
three of these instances are good examples of how proper training can keep mercury from
getting into our environment.
Click here to see an example EMS training procedure. Page 197
Contractors and Suppliers
Communicating your environmental expectations of suppliers is important. They
should at least be aware of your environmental policy; the significant impacts their
activities, products or services can cause; and your objectives and targets. One
facility put together and sent an EMS information sheet to all its contractors/suppliers
(see below). Contractors/suppliers are often partners in meeting EMS objectives and
targets. For example, hospitals often set solid waste reduction goals or purchase only
mercury-free products. The extent to which you partner with suppliers on these
efforts can impact how well you meet and exceed such an objective/target.
You may choose to send an EMS letter and information sheet to your
suppliers/contractors; be aware that corporate office do not always communicate the
information to the employees who actually come out and work. You may want to
have EMS training for contractors/suppliers, perhaps in conjunction with safety
training you provide.
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[Sample Hospital Document - Revise As Needed]
ENWRGNMENTAL AWARENESS
[HOSPITAL] ENVIRONMENTAL RULES
• Report all environmental emergencies or
potential incidents to the EMS Representative,
Safety Specialist, Project Coordinator/
Engineer, Department Manager or Supervisor.
• Do not dump any chemical or processed water
into the drains or sinks at any time.
• If using new chemicals, they must be approved
by the EMS Representative and/or Safety prior
to use.
• A MSDS sheet is required for all chemicals,
paints, solvents or fluids used in this facility.
[ENVIRONMENTAL OBJECTIVES AND TARGETS|
Objective
*> Reduce Solid Waste by:
*> Increase Recycling by:
*> Reduce Hazardous Waste by:
Target
6%/yr
5%/yr
5%/yr
Help us recycle aluminum cans by placing your
used cans in the aluminum can recycling
containers located in the break room and on the
outside patio.
Increase recycling of cardboard and paper by
placing your used cardboard and paper in a
recycling container located near you. If you are
unable to locate a container, just ask any
employee where one is located.
Performing both of the above tasks will not
only increase recycling, but it will also
decrease our solid waste.
Reduction of hazardous waste is accomplished
within the Laboratory and waste disposal
area(s). Environmental work instructions
outline the proper procedure to follow.
All question, concerns or comments should be
directed to the EMS Representative and/or
Safety Specialist
All environmental questions from outside
sources should be directed to the EMS
Representative and/ore Safety Specialist by
completing the External Communications Form
HOSPITAL CREED
WORK INSTRUCTIONS
Operator "Work Instruction" are posted at all work
stations. The purpose of these instructions are to
describe the work conducted at the station (e.g.
setup, inspection, operating perimeters,
environmental, etc.)
NECESSARY DOCUMENTATION
Please read and become familiar with the following
hospital documents:
[insert title and date of documents]
[Insert the Hospital's Name and Address]
[Insert the Hospital's Logo]
[Insert Hospital Contact Name and Number]
[insert Doc. Number & Document Approval Datej
In full awareness of our responsibilities as a
hospital, we will strive to promote health and well
being within the community and within our facility.
QUALITY POLICY
We here at [insert hospital name] have as our
quality policy a dedicated focus, by all hospital
staff, to provide patients, visitors and the
community with service that meets and exceeds
their expectations.
Our basic efforts are rooted in the areas of
continuous product and process improvement to
lower product cost and exceed our customer quality
requirements, while providing dependable product
delivery.
ENVIRONMENTAL POLICY
We the employees of [insert hospital name] are
committed to proactive environmental protection,
preventing of pollution, and continual program
improvement.
We will continually strive to meet or exceed local,
state, and federal environmental regulations and
other environmental programs to which the hospital
subscribes.
We challenge ourselves to attain our environmental
objectives and target, which will be reviewed and
revised as needed on an annual basis.
Security Rules
• Never give your badge or ID number to
anyone.
• Report all vandalism to the Safety
Representative or your Supervisor.
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[Sample Hospital Document - Revise As Needed]
• Never let unknown personnel in the
building at any time.
• Report all suspicious activities.
• Report any potential violence or threats of
violence.
Emergency Evacuation Procedures
Additional Emergency Situations/Procedures:
Important Phone Numbers
Facility Emergencies:
Project Coordinator/Engineer:
EMS Representative:
Safety Specialist:
Security:
Human Resources:
Engineering/Maintenance:
Quality:
Safety
Hazardous Communication Haz-Com
A written Haz-Com program is located in the
Employee Health office.
Material safety data sheets, (MSDS), are
located in the Employee Health Office and at
each workstation.
Labels are required on all containers, NO
EXCEPTIONS.
Emergency Codes
The hospital has a number of "emergency codes" to
handle emergency situations. Please familiarize
yourself with the following Codes (full versions
available from Department Manager/Supervisor)
prior to starting any work at the facility:
[Add in additional Codes as they apply]
The following Codes differ in hospitals. Apply as
necessary.
Code Red- Fire
Pull the fire alarm and exit the building. Follow
Hospital Code Procedures.
Code Green- Evacuation
Evacuate building as per hospital's Code Green
procedure
Code Black- Bomb Threat
Execute site search as per hospital's Code Black
procedure.
Code Brown- Internal/External
Chemical Spill Response
Ensure the hospital's Spill Team is promptly
notified and that spills are properly handled,
contained, and cleaned-up as per the hospital's
Code Brown procedure.
Tornado
Tornado shelters are located in the rest rooms and
locker rooms. Proceed to the shelter nearest your
work area during a tornado "Warning". A weather
radio is monitored for this purpose.
Lock Out Tag Out
Lock Out Tag Out procedures are to be followed
when performing maintenance on machines or other
equipment that could cause injury by the
unexpected release or start up of energy. The
Supervisor of the Engineering/Maintenance
department will have the lock and key.
Accidents
Report all accidents to your Supervisor or Safety
Representative immediately. Failure to do so can
result in corrective action. This facility has trained
First-aid personnel that can assist with injuries
and/or make arrangements for further treatment.
Fork Lift
No employee is allowed to operate a fork lift unless
they have completed the fork lift operators course.
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Getting Started
Providing the EMS work area and compliance training is time-intensive. You
already provide compliance training and know what job positions can impact whether
you stay in compliance. Do the same for significant aspects. First, identify your
significant impacts and determine where these are in your hospital. Second, determine
which job positions are tied most closely to the impacts. These are the folks for whom
you will want to provide EMS work-area training. In some cases, you may be able to
combine your EMS and compliance training. Consider establishing a training matrix
outlining which employees' work is tied most closely to the significant impacts and
objectives and targets, which training each job function should receive, and how often the
training is needed.
Frequency of Training
Much of your training efforts will be as you implement and start the EMS. There
may be other times down the road you will need to repeat the training described above.
Examples include new employees; employees transferred across work areas within the
hospital; introduction of new activities, products and services; new contractors and
suppliers; and as part of corrective/preventive actions.
Lessons Learned
• Many EHS managers focus on EMS implementation as a two-step process. First,
write EMS documentation, and then train people on what they need to know
of/from the documentation. This can prove to be a faulty approach depending on
how involved staff has been in writing the procedures and documentation. If staff
involvement is minimal, it will take more training time to bring them up to speed.
Further, their buy-in and involvement may be harder to obtain later in the process.
Plan extra training time with this approach! It is advisable to seek staff input in
writing work instructions.
• Incorporate needed EMS training into existing, already required training or
meetings (for example, use your Management Review as a time to provide EMS
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training to top management). People will appreciate this approach over having to
attend additional meetings.
• How you provide training is up to you! One EHS manager spread the word on the
policy, significant aspects, and objectives and targets by posting these on an EMS
bulletin board near the time clock where employees waited to punch in/out.
• Look for opportunities to begin training early. Training is one way of
communicating your EMS efforts and building familiarity. Be sure to
communicate the results of people's work back to them, particularly on successes!
• Don't forget about the training qualifications of individual providing the EMS
training. How are you and others prepared and qualified to give EMS training.
Communication
Most organizations already have procedures in place on how they communicate their
policies internally and externally. If you've been implementing your system as you've
been reading this manual, you've undoubtedly been in communication on various issues
with various people in your hospital—top management, fellow EHS staff, doctors,
nurses, and other staff throughout the hospital.
External Communication
An EMS requires that you communicate internally and externally. The only thing
you are required to provide externally is your environmental policy. In practice, you
probably provide much more information about your environmental efforts through P2
plans, annual reports, regulatory records, and emergency response planning. However, it
is ultimately up to you what, if anything, you provide on the EMS beyond the policy.
You do need to have a procedure, though, to handle external requests for information on
the EMS. The basics you should document for external requests include who made the
contact, the date, the nature of the request and response, and what, if any, materials were
sent.
There are various interested parties who may request information on your EMS.
While environmental groups generally spring to mind first for most EHS managers, there
are other potential interested parties including other hospitals, state and federal regulatory
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authorities, contractors/suppliers, local emergency officials, and neighbors. Your
external communication procedure may say that you'll consider requests on a case-by-
case basis, giving you the flexibility to assess the credibility of the contact and what
information you provide.
Click here to see an example EMS external communication procedure. Page 204
Internal Communication
What an EMS requires is that you have a formalized procedure for how you
communicate EMS information at various levels and functions throughout the hospital.
This doesn't preclude informal communication, but attempts to ensure some way of
consistent and systematic communication. Information you'll need to communicate
internally includes the EMS policy, responsibilities, and results. Environmental aspects
(and subsequent changes to aspects) needs communicated. Changes such as revised
objectives and targets, updates to existing procedures, environmental incidents, and new
regulatory requirements will also need communicated. Your internal communication
procedure should have some way to receive feedback from employees on the EMS and
environmental performance; in other words, communication on the EMS needs to be two-
way.
Training will be one of your most common ways to communicate with people
throughout the hospital but there are many other ways including email, in-house
television, and newsletters. Think through which are most effective at your hospital and
use them. The type of EMS information you share will depend on your audience. Refer
back to the Training section for the basics of who needs to know what on the EMS.
Tailor the nature and frequency of communications to your peoples' expectations and
needs. This varies from organization to organization.
Click here to see an EMS internal communication procedure and form. Page 206
Documentation/Document Control
No part of an EMS causes more stress, it seems, then documentation and
document control. It is the reason most argued against implementing an EMS. But how
you tackle your documentation will have a direct bearing on how much of a task it is to
develop and maintain. And despite the criticism, documentation proves in hindsight to be
one of the most significant benefits for many EMS organizations. Where preventing the
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loss of operational details, controlling the sequence of activities or events, or consistency
of results or outcomes is important, documentation will be valued accordingly.
Documentation such as written work instruction can be a valuable EMS training aid.
While there are some basic documents you should consider having (see List of
Documents), your hospital ultimately makes the call as to what and how to document.
There are practical considerations you should think about in deciding whether and how
much to document. First, if the task is important enough for two people to do the same
way, document. The system has to work and make sense for you. Second, determine if
there is any existing documentation within your hospital you can use to meet the EMS
requirement. If so, with needed modification, you can use it for your EMS and save
considerable time and expense. Third, use the 'new employee' test to determine if there
is sufficient detail in the procedure. That is, once you write a piece of documentation, is
there enough detail there that someone new to the position could pick up the
documentation and successfully complete the task? This is a critical test because it
challenges you to write down the knowledge and more importantly, the experience, that
people walking around have in their heads. This requires talking to your employees.
Many times organizations don't incorporate this experience in their work
instructions and procedures, generating interesting consequences. The facility saves time
in the short run by shortchanging the details, but upon completion and use of their
documentation on the floor, is left feeling like something is missing from having gone
through the whole exercise of preparing the documentation. The documentation proves
not all that helpful and people don't use it. Sometimes there are less subtle
consequences. At one industrial chemical facility, there were two augers that connected
to provide chemical feed to a storage pump that had to be replaced periodically. There
was one maintenance man who knew from experience how to "jiggle" the augers to get
them to align so they wouldn't contact and spark upon operation. When he left the
company, the experience went out the door. Upon subsequent replacement of the augers,
misalignment and sparking occurred, causing a fire and shutting down production.
Luckily, no one was hurt.
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LIST OF EMS DOCUMENTS
Typical Environmental Management System Manual Documentation
• Annual Objectives and Targets
• Action Plan (to achieve objectives and targets)
• Tracking and Measuring Progress
• Master Document Control List
• Organization-wide Procedures (in some cases, could be several procedures)
Environmental Aspects and Other Requirements
- Access to Legal and Other Requirements
Training, Awareness and Compliance
Internal Communication
External Communication
- Document Control
Change Management Process(es)
- Management of Suppliers/Vendors
- Emergency Preparedness and Response
Monitoring and Measurement
Calibration and Maintenance of Monitoring Equipment
- Compliance Evaluation
Corrective and Preventive Action
Records Management
- EMS Auditing
Management Review
• Procedures/Work Instructions for Specific Operations or Activities
E.g., Waste Management
• Forms, Drawings, and Checklist (that support the EMS procedures)
You will likely need an EMS manual. The manual should contain the
environmental policy, a master document control list, your main procedures, and work
instructions (if you choose). The master document control list is essentially a road map
to all of your EMS documentation. It should list the name of the document, where it is
kept, and the most recent revision. The basic purpose of listing the most recent revision is
for document control purposes.
Document control helps make sure everyone's working from the latest version of how
your hospital does things. If possible, set up your EMS document control system
electronically. Instead of having to replace multiple paper copies, you change out one
electronic copy. Plus, employees can pull up documents easier from their work location.
Other document control pointers include the following.
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• Choose who must approve documents carefully. Choosing too many people or
individuals rarely in the office (e.g., due to work travel) will make document
control difficult.
• Frequency of revision. Some documentation such as work instructions may
change somewhat frequently. Other documentation such as the environmental
policy and your system procedures will be fairly static.
• Communicate changes in documentation. There are various ways to do this.
Training is one way. Highlighting the changes in the procedures or
documentation for one revision is a visual reminder. At the back of each
procedure, consider having a table (as shown in examples) for recording changes
to procedures.
• Build on existing document control systems where possible.
• Pay attention to location, availability and protect against loss. If your
documentation is all electronic make sure it's backed-up to a safe location. If
your documentation (e.g., compliance reports) is hard copy, consider storing in
locked, fireproof cabinet.
Click here to see and example EMS document control procedure and Master
Document Control list. Page 211
Record Keeping
Records are historical in nature; they prove that your EMS is working as you
indicated it would in your documentation. Along with documentation, record keeping
requirements are probably the most maligned part of what an EMS requires. But how
you tackle this has a lot to do with how easy or difficult it is. Focus on records that add
value. Don't keep unnecessary records. Other tips to consider include the following.
• Determine who will have access to records.
• Determine how records will be kept. Consider storing hard copies in locked,
fireproof cabinets. Electronic records should be backed up and the backup copy
stored in a secure location.
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• Think about retention and destruction issues. Factors to consider in how long to
keep a records are: 1) any legally mandated retention requirements (e.g., in U.S.,
organizations must generally keep Clean Air Act documentation for five years);
2) hospital retention guidelines; and 3) the usefulness of the record to your
organization. Consider carefully what to record and how long to keep. At one
facility, an accident occurred involving a forklift operator. Upon review of the
operator's training exam, it was observed that the operator had incorrectly
answered a question, demonstrating management knowingly not correcting the
problem. This record was used against the company during legal proceedings.
Record should have been made at the time of training that the correct answer was
reviewed with and understood by the operator.
You may choose to have a Master Records List and include in your EMS manual. Some
records to keep for your EMS include the following.
Aspect/impact identification & evaluation
Compliance-related materials including permits, reporting, notifications, etc.
Performance measurements against significant impacts and objectives and targets
Monitoring equipment calibration
Sampling monitoring data
Internal/external EMS correspondence
Testing of procedures (e.g., under emergency preparedness and response)
Decision on external communication
Changes from corrective & preventive action
Training records
Audit results
Management review
Click here to see an EMS recordkeeping procedure. Page 219
Management Review
Management review is the point in EMS operation that ensures continued suitability,
adequacy, and effectiveness. Making sure the EMS remains cost-effective is a priority.
In short, an EMS requires you have management review at least once a year. Some
organizations insist on having management review two, three, and sometimes even four
times a year. Inevitably, this changes the nature from a longer-term, strategic outlook to
one with a shorter outlook; the review no longer meets what it was meant for.
-------
Management review looks at performance trends over the past year and in the future. In
particular, these are things your top managers should consider in management review.
Remember, top management is how you define it in your EMS; top management is
expected to show up and participate in the review
• Are EMS roles, responsibilities, and procedures clear, applicable, and relevant?
• What effects have changes in materials, products, or services had on our EMS and
its effectiveness?
• Are there patterns in non-conformances showing up from internal EMS or
compliance audits that need addressed?
• Are there compliance requirements could impact the hospital in the future for which
we need to plan and allocate resources?
• Are there changes we need to make to the policy, objectives & targets, or EMS? Is
progress being made toward current objectives and targets?
• Are there any trends in performance date from EMS monitoring and measuring?
• What stakeholder concerns (if any) have been raised since last review?
Consider using management review is a key training opportunity to train managers on
the EMS. Be sure to document who is at the meeting, items discussed, decisions made,
and who is responsible for which follow up action(s).
Click here to see an EMS management review procedure. Page 226
Additional System Examples
Example Aspects and Impacts for a Health Care Facility - Page 141
Sample Environmental Aspects and Impacts Inventory Format - Page 148
Significant Evaluation Criteria - Page 149
Tool to Determine Significance - Page 150
Aspects Lab Worksheet - Page 151
Aspects Worksheet-Energy - Page 152
Aspects Worksheet-Janitor - Page 153
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Table 1: Example Aspects and Impacts for a Health Care Facility
Activity/Service Aspect Possible Impact(s)
1. Nursing/Medical Floors/Operating Rooms/Day Surgery/Emergency/Intensive and Critical Care Units/Isolation Areas, etc.
Basic Patient Care (including
surgical procedures, daily care,
isolation cases, etc.)
Operation of Medical and
Other Equipment
Compressed Gas Usage
(oxygen, nitrous oxide, etc.)
Laser Usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Biomedical waste generation (sharps,
items contaminated with blood and/or
body fluids, isolation supplies, etc.)
Raw material usage (cleaning chemicals,
sterilants, high-level disinfectants,
formaldehyde, medications, etc.)
Potential chemical spills (emergency)
Energy usage
Hazardous waste generation (batteries)
Raw material usage (chemicals)
Possible fire hazard (emergency)
Chemical leakage (emergency)
Energy usage
Possible fire hazard (emergency)
Possible occupational exposure to
radiation
Potential water pollution from leaking landfill,
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air/Water Pollution, Resource
Depletion (e.g., raw material depletion)
Air, Water, and Soil Pollution (e.g. air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. smoke)
Human Health, Air Pollution (e.g. chemical vapors),
Resource Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air emissions (smoke)
Human Health
2. Diagnostic Imaging (Nuclear Medicine, X-Ray, Radiology, Ultrasound, Cat Scan, Cardiac Catherization Procedures, etc.)
Basic Patient Care (Operating
Medical Equipment,
Performing Invasive
Procedures and Contrast
Injections)
Film Processing (Wet and Dry
Laser)
Biomedical waste generation
Radioactive biomedical waste generation
(Half-life of radioactive isotope must be
spent before leaving department)
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material usage (cleaning, high-
level disinfectant, etc.)
Possible ehemical spill (emergency)
Possible occupational exposure to
radiation during x-ray process
Minor radioactive excreta sanitary
disposal
Possible radioactive spill (emergency)
Solid waste generation (packaging, film,
etc.)
Raw material usage (film processing
chemicals, plastic film, etc.)
Water consumption
Wastewater discharges (depends on state
or socal water regulations)
Silver recovery from film
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous)
Human Health
Natural Resource Depletion (water)
Human Health, Waste (Hazardous)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Natural Resource Depletion (water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Positive Impact (reduced impacts on air, water, soil
(pollution); reduced energy resources impacts
(combustion & depletion of natural resources);
reduced impacts on mineral resources (depletion)
-------
Nuclear Laboratory Work
Possible occupational exposure to
radiation
Possible Air emissions (often fume
hoods are used as precautionary
measures when preparing injectables)
Human Health
Human Health, Air Pollution (e.g. vapors discharged
through fume hoods)
3. Laboratory (Histology, Pathology, Morgue, Autopsy, Blood Bank,
Daily Operation of Analysis
Machines (Aspects may differ
depending on the type of
equipment and how the
chemical waste is disposed of)
Manual Analysis (urine, blood,
staining, etc.)
Chemical Use, Transportation,
& Disposal
Flammable Storage Rooms
Chemical Recycling (Process is
used to reclaim used chemicals
such as alcohol, Formalin,
Xylene, etc.)
Processes Utilizing Fume
Hoods and Ventilation
Equipment
Biomedical waste generation
Hazardous waste generation
Raw material usage (chemicals)
Possible chemical spill (emergency)
Energy usage
Water consumption
Wastewater discharges (depends on state
or local water regulations)
Biomedical waste generation
Raw material usage (chemicals)
Possible chemical spill
Water consumption
Wastewater discharges (depends on state
or local water regulations)
Raw material usage (chemicals)
Possible chemical spill
Air emissions
Hazardous waste generation
Possible fire/explosion hazard
Possible Wastewater discharges (depends
on state or local water regulations)
Chemical Storage & Raw material usage
(chemicals)
Possible chemical spill (emergency)
Possible fire/explosion hazard
Air emissions
Raw material usage (chemicals)
Chemical Recycling
Air emissions
Hazardous waste generation
Possible chemical spill (emergency)
Possible fire/explosion hazard
Air emissions
Energy usage
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Air, Water, or Soil Pollution (e.g. chemical
contamination to water), Natural Resource Depletion
(water)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Positive Impact (+) (e.g. reduced purchase of
chemical, reduced impacts associated with disposal)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
4. Environmental Services/ Housekeeping
High-level Disinfecting and
Cleaning Procedures
Raw material usage (chemicals)
Possible chemical spill (emergency)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
-------
Transporting Biomedical Waste
Laundry (may be a separate
department at your hospital or
contracted off-site)
Water consumption
Wastewater discharges
Air emissions (ex. chemicals used for
stripping floors)
Possible Biomedical Waste Spill
(Emergency)
Energy usage
Raw material usage (detergents, fabric
softeners)
Possible chemical spill (emergency)
Water consumption
Wastewater discharges
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
5. Central Sterilization
Operation of Ethylene Oxide
Sterilizer
Operation of Hydrogen
Peroxide Sterilizers
Operation of High
Temperature/ Pressure/ Steam
Sterilizers
Biological Testing
Compressed Gas Storage and Raw
material usage
Air emissions
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material usage (Hydrogen peroxide,
packaging, etc.)
Energy usage
Water consumption
Wastewater discharges
Water consumption
Wastewater discharges
Energy usage
Biomedical waste generation
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
6. Nutrition/ Food Services/ Cafeteria/Restaurants
Dish Machine Operations, Belt
Lines and Other Food
preparation processes
Energy usage
Water consumption
Wastewater discharges (some hospitals
use garberators where food is shredded
and disposed of down sanitary sewer)
Raw material usage (detergents, etc.)
Possible chemical spill (emergency)
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled (food
waste, plastic, cans, glass, etc.)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (reduced natural resources needed
for landfill)
7. Pharmacy
Preparing Antineoplastic/
Cytotoxic Drugs
Biomedical waste generation
(Cytotoxic/Antineoplastic drugs)
Air emissions (Requires Fume Hood)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
-------
Disposing of Narcotics
(Possible on-site disposal by
Pharmacists)
Needle, Vial, IV Bag, Drug
Return Disposal
Possible Occupation Exposure to
Cytotoxic Material
Biomedical waste generation (May be
regulated in your area-to dispose of
narcotics already rendered
unrecoverable)
Generation of Biomedical Waste (May
be regulated in your area)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
8. Physiotherapy/ Occupational Therapy, Welhiess Clinics, Recreational Therapy, etc.
Daily Operation of Equipment
(ex. Wax Machine,
Hydrocollator, Whirlpool,
Ultrasound, Laser, etc.)
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Water consumption
Wastewater discharges (depends on state
or local water regulations)
Raw material usage (These departments
mainly use cleaning chemicals and
possibly chlorine for the whirlpool)
Possible chemical spill
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
9. Engineering/Maintenance
Operation of Powerhouse
Equipment (Boilers, Water
Softeners, Dealkalizers, Fire
Pumps, Vacuum Pumps,
Medical Air Pumps,
Cleaning Salt (Brine) Tank
Welding/Cutting Metal
PCB Storage (Outside or
Inside)
Asbestos Handling and
Removal
Above-Ground and/or Under-
Ground Storage Tanks
Operation of Diesel Generator
(Back-Up Power)
Energy usage (powerhouse equipment
are high consumers of energy- often to
produce energy)
Air emissions (often regulated discharges
through a stack)
Water consumption
Wastewater discharges (ex. blow down
from boiler, flushing pumping systems,
etc.)
Raw material usage (there are a number
of chemicals, mainly in drums, used for
Powerhouse equipment)
Possible chemical spill (emergency)
Fuel consumption- natural gas (back-up
diesel fuel)
Hazardous waste generation
Air emissions
Scrap metal recycled
Chemical (compressed gas) use as fuel-
acetylene, oxygen, argon, etc.
Compressed Gas Storage
Noise/Heat/Radiation Exposure
Possible Fire/Explosion (Emergency)
Possible PCB Leak (Emergency)
Hazardous waste generation (Asbestos)
Air emissions
Possible Improper Handling of Asbestos
Waste (Emergency)
Possible Fuel Spillage (Emergency)
Air emissions
Energy usage
Fuel Consumption (Diesel)
Air emissions
Possible Fire Hazard (Emergency)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. emissions as a
result of combustion, chemical emissions, etc.)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health
Positive Impact (+)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air
Human Health, Groundwater, Storm Sewer
Human Health, Air Pollution (e.g. airborne asbestos
fibers), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. vapors)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (e.g. diesel oil)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. smoke, vapors)
-------
Electrical Operations (repairing
electrical equipment, changing
light fixtures and ballasts, etc.)
Cooling and Heating Processes
Painting Processes
Hazardous waste generation- Possibly
Recycled (Fluorescent Tubes, Ballasts)
Hazardous waste generation- PCB
Ballasts (if you have these in your
facility), Mercury (small mercury pods in
light switches)
Solid waste generation (packaging, use
of disposable materials, etc.)
Possible Electrical Fire/Electrical Shock
Scrap Electrical Wire - Recycled
Water consumption
Wastewater discharges
Air emissions
Energy usage
Raw material usage (biocides)
Possible chemical spill (emergency)
Raw material usage (Latex, alkyd and
oil-based paints, varsol, urethane, etc.)
Possible chemical spill (emergency)
Air emissions (chemical, dust from
sanding dry wall, etc.)
Water consumption
Wastewater discharges (process of
cleaning brushes)
Hazardous waste generation
Solid waste generation (packaging, use
of disposable materials, etc.)
Positive Impact (+) if Recycled, if not, Human Health,
Air Pollution (e.g. mercury vapor), Waste
(Hazardous), Natural Resource Depletion (Land)
Human Health, Air Pollution (e.g. chemical/mercury
vapor), Waste (Hazardous), Natural Resource
Depletion (Land)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Air Pollution (e.g. smoke)
Positive Impact (+) - (decreased natural resources
required for landfill)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. dust, chemical
vapors)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
10. Shipping/Receiving/Stores
Receiving, Storing and
Transporting High Risk
Supplies (Chemical, Pharmacy,
Radioactive, etc.)
Unpacking Supplies
Chemical Storage (Priority, high risk
items should be transported to their
designated destination immediately after
arrival, however, due to timing there may
be a period of time where these items are
stored)
Possible Radioactive Isotope Spillage
(Emergency)
Possible chemical spill Internal/External
(Emergency)
Possible fire/explosion hazard
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled
(cardboard, boxboard, plastics, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (decreased natural resources
needed for landfill)
11. Landscape Management/ External Environment
Grounds-keeping Practices
Snow Removal/Salting During
Water consumption
Raw material usage (Pesticides/
Herbicides/ Fertilizers)
Possible chemical spill (emergency)
Raw material usage (salt, sand,
Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion), Air emissions, Groundwater
contamination , Impact to local Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora Fauna
Human Health, Resource Depletion (e.g. raw material
-------
Winter Months
Use of Equipment (Gas-
Powered Lawn Mowers)
environmental alternatives available)
Air emissions (Particularly problematic
to passing staff, visitors, etc., on high
SMOG Days)
Fuel Consumption
depletion), Other- Flora and Fauna
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
Natural Resource Depletion (e.g. gasoline, oil)
12. General Hospital Operations & External Concerns
General Hospital-wide
operations and Administration
Processes
Use of Mercury Containing
Devices
On-Site Waste Disposal
(Incineration)
Compressed Gas Storage
Parking Lots
Railway or Highway
Environmental Incident (in
close proximity to your
hospital's location)
Local Industry Environmental
Incident (in close proximity to
your hospital's location)
Construction- Demolishing and
Re-building Structures
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled
(paper, cardboard, boxboard, plastic,
cans, glass, etc.)
Energy usage (office equipment-
computers, photocopiers, personal
radios, heaters, fax machines, lighting,
etc.)
Air emissions (possible photocopier
emissions)
Water consumption (toilets, sinks, water
fountains, etc.)
Wastewater discharges (toilets, sinks,
water fountains, etc.)
Possible chemical spillage (Emergency)
Air emissions
Heat/Noise/Vibration
Generation of Hazardous and Non-
Hazardous Waste (Ash may be
considered hazardous or non-hazardous
depending on your state regulations)
Possible fire/explosion hazard
(Depending on what is put into the
incinerator- look to state regulations to
determine what waste can be disposed of
by incineration)
Possible Air emissions/Gas Leak
(Emergency)
Possible fire/explosion hazard
(Emergency)
Possible chemical spill (emergency)
Possible chemical spill (emergency)
Possible fire/explosion hazard
(Emergency)
Possible chemical spill (emergency)
Possible Fugitive Air emissions
(resulting in external air exclusion
procedures)
Solid waste generation (materials not
reusable or recyclable)
Fuel Consumption- (mainly mobile
equipment)
Energy usage
Air emissions- exhaust from forklifts,
trucks, dust, fugitive emissions, etc.
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (decreased natural resources
needed for landfill)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. combustion
emissions)
Human Health
Human Health, Air Pollution (e.g. combustion
emissions), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. smoke, combustion
emissions)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Water Pollution (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
-------
Compressed Gas Use and Storage
Possible fire/explosion hazard
Noise and Vibration
Raw material usage (chemicals,
construction materials, etc.)
Possible chemical spill (emergency)
Human Health, Air Pollution (e.g
Other- Flora and Fauna
Human Health, Air Pollution (e.g.
vapors), Other- Flora and Fauna
chemical vapors),
smoke, chemical
Human Health
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g.
Other- Flora and Fauna
chemical vapors),
Other Areas to Consider Including:
Day Clinics
Special Testing
Off-Site or Satellite Facilities
Mobile Units owned and operated by the hospital such as Ambulance and Patient Transport services
-------
TABLE 2: SAMPLE ENVIRONMENTAL ASPECTS AND IMPACTS INVENTORY FORMAT
DEPARTMENT: Nursin
g/Medical Floors
DATE APPROVED: 04/04/01
DATE LAST REVIEWED: 10/04/02
Impact Abbreviation Definitions: AIR: Air/ Atmosphere, SOIL: Soil , GW: Groundwater/Waterway, ST.S: Storm Sewer, SN.S: Sanitary (City) Sewer (water to be treated at wastewater treatment plant), WASTE- HAZ:
Hazardous Waste, WASTE-NON: Non-Hazardous Waste (i.e. recycled, garbage, etc.) , HH: Human Health effects (patients, visitors, staff, community), NR: Natural Resources (renewable or non-renewable) , OTHER: Other
negative environmental issues
ACTIVITY/SERVICE
Basic Patient Care (including
surgical procedures, daily care,
isolation cases, etc.)
Operation of Medical and Other
Equipment
Compressed Gas Usage (oxygen,
nitrous oxide, etc.)
Energy usage
Possible Fire Hazard (Emergency)
Possible Occupational Exposure to
Radiation
ENVIRONMENTAL ASPECT
Solid waste generation (packaging, use
of disposable materials, etc.)
Biomedical waste generation (sharps,
items contaminated with blood and/or
body fluids, isolation supplies, etc.)
Raw material usage (cleaning
chemicals, sterilants, high-level
disinfectants, formaldehyde,
medications, etc.)
Potential chemical spills (Emergency)
Energy usage
Hazardous waste generation (batteries)
Raw material usage (chemicals)
Possible Fire Hazard (Emergency)
Chemical Leakage (Emergency)
Energy usage
Possible Fire Hazard (Emergency)
Possible Occupational Exposure to
Radiation
LEGAL
REQ'MNTS
POTENTIAL AREA(s) OF IMPACT
(positive impacts +)
AIR
X
X
X
X
X
X
X
X
SOIL
X
X
X
GW
X
X
ST.S/
SN.S
WASTE
HAZ
X
X
X
X
NON
HH
X
X
X
X
X
X
X
X
X
NR
X
(land)
X
(land)
X
(oil,
natural
gas)
X
(land)
X
(oil,
natural
gas)
OTHER
Resource
Depletion
Resource
Depletion
Resource
Depletion
CONSEQ.
RATING
FREQ.
RATING
DEGREE
OF
CONTROL
TOTAL
SIGNIF.
Source: St. Mary's General Hospital, Ontario, January, 2001
140
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TABLE 3: SIGNIFICANT EVALUATION CRITERIA FOR ENVIRONMENTAL
IMPACTS
Total Significance = Consequence x Frequency x Degree of Control
Note: **Any Environmental Impact at or above 27 is "Significant. "
CRITERIA
Consequence
The severity of an
anticipated impact.
Frequency
The likelihood of the
impact occurring.
Degree of Control The
amount of control the
facility currently has over
the occurrence of the
impact.
RANKING
Critical- 5
Major- 4
Significant- 3 * *
Marginal- 2
Negligible- 1
Positive- 0
Frequent- 5
Probable- 4
Possible- 3**
Remote- 2
Improbable- 1
Positive- 0
No Control- 5
Minimal- 4
Moderate- 3**
High Level- 2
Full Control- 1
Positive- 0
DESCRIPTION
Non-reversible, major environmental damage, OR the
possibility of endangering human life.
Major reversible environmental or human health (long term)
damage, OR currently exceeds regulatory limits.
Moderate reversible environmental or human health (short-
term) damage, legislative/regulatory/other requirements
apply.
Minimal loss to the environment, reversible, within
regulatory limits.
Insignificant effects on environment (i.e. nuisance, odor,
noise, etc), within regulatory limits, OR no loss to the
environment.
Positive Environmental Impact
Impact occurs continuously or in intervals throughout the day
and/or night.
Impact is expected to occur at least once per day.
Impact is expected to occur occasionally (at least once per
week or once per month.)
Impact is expected to occur at least once per year.
Impact is unlikely to occur or is not expected to occur during
the lifetime of the facility.
Positive Environmental Impact.
The facility has zero preventative measures in place.
The facility has minor preventative measure in place.
The facility has some preventative measures in place.
The facility has numerous preventative measures in place
The facility has extensive preventative measures in place.
Positive Environmental Impact
Source: St. Mary's General Hospital, Ontario, January, 2001
to - 140
-------
TOOL TO DETERMINE SIGNIFICANCE
List your top 5 aspects/impacts below. Rank them using the scale of 1-5, five being
the most significant. Add the scores to get a first cut priority.
• How to Prioritize? (ONE SUGGESTION for Scoring Guide)
Scale
1
2
3
4
5
Scope
unnoticeable
only one department
organization-wide
outside the
organization; local
impact
outside the
organization;
regional impact
Severity
no potential impact on
health/environment
no actual impact on
health/environment
low impact on
health/environment
significant damage to
health/environment
severe damage to
health/environment
Cost
$0- 200
$200-5,000
$5,000-
50,000
$50,000-
250,000
greater
than
$250,000
Compliance
minimal
recordkeeping
only, warning
only
civil penalty:
minor fine
civil penalty:
major fine
criminal penalty:
striped suit
Do-able
resources in-
house
time
available and
budget
planned
time
available
planning will
be done
no planning
done
Occurrence of
Impact
improbable /
never
infrequent (l/yr
but l/mo)
continuous (on-
going basis)
Aspect / Impact
Scope
Severity
Cost
Compliance
Do-able
Occurrence
Total
140
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ENVIRONMENTAL ASPECTS - LABORATORIES
DEPARTMENT:
LAB SUPERVISOR:
TYPE OF LAB: Q Chemistry Q Biological Sciences D| Medical Science
Q
D
Q
D
D
Responsible Person
Effective Date
Ba> !!! k III III list Ill -(e 140
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ENVIRONMENTAL ASPECTS AND IMPACTS: ENERGY
EXAMPLE
USE
Activity or
Operation
Computers/
Information
Systems
Heating and
Cooling
Lighting
Lab
Equipment
Refrigeration
Common Sources
Q Personal Computers
Q Servers
Q Computer Lab Operation Overhead
Q Air Conditioners
Q Furnaces
Q Fans
Q Boilers and Water Heaters
Q Offices/ Admin Lighting
Q Outdoor Lights
Q Laboratories
Q Operating rooms
Q Spectrometers
Q Ovens
Q Hoods
Q Cleaning Equipment
Q Microscopes
Q Food Service/Campus Dining
Q Vending
Q Laboratory Cooling Needs
Q On-campus Commercial
Use Rate per Month
(therms or kw/mo and
$/mo)
1 56,250 kw/month
$25,000 mo
390,625 kw/month
$62,500 month
3 12, 5 00 kw/month
$50,000 month
109,375 kw/month
$17,500
234,375 kw/month
$37,500 month
Reduction Efforts
0 Auto-sleep mode
Q Shut-down enforcement
0 Lab Management
Q System upgrades
Q Insulation/windows
0 Temperature Controls
0 O&MBMP's
0 Sensor Controls
Q Delamping
0 High efficiency bulbs
Q Relamping
Q Tandem wiring
0 O&M BMPs
Q Technology upgrade
Q Coil maintenance
0 System upgrade
Q O&M BMPs
Responsible Person/Date
! ck to Example III list
-------
ENVIRONMENTAL ASPECTS - JANITORIAL OPERATIONS
ACTIVITY OR
OPERATION
COMMON CONCERNS
USE RATE PER
MONTH
REDUCTION EFFORTS
BATHROOM
CLEANING
•S Toilet Bowl
•S Cleaners
-S Disinfectants
Hydrochloric acid
Phosphoric acid
Sulfamic acid
Other acid
2-Butoxy ethanol
Isopropyl alcohol
Other toxic ingredients4
"Environmentally Preferable" Productl
Dilute
Use Reduction and Minimization
Method2
Other:
FLOOR CARE
S Carpet Cleaners
-S Floor Finish
•S Hard Floor Care
D Carcinogens / Neurotoxins
D Solvents
a voc's
Q Other toxic ingredients
"Environmentally Preferable" Product
Dilute
Use Reduction and Minimization
Method
Other:
FIXTURE/FURNITURE
CLEANING
-S Furniture Polish
S Metal Cleaner
•S General Purpose
Cleaners
2-Butoxy ethanol
Isopropyl alcohol
Chlorinated solvents
Hydrocarbon solvent
Other toxic ingredients
"Environmentally Preferable" Product
Dilute
Use Reduction and Minimization
Method
Other:
-------
GLASS CLEANING
o Glass Cleaners
Q 2-Butoxy ethanol
Q Isopropyl alcohol
Q Other toxic ingredients
Q "Environmentally Preferable" Product
Q Dilute
Q Use Reduction and Minimization
Method
Q other-
Notes:
1. Environmental Preferable Product refers to an alternative product that eliminates or minimizes common chemicals of concern.
2. Minimize use of product by only using product when needed, rather than following predetermined schedule. Also, minimize exposure through use of personal protective
equipment and/or alternative product forms (for example, trigger vs. aerosol container).
3. See Occupational Safety and Health Administration's website: http://www.osha-slc.gov/SLTC/carcinogens/index.html or U.S. Department of health Information Service
National Toxicology Program's website: http://ehis, niehs.nih.gov/roc for listing of known carcinogens.
4. See the Janitorial Pollution Project's website for listing of potentially harmful chemicals: www.westP2net.org/janitorial/jp4.htm
Responsible Person
Effective Date
-
-------
Environmental Procedure
Procedure Number: Effective Date:
Title: Identification of Aspects, Determination of Significant
Aspects, and Setting of Objectives and Targets
Authorized by:
1 PURPOSE:
The purpose of this procedure is to determine the method by which aspects are identified
and by which significant aspects are determined.
2 ACTIVITIES AFFECTED:
2.1 Cross Functional Team
2.2 Plant Operating Committee (OCM)
2.3 Internal Auditors
3 FORMS USED:
None.
4 REFERENCES
4.1 Aspects and Significant Aspects and Establishing Environmental Objectives
and Targets
4.2 Environmental Regulations and Other Requirements - Obtaining and
Maintaining information
4.3 External Communications
4.4 Internal Environmental Communications
4.5 Internal Environmental System Audits
4.6 Compliance Assurance
4.7 Responding to Community Complaints/Inquiries
4.8 Contractor Management
4.9 Aspects Database
4.10 Environmental Aspects Identification Worksheets
5. DEFINITIONS:
SARA - Superfund Amendment Reauthorization Act
- Tier II Reporting Levels (10,000 Ib)
- Toxic Chemical Release Inventory Levels (25,000 Ib manufactured, processed,
10,000 Ib - otherwise used)
-------
6 EXCLUSIONS:
None.
7 PROCEDURE:
7.1 Aspects will be identified, significance determined, and objectives and targets
set following Aspects Procedure.
7.2 A Cross Functional Team (CFT), whose membership shall represent each
functional activity of the facility, is responsible for the identification of aspects,
the determination of significant aspects, and the setting of objectives and
targets.
7.3 Aspects are identified by using Aspects Spreadsheets, expert knowledge, and
interviews of functional areas.
7.4 Aspects encompass all functional areas whose activities, products, or services
the plant can control or over which the facility can have influence.
7.5 Consideration of interested parties shall be utilized in the determination of
significant aspects. Interested parties are defined as employees, customers,
stockholders, agencies, business and residents adjacent to the facility. Views of
interested parties are received through the external communications procedure,
Responding to Community Complaints/Inquiries.
7.6 Legal and other requirements are considered to be significant.
7.7 Volumes of materials stored/consumed are considered significant when
meeting SARA reporting.
7.8 Other criteria used for significance determination shall include but, not limited
to, emission inventories, pollution prevention and waste minimization
programs, property assessments, contractor activities, and environmental
compliance audits.
7.9 Objectives and targets shall be established at each relevant functions and level
within the plant organization.
7.10 Legal and other requirements, significant environmental impact, technology
options, financial, operational, and business requirements shall be considered in
setting of objectives and targets.
7.11 Objectives and targets shall be established for all significant aspects.
7.12 The aspects, significant aspects, and objectives and targets shall be summarized
and presented at the Operating Committee Meeting (OCM) for review and
concurrence.
8 GENERAL RULES:
Exceptions to the criteria listed in section 7, shall be justified and noted in the Aspects
Database.
9 ENVIRONMENTAL RECORDS:
9.1 Completed Aspects Spreadsheets
-------
9.2 Completed Aspects Database
10 RECORD OF REVISIONS:
Date:
Description:
Converted into a procedural
format
Reformat header and footer
Changes made to reflect Visteon
Pages affected:
All
All
Authorized by:
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4.3 PROCEDURE OBJECTIVES AND TARGETS
Document No: EMS-4.3
Date Approved: 06/01/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To describe the methods utilized by the hospital to identify environmental
objectives and targets.
2. Scope
2.1 This policy governs the operations and programs conducted by [hospital name],
located at [insert hospital address].
3. Responsibility
3.1 It is the responsibility of the EMS Representative and/or designate, in consultation
with the Green Team, to ensure that environmental objectives, measurable targets
are set on a regular basis.
3.2 It is the responsibility of the EMS Representative and/or designate to track
environmental performance of the environmental objectives and targets, and to
communicate progress to the Green Team, Senior Management Team and hospital
staff.
3.3 It is the responsibility of the Senior Management Team to designate resources and
staff to ensure that environmental objectives are met.
4. Procedure
4.0 Annually, the EMS Representative and/or designate, the Green Team and/or
Senior Management (if objectives require actions that have a financial cost of
>$1000.00) will set and approve environmental objectives and targets based on:
• the Environmental Policy (EMS- 4.2);
• significant Hospital Environmental Impacts (EMS-4.3.1);
• input from hospital staff, Senior Management and interested parties,
• changes in legal or other requirements (EMS- 4.3.2);
• compliance and other internal audit findings;
• environmental emergencies or incidents;
• technological options available; and
• financial and operational requirements.
The environmental targets must be S.M.A.R.T. (Specific, Measurable, Achievable,
Results-oriented, and Time-dependant.)
Procedure for Environmental Policy, EMS-4.2, Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
4.2 The approved environmental objectives and targets will be documented on the
"Objectives and Targets Chart" (Exhibit 1- EMS-4.3.3-1).
4.3 Refer to the Procedure for Environmental Management Program(s) (EMS-4.3.4)
for the identification of actions to achieve designated environmental objectives and
targets.
4.4 The EMS Representative and/or designate will communicate objectives and
targets to the hospital staff via email, displays, environmental information sessions,
and hospital orientation, on a regular basis.
4.5 The EMS Representative and/or designate monitors the progress of environmental
objectives and targets in the through identifying performance indicators. Regular
progress reports are presented to the Green Team during monthly meetings.
Maintenance of data pertaining to progress of environmental objectives and
environmental performance is outlined in the Procedure for Monitoring and
Measurement (EMS- 4.5.1).
4.6 If at any time, the EMS Representative and/or designate, Green Team and/or
Senior Management wishes to change, revise or alter the approved environmental
objectives and targets to represent progress or lack thereof, the EMS
Representative and/or designate will make the needed changes and send the
resulting document back to the Green Team for approval.
4.7 Significant aspects and environmental issues not formally addressed through this
procedure will be addressed/managed on a priority/as-needed basis by the EMS
Representative and/or designate and the Green Team.
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001 - 96 - Environmental Management System Standard
EMS- 4.2 Environmental Policy
EMS- 4.3.1 Procedure for Environmental Aspects
EMS- 4.3.2 Procedure for Legal and Other Requirements
EMS- 4.3.4 Procedure for Environmental Management Program(s)
EMS- 4.4.7 Procedure for Emergency Preparedness and Response
EMS- 4.5.1 Procedure for Monitoring and Measurement
EMS- 4.5.3 Procedure for Records
7. Exhibits
Exhibit 1- EPPM-4.3.3-1, Objective and Targets Chart
Procedure for Environmental Policy, EMS-4.2, Page 2 of 2
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4. 3. 4 PROCEDURE FOR ENVIRONMENTAL MANAGEMENT
PROGRAMS
Document No: EMS-4. 3. 4
Date Approved: 06/01/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To ensure that a procedure is in place to establish and maintain Environmental
Management Program(s) to achieve the identified objectives & targets.
2. Scope
2.1 This policy governs the operations and programs conducted by [hospital name],
located at [insert hospital address].
3. Responsibility
3.1 It is the responsibility of the EMS Representative and/or designate, in consultation
with the Green Team to develop, on a regular basis, Environmental Management
Program(s) for each environmental objective and target.
3.2 It is the responsibility of the EMS Representative on behalf of the Green Team, to
approve the Environmental Management Program(s) under $1000.00 and to
designate appropriate resources and staff to ensure that these programs are
implemented and maintained.
3.3 It is the responsibility of a representative from the Senior Management Team to
comment and approve those Environmental Management Program action(s) that
require $1,000.00 or more (capital) for implementation.
3.4 It is the responsibility of designated staff to follow through with the Environmental
Management Program(s) and to track and report progress of activities to the EMS
Representative and/or designate.
4. Procedure
4.1 Annually, the EMS Representative and/or designate, in consultation with the Green
Team, will develop and set environmental objectives and targets as described in
the Procedure for Objectives and Targets (EMS- 4.3.3).
4.2 The EMS Representative and/or designate, in consultation with the Green Team
then develops and documents the "Environmental Management Program(s)"
(Exhibit l-EMS-4.3.4-1) for achieving the appointed environmental objectives and
targets.
Procedure for Environmental Management Program(s), EMS-4.3.4, Page 1 of 3
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
4.3 Environmental Management Program(s) must include (but is not limited to): actions
for achieving the objective and target, responsible parties, the time-frame(s) for
completion, and other stakeholder involvement.
4.4 A member of the Senior Management Team will review the Environmental
Management Program(s) to ensure economic feasibility, appropriateness and to
allocate adequate resources for implementation.
4.5 After inputting comments from the representative of the Senior Management Team,
the EMS Representative approves the Environmental Management Program(s) for
under $1000.00. The Senior Management Team approves all actions with a cost of
$1000.00 or over (capital).
4.6 The EMS Representative and/or designate, Green Team members, and other
designated personnel, will accomplish the duties set forth in the Environmental
Management Program(s) in the time-frame determined.
4.7 The EMS Representative and/or designate monitors the progress of Environmental
Management Program(s) and reports the progress of the program(s) to the Green
Team, Senior Management, and hospital staff, on a regular basis. Maintenance of
data pertaining to the progress of the Environmental Management Program(s) is
outlined in the Procedure for Monitoring and Measurement (EMS- 4.5.1) and the
Procedure for Records (EMS- 4.5.3).
4.8 If at any time, the EMS Representative and/or designate, members of the Senior
Management Team and Green Team wishes to change, revise or alter the approved
environmental management program(s) to represent progress or lack thereof, the
EMS Representative and/or designate will make the needed changes and send the
resulting document back to the Green Team for approval.
4.9 Upon completion of the Environmental Management Program(s), the EMS
Representative and/or designate will review the overall effectiveness of the
program(s) against the intended objective and target. If any issues or concerns
arise, action plans may be developed to correct any deficiencies.
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001 - 96 - Environmental Management System Standard
EMS- 4.3.3 Procedure for Objectives and Targets
EMS- 4.5.1 Procedure for Monitoring and Measurement
Procedure for Environmental Management Program(s), EMS-4.3.4, Page 2 of 3
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
EMS- 4.5.3 Procedure for Records
7. Exhibits
Exhibit 1- EMS-4.3.4-1, Environmental Management Program Chart
Procedure for Environmental Management Program(s), EMS-4.3.4, Page 3 of 3
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Environmental Review of Projects
1.0 Purpose/Scope
This procedure defines the method for identifying and evaluating the environmental
issues of new projects at the [hospital name] to:
a) Ensure that appropriate consideration I given to environmental issues prior
to project approval and funding;
b) Ensure that new environmental aspects generated by projects are identified
and their significance evaluated; and,
c) Provide a mechanism for the amendment of environmental management
system elements and programs, where relevant, to ensure that the
environmental management system applies to such projects.
2.0 Activities Affected
All areas and departments
3.0 Forms Used
Project Environmental Checklist
4.0 References
EP-002 Environmental Aspect, Objectives and Targets and Management
Programs
5.0 Definitions
None.
6.0 Exclusions
None
7.0 Procedure
7.1 Areas/departments initiate Project Appropriation Requests when needed
for project funding becomes apparent.
7.2 The initiating activity or designee shall identify and evaluate
environmental issues associated with the project. A summary of this
evaluation shall be documented on a Project Environmental Checklist
form and the form added to the Appropriation Request. This process may
-------
be undertaken in liaison with the Environmental Coordinator (or other
competent individual) at the discretion of the initiating activity, and shall
include an identification of environmental aspects, and requirements for
obtaining approvals from environmental regulatory agencies.
7.3 The initiating activity shall submit the Appropriation Request and
complete Project Environmental Checklist for review to the
Environmental Management Representative.
7.4 The Environmental Management Representative, or designee, shall review
the proposed project to ensure that all relevant environmental issues have
been identified, and if incomplete shall return the Appropriation Request
and Project Environmental Checklist to the initiating activity for
alteration.
7.5 The Environmental Management Representative, or designee, shall review
the environmental aspects of the project, considering their significant in
line with EP-002.
7.6 Following appropriate review, the Environmental Management
Representative or designee may approve the project by returning the
Appropriation Request to the initiating activity for further processing. If a
project is not acceptable, the initiating activity will coordinate any
necessary actions to satisfy concerns identified. The initiating activity in
conjunction with the Environmental Management Representative or
designee will coordinate any necessary prevention, mitigation or control
activities associated with the project.
8.0 General Rules
8.1 Environmental aspects associated with projects shall be evaluated for
significance by the Cross Functional Team per EP-002.
8.2 Changes to the Environmental Management System resulting from an
environmental review of a project will be approved by the Facility/Plant
Management Team.
9.0 Records
Records shall be retained consistent with EP-013.
Record of Revisions
Revision Date
Description
Sections Affected
-------
[Hospital Name]
Project Environmental Checklist
Project Description:
Project Number:
AIR EMISSIONS
Will this project/process change produce air emissions?
Will this project/process change an air permit or permit modification?
Does the change require air pollution controls?
Does the project/process change require the use or purchase of ozone
depleting substances?
WATER DISCHARGES
Does the project/process change results in a wastewater, sanitary or
storm water discharges?
Will the project/process change result in changes to water discharge
flow rates?
Will the discharge require a permit modification?
Will new or additional pretreatment be required?
Are facility discharges to a common sewer altered?
STORAGE TANKS
Will underground storage tanks be installed?
Will tanks be installed to store hazardous waste or materials,
petroleum products or propane?
WASTE GENERATION
Will the project/process change produce a waste or recyclable
material?
Will the waste be classified as special or hazardous?
Will off-site disposal be required?
Are special handling, abatement or disposal measures required?
ENERGY USE
Will the project/process change effect facility energy usage?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
-------
OTHER CONSIDERATIONS
Do recycling options and costs need to be considered?
Does the project/process change require use of toxic, hazardous or
carcinogenic materials?
Do project/process materials require special handling or storage?
Does the project cause land disturbances?
Do pollution prevention issues need to be addressed?
Does the project/process change impact the surrounding community
(i.e., odor, noise etc.)?
Are there any wildlife or land use issues?
Does the project/process change alter or add to current facility
aspects?
Do the project/process change require a change to Emergency
Response methods?
Yes
No
Yes
No
Initiating Activity Manager
Date
Environmental Management Representative
Date
-------
[hospital name]
EMS Procedure
Effective Date
Subject
2.3
Objectives and Targets
Purpose This procedure is used to (1) develop and update the EMS objectives and
targets and (2) create action plans for achieving the objectives.
Step 1 The EMS Manager and EMS Participants are responsible for developing
the EMS objectives and targets. Similar to the aspects and impacts
review, the EMS Manager solicits input from [hospital name]
departmental staff to ensure that objectives and target are realistic and
achievable.
Objectives are goals that are consistent with the organization's
environmental policy, priority environmental aspects, and applicable
environmental regulations.
Targets detailed performance goals related to, and supporting a specific
objective. Targets should be quantitative, realistic, linked to a source,
measurable, and related to a baseline and normalization metric.
Step 2 Objectives and targets will be linked to significant environmental aspects
and compliance issues identified by EMS Procedures 2.1 and 2.2,
respectively.
Step 3 An action plan will be developed for each objective. Each action plan will
describe specific actions needed to achieve the objective, the resources
needed for each action, the person responsible for each action, and
deadlines.
Step 4 Progress in achieving EMS objectives and targets will be tracked
according to procedures described in Element 4.1, Measurement and
Monitoring.
Step 5 On a monthly basis, the EMS Manager and other [hospital name]
departmental and facility staff will (1) review objectives, (2) discuss the
impact of corrective and preventive actions on objectives and targets, (3)
determine whether existing objectives should be modified based on
experience from the action plan and (4) develop new EMS objectives
when existing objectives are met.
Step 6 Every 6 months, the EMS Manager will prepare a status report of progress
against objectives and targets for the [hospital name] administration for
review and input.
Step 7 Objective and target documentation will be retained for at least 2 years.
Uncontrolled Document- Verify the latest revision date on the Intranet
Authorized by: Environmental Control Specialist Revision Date:
-------
Additional System Examples
Objectives and Targets - Page 169
Environmental Management Program - Page 170
Operational Control - Page 173
Contractor Communication, Letter Requesting Mercury Notification - Page 178
Contractor Communication, Vendor Mercury Disclosure - Page 180
Monitoring and Measurement - Page 181
Calibration - Page 186
EMS Audits - Page 188
Emergency Preparedness and Response - Page 192
Training, Awareness, and Competence - Page 197
External Communication - Page 204
Internal Communication - Page 206
Document Control - Page 211
Records-Page 219
Management Review - Page 226
-------
Form Completed by:
Department/Area:
[Hospital Name]
Environmental Aspects, Objectives
& Targets Determination
Date Completed: -
Process/Activity: _
Environmental Audit Report:
Privileged Document
Aspect Identification
Category */Aspect
Quantity /Volume
Significance
Rationale for
Significance/
Non-
Significance**
S/NS***
Objectives & Targets
Objective
Target
* Aspect Categories: Air Emissions, Wastewater Discharges, Liquid & Solid Wastes, Energy Use, Storm Water Discharge, Water Use,
Storage Tanks, Material Usage, Noise Odor, Natural Environment, Land Condition
**Rationale for Significance/Non-Significance: R=Regulated/Other Req., A=Accidental Release, E=Energy, L=Environmental Load,
NS=Doe not meet significance criteria.
***Abbreviations: S=Significant & NS=Not Significant
--:••:» '•• ii List - 168
Issue Date:
Page:
Document Number:
-------
Significant Aspect:
Department/Area(s):
Objective:
Date:
Program Plan:
[Hospital Name]
Environmental Management
Programs
Program Leader:
Process/Activity:
Target:
Environmental Audit Report:
Privileged Document
Task
Responsible
Party
Schedule
Performance
Monitoring
Key
Characteristics/Operational
Control/Comments
Issue Date:
Page:
Document Number:
-------
Action Plan for EMS Objective and Target
OBJECTIVE:
TARGETS:
BASELINE:
ASPECT(S):
Parameter
Measurement Frequency
OPERATION(S) THAT ARE SOURCE(S) OF ASPECTS ADDRESSED:
ACTIONS PLANNED AND TAKEN TO ACHIEVE OBJECTIVE
Consider what type of actions you are evaluating to achieve objectives and targets. Are
there pollution prevention alternatives such as source reduction, materials substitution, in-
process recycling, or waste minimization that could achieve your objectives and targets?
Try to find an action that addressed the source most directly.
Action 1:
Resources Needed:
Deadline: Responsible Person:
Action Taken:
-------
Action 2:
Resources Needed:
Deadline: Responsible Person:
Action Taken:
Responsible Person:
Effective Date:
to
-------
OPERATIONAL CONTROL EXAMPLES:
Title: Diesel Generator Inspection & Testing Procedure
Document No: Eng-001
Date Approved: 03/20/02
Next Revision Date: 03/03
Prepared By:
Maintenance, Engineering
Services
Approved By:
Director, Engineering
Services
PURPOSE:
To ensure the diesel generator is in proper working order, tested and inspected regularly in order
to provide back-up power for the hospital.
PROCEDURE:
1. The diesel generator must be tested every week for a maximum of 0.5 hours to ensure the
machinery is in proper working order.
2. Inform Switchboard Operators of testing prior to performing any tests.
3. Perform following testing perimeters on a weekly basis:
3.1 Pre-Checks of Diesel Generator:
a) Perform pre-checks & record levels:
- oil level
- coolant level
- battery electrolite level
- battery electrolite level
- block heater
- dip day tank
3.2 Starting Diesel Generator:
a) In Lower Powerhouse (transfer switch area) perform:
- lamp tests,
- turn control switch to "Test" position to start diesel generator, and
- reset any resulting alarms.
3.3 Running Tests of Diesel Generator:
a) Once diesel generator is running perform running checks of the louvres and battery
charger and record the following:
- starts,
- lube oil pressure,
- lube oil temperature,
- coolant temperature,
-RPM,
- percentage load,
- battery voltage (during test),
-------
- generator voltage phases 1,2 & 3,
- generator amperage phases 1, 2 & 3, and
- frequency.
b) After performing running checks, proceed back to lower powerhouse
(transfer switch) and record:
- normal power voltage phases 1, 2,& 3,
- normal power frequency,
- emergency power voltage phases 1, 2 & 3, and
- emergency power frequency.
3.4 Shutting Down Diesel Generator Tests:
a) Prior to the 30 minute mark, turn the control switch to the "Auto" position (machine
will run for 5 minutes before it transfers back to normal operating power.) Wait for
power to transfer.
b) Reset any power alarms that may have gone off.
3.5 Aboveground Storage Tanks:
a) Dip aboveground storage tank(s) and record level(s).
b) Visually observe and record condition of tank(s) (i.e. rusting, leakage, other
abnormalities).
c) Ensure all other safety features are working properly.
-------
Title: Safe Storage of Compressed Gas Cylinders
Document No: HS-001
Date Approved: 03/20/02
Next Revision Date: 03/03
Prepared By:
Health and Safety Specialist
Approved By:
Director, Human Resources
PROCEDURE:
1. Proper Storage:
1.1. Store cylinders in a well ventilated area.
1.2. Store cylinders away from fire risk and away from sources of heat or ignition. Mark the
area "No Smoking".
1.3. Store cylinders upright, on a firm, level, well-drained surface, and secure cylinder (with
chains) to prevent from falling.
1.4. Store nothing else in the cylinder storage area. In particular avoid oil, paint or corrosive or
flammable liquids.
1.5. Segregate full and empty cylinders.
1.6. Segregate cylinders in the storage area according to gas type (i.e. flammable, inert,
oxidizing, toxic, etc.)
1.7. Cylinders containing oxygen or oxidizing gases must be separated from cylinders
containing flammable gases by minimum 3 meters or by a fire resistant partition.
1.8. Cylinders containing inert gases may be stored with cylinders containing oxygen or
oxidizing gases.
1.9. Toxic or corrosive gas cylinders must be stored separately from ALL other gas cylinders.
Follow the instructions on the gas Material Safety Data Sheet.
1.10. Propane or butane cylinders must be stored a minimum of 3 meters away from ANY other
gas cylinder type.
2. Transportation To and From Departments
2.1. Move one tank at a time for transporting to and from department(s).
2.2 Ensure tanks are tied to wall when they reach their destination points.
-------
Title: Mercury Spill Clean-Up & Disposal
Document No: HS-001
Date Approved: 03/20/02
Next Revision Date: 03/03
Prepared By:
Supervisor, Housekeeping
and CSR
Approved By:
Environment, Health and
Safety Specialist
PURPOSE:
To ensure that Mercury spills are cleaned-up properly and promptly and disposed of in
accordance with applicable legislations.
POLICY STATEMENT:
The hospital is committed to the to the immediate reduction and eventual elimination of mercury.
PROCEDURE:
1. Clean-Up
1. In case of a large uncontained mercury spill call a "Code Brown" (procedure found in
hospital policy and procedure manual.
2. For a small contained mercury spill, secure spilled area and immedietley obtain the
"Mercury Spill Kit" and a full-faced respirator (with mercury cartridges) from the
hospital spill kit in the Housekeeping Department (Room #121).
NOTE: Only those individuals who have recieved fit-testing and fit-checking training are
to use the respirators. If you have not recieved training call an Environmental Services
personnel.
3. In all cases wear gloves and a full-face respirator when treating mercury spills.
4. Block the area from foot traffic for a large radius (minimum 6-foot radius) around the
centre of the spill site.
5. Check clothing, footwear, bedding, etc. for mercury and mercury debris. Remove
contaiminated clothing, footwear, etc. and place at the edge of the spill site.
6. Collect and treat any visible and collectible mercury using VYTAC MIS from Mercury
Spill Kit.
7. Wet the MIS with a water spray and aggitate the mixture with a stirring stick or similar
tool to assure that all the mercury is in contact with MIS. In less then a minute all the
mercury should be amalgamated and solidified. If drops of liquid mercury remain, add
more MIS and repeat the procedure until all the mercury is solidified.
Note: It will require approx. 120-150 grams of MIS to treat 100 grams (only 8 ml) of
mercury.
8. The solidified amalgam is safe to collect using the brush and dust pan that is provided in
the Mercury Spill Kit. The collected residue should be placed in a closed plastic container
and clearly marked as "containing mercury".
-------
9. Store the bucket the hospital's Flammable Storage Room for disposal by a licensed
hazardous waste company.
8. Apply VYTAC MVS to all areas that might be contaminated with mercury particles.
Make sure that crevices, cracks and inaccessible areas are covered. For maximum vapour
suppression it is recommended that a 3-5 mm coverage be applied.
(NOTE: MSV should only be regarded as a temporary solution.)
9. MSV will immediately suppress any further generation of vapours. Remove at the earliest
convenience. Contaminated residues should be collected by either sweeping up or the use
of a high filration (HEPA) vacuum which is available through Engineering Services. The
residue contains mercury and should be diposed of in the same sealed plastic container.
MSV darkens as it becomes contaminated with mercury, indicating its presence.
10. If visible mercury is coated with MSV it can be treated using MIS, following standard
procedures. Caution: A slight hydrogen sulphide odour may develop during the
neutralization process.
Back to Example List - Page 168
-------
Sample Letter Requesting Certificate of Analysis
and Sample Certificate of Analysis
[Insert Hospital Name]
January 2, 2002
Name
Vendor Name
And Address
Subject: Certificate of Analysis
Dear Ms. Smith:
As you are aware, mercury is of increasing concern as an environmental pollutant.
Mercury released from air and water sources is transformed into methlymercury in lakes
and rivers. The methlmercury bioaccumalates in the aquatic food chain making
consumption offish hazardous to those organisms high on the food chain. As a result,
regulations on the discharge of mercury to the solid and wastewater are becoming
increasingly stringent.
Because of this knowledge, and our concern for the environment, our institution has
instituted a mercury reduction policy. This policy requires the elimination or
minimization of mercury in all of our purchases. Low level concentrations of mercury in
products (less than 10,000 ppm or one percent) are not required to be listed on Material
Safety Data Sheets. The contribution from the sum of these low concentration sources
accounts for a large fraction of the mercury in the wastewater stream. In order for our
purchasing department to be able to make an informed choice on mercury concentration
within the products that it buys, we are requesting that all vendors supply us with a
certificate of analysis and/or a notarized affidavit which describes product mercury
concentration and the detection method used in the analysis. This information will be
used along with other criteria in the selection process of our vendors.
Please submit the aforementioned information on all products that you intend to supply
our institution. Thank you for your understanding and assistance in this matter.
Sincerely,
Jane/John Smith
Purchasing
-------
Anderson's Acids
98 Molarity Drive
Marathon, Ontario
H2S 04 Canada
Customer: [insert hospital name]
Attn: Jane/John Smith
Fax: 1-800-555-5555
Product Grade: SULFURIC ACID 93% Shipment Date:
B/L Number: 00008650 Quantity (as is): 100.400
T
Customer P/O No.: C125062
Routing: ONR-HEARST-ACSSTMA-WCSUPER-BN-CLOQ-DNE
Tank Car/Tank Truck No.:
UTLX125021
The analysis below is representative of the quality of product loaded into the above
shipment.
Parameter
Strength (%H2S04)
Color (HU)
Iron (ppm Fe)
Sulfur Dioxide (ppm S02)
Appearance (%T)
Oxides of Nitrogen (ppm NO3)
POM(ml0.02NKMn04)
Mercury (ppb)
Detection method for mercury analysis
Analysis
Specification
93.67
11
9
10
100
1
1.00
60
93.19Min
40 MAX
50 MAX
50 MAX
10 MAX
5. 00 MAX
ANALYST:
to - 188
-------
Vendor Product Mercury - Content Disclosure
Hospital name
Name of Hospital Purchasing Agent
Address
Telephone
Our hospital has the policy of minimizing
the hospital. Such products may include:
Barometers
Batteries
Cleansers and soaps
Electrical relays
Gastrointestinal tubes
Laboratory chemicals
Laboratory manometers
Fax
the use of mercury in products purchased for
Lamps
Pharmaceutical products
Sphygmomanometers
Switches
Thermometers
Thermostat probes
Thermostats
Vendor name
Name of vendor's aaent
Telephone
The above-named vendor agrees to:
• Assist
disclosures about the mercury content
• Assist
virtually free of mercury content.
Signature of vendor's agent
Fax
Hospital in obtaining manufactures'
of their products.
Hospital in selecting products that are
Date
to
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4.5.1 PROCEDURE FOR MONITORING AND MEASURMENT
Document No: EMS-4.5.1
Date Approved: 06/17/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
1. Purpose
1.1 To ensure that the key characteristics of the hospital's operations and activities that can have a
significant impact on the environment are tracked and measured, on a regular basis, to ensure
environmental compliance and to provide a basis for environmental performance.
2. Scope
2.1 This policy governs the operations and programs conducted by [hospital name], located at
[insert hospital address}.
3. Definitions
3.1 Definitions relating to the content of the EMS are contained in the Glossary.
4. Responsibility
4.1 The EMS Representative and/or designate is responsible for establishing and maintaining the
monitoring database on a regular basis.
4.2 Department Managers/Supervisors are responsible for ensuring that regular monitoring of key
characteristics of their departments operations are monitored and documentation is maintained
5. Procedure
5.7 Compliance
5.1.1 An Environmental Compliance Audit will be conducted by the hospital at a minimum of every 3 years
using the hospital's subscription compliance software program or by an outside consulting firm, to
assess regulatory compliance issues relating to all "significant environmental aspects" and issues
identified in previous audits, inspections, and assessments.
5.1.2 Monthly workplace safety inspections performed by the members of the Health and Safety
Committee will identify hazards that may have the potential to have negative environmental
impacts. The members of the HSC performing the monthly inspections will relay this
information to the EMS Representative through monthly reports/meetings.
5.2 Control of Monitoring and Measurement Equipment
5.2.1 Any equipment used to measure and monitor key characteristics of the environmental management
system is maintained in order to provide confidence in the accuracy of the measurements. The
following outlines the components of the system designed to provide that confidence.
5.2.2 Department Managers/Supervisors inform the EMS Representative and/or designate when new
measuring and monitoring equipment has been purchased in their departments. The EMS
Representative and/or designate enters the information into the "Monitoring and Measurement
Documentation Chart" (Exhibit 1- EMS-4.5.1-1).
Procedure for Monitoring and Measurement, EMS-4.5.1, Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
5.2.3 Operating procedures relating to the calibration and monitoring processes of departmental
equipment are developed and maintained by the Department Managers/Supervisors and/or
designates.
5.2.4 Trained individuals within each department, Engineering Services personnel and/or external
companies, perform the calibration of hospital monitoring equipment. Hospital equipment
calibrated by Engineering Services is included in the preventive maintenance computer
program in Engineering Services.
Work orders are printed and performed based on the frequency of calibration for each piece of
equipment entered into the system (frequency based on manufacturers guidelines and/or
vendor's recommendations). Records of calibration are placed on, or in a close proximity to,
the piece of equipment undergoing calibration testing and/or are kept by the external company
performing the regular calibration of equipment.
5.2.5 The EMS Representative and/or designate periodically reviews the calibration records, to
ensure that the operations are being performed as scheduled. If not, the EMS Representative
will notify the department, individual, and/or Engineering Services to request that it be done.
5.5 Monitoring of Environmental Performance Indicators
5.3.1 The EMS Representative and/or designate will compile, on a regular basis, data required for
ensuring objectives and targets are met in the Environmental Performance Indicator Binder.
5.3.2 Data relating to, and/or location of data relating to the key characteristics of the facilities
operations are documented in the Environmental Performance Indicators Binder.
6. References
ISO 14001 - 96 - Environmental Management System Standard
7. Exhibits
Exhibit 1- EMS- 4.5.1-1 Monitoring and Measurement Documentation Chart
Procedure for Monitoring and Measurement, EMS-4.5.1, Page 2 of 2
-------
[Hospital Name]
EMS Procedure
Effective Date
Subject
4.1
Measurement and Monitoring
Purpose This procedure is used to implement a measurement and monitoring
program designed to support the EMS and specific EMS objectives and
targets.
Step 1 The EMS Manager and EMS Team will track hospital metrics by
collecting and charting data relevant to the metric, including those
identified below.
Facility
Energy Use
Water Use
Laboratory Hazardous Wastes
Janitorial Chemicals
Computer/IT Wastes
Construction and Renovation-
associated Wastes
Vehicle Fuel Chemical Use
Data Collection
Frequency
Responsibility
Step 2 The EMS Manager and EMS Team will identify and measure unique
parameters for each EMS objective and target.
Step 3 The EMS Manager and EMS Team will measure, monitor, and record
target-specific parameters at a predetermined frequency.
Step 4 The EMS Manager and EMS Team will review campus and target-specific
measurement and monitoring data every 3 months to identify trends,
evaluate progress toward meeting EMS objectives and targets, and discuss
overall environmental performance.
Responsible Person:_
Signature and Date:_
-------
[Hospital Name] Environmental Procedure
Procedure Number: Effective Date:
Title: Monitoring and Measuring
1 PURPOSE:
This procedure defines the mechanism and requirements for verification of measurement
and testing equipment used to monitor and control significant environmental aspects.
2 ACTIVITIES AFFECTED:
PI ant-wide.
3 FORMS USED:
None.
4 REFERENCES:
4.1 Environmental and Energy Reports
4.2 Air Emissions Management
4.3 Significant environmental aspects
4.4 Calibration matrix of key activities
4.5 Agency Reporting
4.6 Internal Environmental System Audits
5 DEFINITIONS:
None.
6 EXCLUSIONS:
None.
7 PROCEDURE:
7.1 The hospital shall identify and list measuring and testing equipment deemed
necessary to monitor and control significant environmental aspects for permitted
sources and other appropriate equipment.
Uncontrolled Document- Verify the latest revision date on the Intranet
Authorized by: Environmental Control Specialist Revision Date:
-------
7.2 The list should include definition of the characteristics, frequencies, and location
of the equipment requiring calibration. Verification will be maintained in the
using department. All equipment not owned by [hospital name], such as utility
meters, will be calibrated and maintained by the owner.
7.3 Approved outside testing organizations may be used to verify measuring and
testing equipment at a prescribed interval.
7.4 All other applicable measuring and testing equipment shall be maintained and
verified by plant personnel according to manufacturer's recommendations.
7.5 The department manager or designee is responsible for maintaining lists, and
verification and maintenance records (if any) for equipment in this area.
7.6 Any deviations from the proper operation or verification of measuring and testing
equipment shall be reported to the department supervisor and/or the
Environmental Control Specialist for the appropriate actions to be taken.
8 GENERAL RULES:
Deviations from procedures which affect environmental compliance shall be reported
immediately to the Environmental Control Specialist.
9 ENVIRONMENTAL RECORDS:
Calibration Documentation
10 RECORS OF REVISIONS:
Date:
Description:
Reformed & add
new references for
calibration &
measurable
Changes made to
reflect division staff
recommendations
Pages affected:
All
All
Authorized by:
Back to Example List - Page 168
Uncontrolled Document- Verify the latest revision date on the Intranet
Authorized by: Environmental Control Specialist Revision Date:
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: CALIBRATION AND MAINTENANCE OF MONITORING EQUIPMENT
Document No: 001
Date Approved: 06/01/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
Management
Representative
I. Purpose
1.1 This procedure defines the mechanism and requirements for verification of
measurement and testing equipment used to monitor and control significant
environmental aspects.
2. Scope
2.1 This policy applies to associated operations and activities conducted by [hospital
name], located at [insert hospital address].
3. Responsibility
N/A
4. Procedure
4.1 The hospital shall identify and list measuring and testing equipment deemed
necessary to monitor and control significant environmental aspects for permitted
sources and other appropriate equipment.
4.2 The list should include definition of the characteristics, frequencies, and location
of the equipment requiring calibration. Verification will be maintained in the
using department. All equipment not owned by [hospital name], such as utility
meters, will be calibrated and maintained by the owner.
4.3 Approved outside testing organizations may be used to verify measuring and
testing equipment at a prescribed interval.
4.4 All other applicable measuring and testing equipment shall be maintained and
verified by facilities personnel according to manufacturer's
recommendations/guidelines.
4.5 The Department Manager/Supervisor or designee is responsible for maintaining
lists, and verification and maintenance records (if any) for equipment in this area.
4.6 Any deviations from the proper operation or verification of measuring and testing
equipment shall be reported to the department Manager/Supervisor and/or the EMS
Representative for the appropriate actions to be taken.
Calibration and Maintenance of Monitoring Equipment Procedure, 001, Page 1 of 2
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
4.7 Deviations from procedures which affect environmental compliance shall be
reported immediately to the EMS Representative.
5. Definitions
N/A
6. References
ISO 14001 - 96 - Environmental Management System Standard
Environmental and Energy Reports
Air Emissions Management
Significant Environmental Aspects
Calibration Matrix of Key Activities
Agency Reporting
Internal Environmental System Audits
7. Exhibits
N/A
to - 188
Calibration and Maintenance of Monitoring Equipment Procedure, 001, Page 2 of 2
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: PROCEDURE FOR EMS AUDITS
Document No: EMS-4.5.4
Date Approved: 07/11/02
Next Revision Date: 07/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To ensure that the EMS is periodically audited in order to determine if it conforms to the
ISO 14001-96 Standard, and has been properly implemented and maintained.
2. Scope
2.1 This policy applies to all EMS related documentation associated with the
operations and activities conducted by [hospital name], located at [insert hospital
address].
3. Responsibility
3.1 It is the responsibility of the EMS Representative to lead the EMS Internal Audit Team in
the auditing process and ensure that audits are conducted on a regular basis.
3.3 It is the responsibility of the EMS Internal Audit Team to, on a regular basis, participate in
the EMS auditing process.
4. Procedure
4.1 The EMS Representative and/or designate will lead a 2-3 member EMS Internal Auditing
Team in conducting an Environmental Management System Audit annually using the
"EMS Audit Checklist" (Appendix B) as a guideline.
Refer to the EMS Internal Auditing Team's Terms of Reference (EMS-4.5.4-1) on the
Meditech system, for specific team and audit report requirements.
4.2 The audit scope will consist of all activities, operations and programs within the physical
boundaries of [insert hospital name and location]. Audit plans will depend on results of
previous audits and areas of "importance" identified by the lead auditor.
4.3 Prior to performing an EMS audit, each member of the EMS Internal Audit Team will
review the current inventory of environmental aspects and impacts, findings and
conclusions from the previous EMS audits, and other relevant EMS documentation.
4.4 Any non-conformances cited by the EMS Internal Audit Team will evoke the Procedure
for Non-conformances, Corrective & Preventive Action (EMS-4.5.2).
4.5 The EMS Internal Audit Team will be responsible for producing an EMS Audit Report,
with corrective action plans, as directed by the lead auditor.
Procedure for EMS Audits, EMS-4.5.4, Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
4.6 The audit reports are forwarded the EMS Management Representative for review and final
approval. He/She allocates resources as required for corrective/preventive actions.
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001 - 96 - Environmental Management System Standard
Appendix 1- EMS Audit Checklist
7. Exhibits
N/A
Procedure for EMS Audits, EMS-4.5.4, Page 2 of 2
-------
ISO 14001 Procedure - Element 4.5.4 - Environmental
Management System Audit
Issue Date -
Revision No. 1
1. Purpose: To ensure that the organization is conforming to the environmental
management system and to ensure that the system has been properly
implemented and is being maintained.
2. Scope: This procedure is for periodic environmental management systems audits
to determine whether the system conforms to the requirements of the standard,
that it has been properly implemented and maintained and provides information
of the results of audits to the management.
3. General: Audits are required so that the organization can demonstrate conformance
to the ISO 14001 standard. The audit programme should cover the following
areas:
• The activities and areas to be considered in audits
• The frequency of audits
• The responsibilities with managing and conducting audits
• The communication of audit results
• Auditor competence
4. Responsibility:
The Environmental Manager is responsible for ensuring that the
Audits of the environmental management system are conducted.
5. Procedure: Development of Audit Programme
i. The Environmental Manager shall prepare an Audit Programme
including a checklist of items to be audited.
Frequency of Audits
i. The Environmental Manager shall conduct an internal audit of the
environmental management system annually.
ii. The Environmental Manager shall arrange for an outside auditor to
conduct an audit of the environmental management system every three
years.
iii. The Environmental Manager shall ensure that the outside auditor is
competent to complete the audit.
Audit Responsibilities
i. The Environmental Manager is responsible for summarizing and
communicating the results of the audit to the Plant Manager.
ii. The Environmental Manager is responsible for identifying action items
from the audit and notifying the appropriate Department Mangers of the
action items.
-------
iii. The Department Managers are responsible for resolving/rectifying action
items in their department. Where the Department does not have
sufficient resources to rectify the item, the Department Manager must
inform the Plant Manger.
iv. The allocation of additional resources is at the discretion of the Plant
Manger.
Communication of Audit Findings
i. The Environmental Manger shall identify all sensitive audit findings as
"confidential". The dissemination of this information will be restricted
to those involved in the rectification of the problem.
6. Related Records:
Schedule 4.5.4a- Audit Programme Checklist
Schedule 4.5.4b - Tracking of Action Items
Annual Audits
Summary of Annual Audits
7. Approval
Environmental Manager
Date
Next Revision:
Revision Schedule:
Document Locations:
Author:
Reviewed by:
Back to Example List - Page 168
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4.4. 7 PROCEDURE FOR EMERGENCY PREPAREDNESS AND RESPONSE
Document No: EMS-4.4.7
Date Approved: 06/12/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
1. Purpose
1.1 To ensure that this procedure and any environmentally related emergency procedures are reviewed and
tested on a regular basis, to ensure their accuracy and effectiveness.
1.2 To establish and maintain procedures to identify potential environmental accidents and/or emergency
situations and the appropriate response requirements.
1.3 To prevent and mitigate the environmental impact(s) associated with an accident and/or an emergency
situation.
2. Scope
2.1 This procedure applies to all potential environmental accidents and/or emergency situations
associated with all operations and programs conducted by [insert hospital name}, located at
[insert hospital address}.
3. Definitions
3.1 Definitions relating to the content of the EMS are contained in the Glossary.
4. Responsibility
4.1 It is the responsibility of the EMS Representative and/or designate, in association with the Green Team
and the hospital's Code/Emergency review committee to identify and/or review potential
environmental accidents or emergency situations through the annual review of environmental aspects
and impacts.
4.2 It is the responsibility of the hospital's Code/Emergency review committee to approve, review, and test
all emergency preparedness procedures.
5. Procedure
5.1 Identification of Potential Environmental Accidents and/or Emergency Situations
5.1. IThe EMS Representative and/or designate, in consultation with the Green Team and the hospital's
Code/ Emergency review committee, identifies and documents all potential environmental accidents
and/or emergencies associated with hospital operations and programs in the "Emergency Preparedness
& Response Chart" (Exhibit 1- EMS-4.4.7-1). Possible emergency situations are also identified when
developing the hospital's environmental aspects inventory.
5.1.2 At any time, a hospital employee can identify the potential for an environmental accident and/or
emergency. He/She must complete a hospital "Employee Incident Report", clearly stating that this is a
"potential" incident and/or hazardous situation. (See Hospital's procedure for Employee Incident
Reporting.)
5.1.3 The Occupational Health Center/Health and Safety Department forwards a copy of the
Procedure for Emergency Preparedness and Response, EMS-4.4.7, Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Employee Incident Report(s) to the EMS Representative and/or designate for his/her review and
records.
5.1.4 If the identified potential environmental accident and/or emergency has not been
previously identified in the environmental aspects inventory or the "Emergency Preparedness &
Response Chart", the EMS Representative and/or designate will add it to the charts.
5.1.5 The EMS Representative and/or designate must relay any information about any corrective and/or
preventive actions taken to remediate the concern to the initiating employee within 2 weeks of action.
5.1.6 The EMS Representative and/or designate will accompany, on a regular basis, the Joint Occupational
Health & Safety Committee members on their monthly inspections, to identify the potential for any
new environmental accidents or incidents.
5.2 Emergency Preparedness and Response Procedures
5.2.1 Environmental emergency procedures, such as the hospital's emergency Code system, are reviewed
and tested on a regular basis by the hospital's Code/emergency review committee.
5.2.3 The hospital's Code/emergency review committee reviews and will periodically test the Code
procedures by performing "Drills", in order to ensure the effectiveness and accuracy of the procedure.
5.2.4 The hospital's Code/emergency review committee will review the code procedures after the
occurrence of an environmental emergency or accident where the procedure was utilized, to
identify any discrepancies
6. References
ISO 14001 - 96 - Environmental Management System Standard
Exhibit 2- EMS- 4.3.1-2 Environmental Aspects and Impacts Chart
[List Hospital Emergency Codes]
1. Exhibits
Exhibit 1- EMS- 4.4.7-1 Emergency Preparedness & Response Chart
Procedure for Emergency Preparedness and Response, EMS-4.4.7, Page 2 of 2
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Mercury Spill Clean-Up Procedures
Broken Thermometers: (There is not enough mercury involved to present a hazard; you do not
need to respond with a vacuum.)
1 . Using two 3"x5" cards push mercury into a pile.
2. Draw up into a syringe (no needle) and place in a sealed container or scoop onto a specimen
container or other sealed container.
3. Disposal:
Non-patient area: Fill out a hazardous waste tag and call the Hazardous Waste
Management Unit for pick up.
Patient are: Label container (mercury) and place on cart to bee returned to Sterile
Supply.
SMH patient area: Call should be referred to SMH Housekeeping.
Other area: Contact an Industrial Hygienist for immediate clean up.
**Note: Any call which sounds unusual (i.e. spilled on patient, on carpet, in toilet, not a
thermometer or manometer) should be referred to an Industrial Hygienist.
It is important to respond as soon as possible (within 1 or 2 hours) to clean up any spill.
1. Make sure everyone is removed from the room (patient(s), visitors, staff).
Patient bed should not be removed from the room.
2. Gather equipment
• Mercury vacuum* and attachments (stored in the SMH Housekeeping Office- If locked
have one of the supervisors paged)
• The mercury vacuum is designed to clean up liquid mercury spills. Regular vacuum
cleaners can volatilize the mercury and below the mercury vapors into the air. An
activated carbon filter in this vacuum will absorb and contain the mercury vapors.
• Toolbox. The following items should be in the tool box:
• Flashlight
• Screwdriver
• Putty knife
• Mercury holding j ar
• Respirator (3M 9908 Duct/Mist Respirator)
• Yellow or pink wash basin (from clean utility room on unit)
• Heavy plastic bag
3 . Before entering room put on protective equipment.
• Respirator
• Long sleeve shirt
• Long pants
• Disposable gloves
• Remove all jewelry
-------
4. Assess the extent of the spill. Upon entering the room use flashlight (hold angled at floor
level, put head close to floor to see where mercury is located). Also check wall, bed frame
and mattress. Do not walk in contaminated areas.
If there is anything unusual about the spill (i.e. on carpet, in a toilet, on patient, etc.) a member of
the Industrial Hygiene Unit should be consulted.
5. Set up mercury vacuum using the following steps:
A. Place plastic dishpan under separator.
B. Remove red cap off mercury separator and screw jar onto vacuum.
C. Remove red end cap from hose.
D. Place required attachment on hose.
6. Begin vacuuming at outer edges of spill and work towards center of spill (usually the wall
under the manometer). Set up an organized approach (i.e. begin vacuuming one block and
move slowly, in a row to assure that you cover the entire area). Draw vacuum hand-piece
slowly towards yourself. Pay special attention to floor moldings. If molding is pulled away
from the wall and you suspect that mercury may have gotten behind it, remove the molding
using the putty knife and vacuum behind it.
7. Once the area under the manometer has been vacuumed, remove the manometer from the
wall bracket by unscrewing the top holding screw. Place the manometer in the washbasin. If
the glass tube is not broken on the front of the manometer and there is no visible mercury on
the outside of the manometer, put the manometer inside the plastic bag. Seal the bag and
place in washbasin. If the tube is broken, empty mercury into the washbasin to be vacuumed.
Then put the manometer into plastic bag and seal.
8. Once all the mercury has been vacuumed, take the flashlight and check again for beads of
mercury on the floor, wall and bed. Several attempts may be needed to vacuum all the
mercury from the spill.
9. Place washbasin under mercury separator and unscrew jar. Place red cap over bottom of
mercury separator and place red end cap on base. Any mercury that may have fallen on the
paper should be dumped into the jar. Place lid and return jar to toolbox*.
If water has been vacuumed, notify Environmental Health and Safety (EH&S) immediately
so that the appropriate maintenance can be preformed.
10. Pick up all materials and leave room.
11. Leave manometer (in sealed bag) in the soiled utility room. The unit secretary should be
informed to call to have the manometer replaced.
12. Post sign on the door to assure that the room remains browned out and no one enters until
EH&S has checked the room.
13. Notify EH&S that the spill has been clean up. If the spill occurs during the normal 8-5:30
day, call EH&S immediately after clean up is complete. Please give the secretary the room
number and other important details. If the spill occurs after 5:30 or on a weekend, leave a
message on phone mail giving the room number and any other details about the spill.
-------
14. EH&S will respond with the mercury vapor sniffer and a flashlight to assure adequate clean
up. Mercury vapor levels should be insignificant (<0.02 mg/m3) at floor level.
15. The patient(s) may be returned to the room after EH&S has approved the room for use.
*Note: If mercury and spill debris reach the fill line on the jar, a Hazardous Waste
Tag must be filled out. The tag should be completely filled out and attached to
the jar. The Hazardous Waste Management Unit should be called to pick up the
mercury.
Back to Example List - Page 168
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4.4. 2 PROCEDURE FOR TRAINING, AWARENESS AND COMPETENCE
Document No: EMS-4.4. 2
Date Approved: 06/12/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
1. Purpose
1.1 To ensure that environmental training needs are identified and appropriate training is provided.
Employee training is required for a number of regulations that have specific training
requirements, as well as to improve knowledge of the Environmental Policy and
environmental management system, general environmental performance and reduce
environmental risk. The main topics of training include, but are not limited to:
- Environmental Policy,
- Environmental Management,
- Emergency Response,
- Waste Management,
- Transportation of Dangerous Goods,
- Chemical Management and Spill Response, and
- Environmental Awareness.
1.2 To ensure that employees with job functions that exhibit significant aspects are aware of:
- The importance of their roles and responsibilities in conforming with the
Environmental Policy, job specific procedures and the requirements of the EMS;
and
- The significant environmental impacts related to their work activities.
2. Scope
2.1 This procedure applies to all personnel whose work can have a significant impact on the
environment and relates to all operations and programs conducted by [insert hospital name},
located at [insert hospital address}.
[Insert hospital name} personnel also includes contracted personnel or contracted agencies.
3. Definitions
3.1 Definitions relating to the content of the EMS are contained in the Glossary.
4. Responsibility
4.1 It is the responsibility of the EMS Representative to reinforce and
communicate commitment to the Environmental Policy (EMS- 4.2) and EMS related
procedures.
4.2 It is the responsibility of all Department Managers/Supervisors to identify and hire personnel
with the minimum education level, experience and skills for each job function in their areas,
and to ensure training associated with operational controls is provided to these staff.
4.3 It is the responsibility of the EMS Representative to deliver needed environmental training, or
Procedure for Training, Awareness and Competence, EMS-4.4.2, Page 1 of 3
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
to obtain contracted service providers to deliver training.
5. Procedure
5.1 Job Qualifications
S.l.lHuman Resources, in collaboration with Department Managers/Supervisors, are responsible
for determining the minimum education, experience, skill and competence levels that are
needed to perform each job function in the hospital.
5.2 Training/Awareness for Department Specific Operational Controls
5.2.1The EMS Representative and/or designate, in collaboration with Department
Managers/Supervisors and Human Resources develops the "Operational Control and Training
Requirements Chart" (EMS-4.4.6-1). The chart displays the environmental
training/awareness activities identified for the employees that perform operations and
activities with associated significant environmental aspects.
5.2.2 Attendance and other training related information is to be documented as per the hospital's
existing Human Resources/Educational Services training documentation procedures.
5.2.3 Unless otherwise arranged, the Department Manager/Supervisor and/or designate conducts
and/or arranges for his/her employees to receive the needed training/awareness and records
the date of occurrence.
5.2.4The EMS Representative and/or designate will periodically review the training records chart to
ensure that needed training is being provided to department staff and that records are being
kept up-to-date by Department Managers/Supervisors/ Educational Services.
5.3 Legislative and EMS Training
5.3.1 The EMS Representative and/or designate, in consultation with Department
Managers/Supervisors and the Green Team, identifies the legislative and EMS training needs
of hospital staff by completing a "Training Needs Analysis Worksheet" (Exhibit 1- EMS
4.4.2-2).
The EMS Representative and/or designate adds the identified legislative, EMS and other
training needs to Exhibit and informs the Department Managers/Supervisors of the specific
training requirements for their areas.
The EMS Representative and/or designate, will deliver or arrange for needed legislative
and/or environment-related training.
5.3.2 Once the employee has completed his/her required training the EMS Representative and/or
Educational Services will retain attendance sheets, tests, and other related information and
forward a copy to associated Department Managers/Supervisors for their records.
5.4 New Employees
5.4.1 All new employees receive Environmental Awareness Training during the
Orientation process.
5.4.2 Attendance sheets from the Orientation sessions are documented by Educational Services.
Procedure for Training, Awareness and Competence, EMS-4.4.2, Page 2 of 3
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
5.5 Contractor Training
5.5.1 All contractors/suppliers that the hospital has dealt with in the last year will be sent "EMS
Information Packages" to inform them of their responsibilities in the hospital's EMS.
5.5.2 All departments that bring contractors on-site at the hospital will ensure that the contractors
have received required EMS training.
6. References
CAN/CSA-ISO 14001 - 96 - Environmental Management System Standard
EMS- 4.2-Procedure for Environmental Policy
EMS- 4.4.6-1 Operational Control and Training Requirements Chart
7. Exhibits
Exhibit 1- EMS-4.4.2-1, Training Needs Analysis Worksheet
Procedure for Training, Awareness and Competence, EMS-4.4.2, Page 3 of 3
-------
Title:
Training, Awareness and
Competency
Number:
Effective Date:
N/A
VICE PRES/PRESIDENT
MGR./GEN.MGR
Date Revised:
Revision No.: 0
Page:
Purpose
To establish a consistent approach to implementing the training that has been
identified as being needed.
Scope
All employees' contractors and suppliers whose work at XXXX may create a
significant impact upon the environment.
Definitions
None.
Reference Material
EMS Organizational Structure
Significant aspects
Environmental Policy
All Operational Control Procedures
Emergency Preparedness and Response Procedure
ISO 14001
Identification of Training Needs Procedure
Training Needs Matrix
V. Procedure/Policy
A. The Environmental Affairs or the control department will determine who needs which
type of training, how long the training should last and the frequency of the training.
The Environmental Affairs or the control department will also develop outlines for,
descriptions of each type of training performed to promote consistency in the delivery
and the content of the training.
B. Environmental Affairs or control department will coordinate all EMS related courses
identified. Training related to the job specific operational controls will be conducted
by production or related section supervisors. The primary method to train employees
on the job specific operational controls is through training on the work instruction.
C. Personnel performing tasks which can cause significant environmental impacts shall be
competent based on training, education, or experience.
D. Records of the training activities will be controlled as appropriate.
Retention Requirement
This document will be retained until revised.
Special Circumstances
None
-------
Measurement of Performance
The performance of this portion of the EMS shall be measured through audits conducted
by internal auditors, audit team and 3rd party auditor of which certification is acquired.
Appendix
N/A
-------
Effective Date:
Revision Number:
Last Revision Date:
iso COORD IMGMT REP IENVMGR
**?
ENVIRONMENTAL TRAINING
RCRA Hazardous Waste Mgt. Training
ANNUAL RCRA TRAINING TO
INCLUDE:
l.RCRA
2. Emergency Response
3. Solvent Management
4. Spill Kit Training
Lab Safety
[SO 14001 General Awareness Training
Significant Aspect Area Training
ISO Lead Auditor Training
ISO Internal Auditor Training
HAZWOPER
Required For:
All team members
X
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X
X
X
X
X
X
Group Leaders/Team Leaders/Assistant Man
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X
X
X
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X
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X
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-------
Title:
External Communication
Procedure
Number:
Effective Date:
N/A
VICE PRES/PRESIDENT
MGR./GEN.MGR
Date Revised:
Revision No.: 0
Page:
I. Purpose
To define the method(s) that will be utilized to receive, document and
respond to relevant communication from external interested parties.
II. Scope
All of the external communication that relates to environmental aspects.
III. Definitions
External Communication - That communication that occurs with
interested parties in which there is a concern or a complaint from the
external interested.
Reference Material
Emergency Preparedness & Response Procedure
Significant Aspects
Environmental Policy
Environmental Communications Request Form
Emergency Response List
IV. Procedure/Policy
A. The communication from an external interested party is received by the
Company Receptionist or Corporate Communications or by a member of the
Environmental Affairs Section.
B. Information received by the company receptionist or Corporate Communication
is forwarded to Environmental Affairs.
C. The members of environmental affairs will verify the nature of the
communication and either address it immediately (not requiring written
documentation) or record the individuals/groups name and phone number and
nature of the communication on the Environmental Communication (EC) and
Environmental Affairs will either address the communication in a timely
manner or consult with upper management if necessary.
D. The decision to communicate significant environmental aspects is done on a
case by case basis by the manager of environmental affairs and upper
management if necessary. An EC will be used to document the
communication.
-------
E. Once in the tracking system, the communication will be kept for consideration
during updating significant aspects and objectives and targets.
F. The communication will be completed by Environmental Affairs or Corporate
Communications depending upon the nature, size and scope of the situation.
G. A summary of the response or a copy of the response (if written) will be logged
into the Environmental Communications (EC) tracking system.
H. In the event the emergency response system is activated, communication
methodologies will be implemented consistent with those outlined in the
Emergency Response Plan.
V. Retention Requirement
This document will be retained until revised.
a. Special Circumstances
N/A
b. Measurement of Performance
The performance of this portion of the EMS shall be measured through audits
conducted by internal auditors, audit team and 3rd party auditor of which
certification is acquired.
Appendix
N/A
i-sk to
-------
Title:
Internal Communication
Procedure
Number:
Effective Date:
N/A
VICE PRES/PRESIDENT
MGR./GEN.MGR
Date Revised:
Revision No.: 0
Page:
.L. Purpose
To establish the methods that will be utilized to communicate internally on
environmental aspects and the Environmental Management System.
The scope includes all of the internal communication that relates to
environmental aspects.
I. Definitions
Internal Communication - That communication that occurs between
employees, or contractors/suppliers who work on behalf of [insert hospital
name] within the confines of the site.
Reference Material
All EMS Procedures
All EMS Records
Environmental Policy
//. Procedure/Policy
B. XXXX Environmental Affairs communicates to facility personnel relevant
information regarding the environmental management system in the following
manner:
1) Policy - Distribute Policy Cards and send fliers to all employees
2) Significant Aspects - The list is discussed with section managers.
3) Legal and Other requirements - Distribute a list of general
regulations through General Awareness Training. Distribute
specific legal requirements to relevant engineering sections.
4) Objectives and Targets - The objectives are discussed with section
managers.
5) EMP - The EMP's are given approval or disapproved with reason
why disapproved.
6) Structure and Responsibility - Roles and responsibility are
distributed.
7) Training Awareness Competency - All training is considered
communication.
8) Communication - The methods to communicate to Environmental
Affairs through general awareness training.
-------
9) EMS Documentation - Copies of the manual will be
communicated via the web site.
10) Document Control - General document control requirement are
communicated to section managers via review meeting and section
ISO Representatives via Internal Auditor Training Class.
11) Operational Control - General document control procedures are
reviewed and recommendations are communicated to relevant
sections via the Environmental Key Point proposal.
12) Emergency Preparedness and Response - The Emergency response
are communicated during the annual RCRA training.
13) Monitoring and Measuring - The requirements for generating
documented monitoring/measuring Procedures and to perform
calibration on monitoring/measuring equipment is communication
to section ISO representatives via "objectives and targets".
Performance tracking for objectives and targets are communicated
back to the responsible sections.
14)Nonconformance Corrective and Preventive Action -
Nonconformance reports will be reviewed and response will be
communicated back to the report initiator.
15) Records - General record keeping requirement will be
communicated to section managers.
16) EMS audits - Results of EMS audits are communicated to upper
management and relevant section managers. Training
requirements for internal auditors and training schedules are
communicated to relevant ISO section representatives.
17) Management Review - The necessary information to carry out the
review will be communicated to upper management.
C. Facility personnel communicate to Environmental Affairs and other relevant
sections regarding the environmental management systems in the following
manner:
1) Significant Aspects - New developments that might impact the
environmental Impact Assessment Form.
2) Objectives and Targets - Relevant sections will communicate
status.
3) EMP - Relevant sections will communicate status.
4) Structure and Responsibility - Changes in the organizational
structure will be communicated from HR.
5) Training Awareness and Competency - Training personnel and
reporting results back to E/A.
6) Document Control - More specific (section) document control
requirements are communicated to those employees who have
responsibility to generate or modify documents.
7) Operational Control - Status of controlling the relevant operations
(activities).
8) Emergency Preparedness and Response - Report emergencies.
-------
9) Monitoring and Measuring - Inform E/A of the current
monitoring/measuring and calibrations being done or needing to be
done. Report appropriate monitoring and measuring results to
E/A.
10) Nonconformance Corrective and Preventive Action - Report non-
conformances and communicate new procedures or requirements
that are a result of corrective and preventive action.
11) Records - Submit Environmental related records to E/A.
12) EMS audits- Communicate results within own section and to
Environmental Affairs to promote awareness and to prevent future
occurrences.
13) Management Review - Communicate results to relevant personnel
within own sections.
a. Retention Requirement
This document will be retained until revised.
b. Special Circumstances
None.
c. Measurement of Performance
The performance of this portion of the EMS shall be measured through audits
conducted by internal auditors, audit team and 3rd party auditor of which
certification is acquired.
Appendix
N/A
-------
ENVIRONMENTAL COMMUNICATION FORM
Tracking #
Date: Extension;
Originated by: Mail Code^_
Cost Center:
Step 1. Communication Details:
(Environmental Affairs Only)
Step 2.
Recommendation
Specialist Assigned:
Responded on:
Response to Dept.:
-------
Step 3.
Dept. Response (Long Term C/M required)
Short Term C/M (Corrective Action)
Dept.
Mgr
Env Mgr
Long Term C/M (Preventive Action)
C/M Completed
C/M to be Completed Completion Date:
(Return to XXXX)
Back to Example List - Page 168
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4. 4.5 PROCEDURE FOR DOCUMENT CONTROL
Document No: EMS-4. 4. 5
Date Approved: 08/12/02
Next Revision Date: 08/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To ensure that all EMS documentation required by the ISO 14001 Standard is
established and maintained so that they can be located, periodically reviewed, and kept
up-to-date.
1.2 To ensure documentation is available at all locations where operations essential to the
effective functioning of the environmental management system are performed.
2. Scope
2.1 This policy governs the EMS documentation related to the operations and
programs conducted by [hospital name], located at [insert hospital address].
3. Responsibility
3.1 It is the responsibility of the EMS Representative and/or designate to maintain the EMS
documentation in a manner consistent with the ISO 14001 requirements.
4. Procedure
4.1 An electronic version of the EMS Policy and Procedure Manual is available to all hospital
staff on the hospitals computer system.
4.2 The EMS Representative and/or designate is the only individual with open access to the
electronic EMS Policy and Procedure Manual. The EMS Representative and/or designate
is responsible for maintaining the electronic version of the manual.
4.3 A paper copy of the EMS Policy and Procedure Manual is retained and available for use
in the EMS Representative's office.
4.3.1 Both the paper copy and electronic copy of the EMS Policy and Procedure Manual
are "Master" copies and are maintained by the EMS Representative and/or
designate.
4.3.2 If a new document supercedes an existing document, the existing document is
removed and recycled by the EMS Representative and/or designate.
4.3.3 The EMS Representative and/or designate must ensure that "Obsolete" documents
are replaced with dated "Master" copies.
Procedure for Document Control, EMS-4.4.5, Page 1 of 2
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SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
4.3.4 Documents retained for legal and/or knowledge preservation are identified in the
"Master Document Control List" (Exhibit l-EMS-4.4.5-1).
4.4 Versions or specific components of the manual are available to community members
and/or staff as "Educational/Informational Tools" only.
4.5 If at any time, an employee wishes to comment on an EMS procedure, he/she must contact
the EMS Representative to request needed changes.
4.6 If at any time an employee would like to report a nonconformance, he/she must fill out an
"Employee Incidence Report" (EMS-4.5.2), and/or inform the EMS Representative of the
occurrence.
4.7 The following is documented on the "Master Document Control List":
identification, location, current revision number, revision schedule and the retention
time of key EMS documents required to ensure compliance with the ISO 14001
Standard, and
- applicable environmental legislation, and/or potential liabilities
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001-96- Environmental Management System Standard
EPPM-4.4.3- Procedure for Communication
EPPM-4.4.4- Procedure for Environmental Management System Documentation
EPPM-4.5.2- Procedure for Nonconformance and Corrective and Preventive
Action.
7. Exhibits
Exhibit 1- EMS-4.4.5-1- Master Document Control List
Procedure for Document Control, EMS-4.4.5, Page 2 of 2
-------
Hospital Environmental Procedure
Procedure Number: Effective Date:
Title: Document Control
1 PURPOSE:
This procedure describes the process for creating, issuing and controlling
Environmental Management System (EMS) documents, both electronic and hard
copy.
2 ACTIVITIES AFFECTED:
All hospital environmental activities.
3 FORMS USED:
None.
4 REFERENCES:
4.1 Creating, Issuing, Numbering, and Controlling EMS Documents
4.2 Document and Data Control
4.3 Records Management
4.4 Internal Environmental Communications
4.5 Training
4.6 Spill Prevention Control and Countermeasures (SPCC) Plan
4.7 Computer System Disaster Recovery
4.8 Master List of Environmental Records
5. DEFINITIONS:
5.1 Document - a set of instructions, in any form, pursuant to implementing
and maintaining the established environmental management system. A
document may be initiated, revised, or deleted at any time as the situation
warrants. Examples of a document include (but are not limited to):
5.1.1 Procedure
5.1.2 Work Practice
5.1.3 Policies
5.1.4 Forms
5.1.5 SPCC Plan
5.2 Controlled document - a document subject to the creation, review,
modification, approval and distribution requirements described in this
Uncontrolled Document-Verify the latest revision date on Intranet Page:
Authorized by: Environmental Control Specialist Revision Date:
-------
procedure for local documents, or to the method employed by the activity
supplying the document. Normally, a controlled document is used to
provide instruction. The status of a document as controlled is specified on
and verified through the master Document List located on the Intranet.
5.3 Master Document List - a list identifying all controlled documents relating
to the EMS. The list contains the following items for each document:
5.3.1 The document titl e.
5.3.2 If the document is stored in a computer system, the file name for
the document.
5.3.3 The location of the master copy.
5.3.4 The latest authorized version date.
5.3.5 The user location(s).
6 EXCLUSIONS:
None.
7 PROCEDURE:
7.1 HARDCOPY CONTROLLED DOCUMENTS (SPCC PLAN ONLY):
7.1.1 The Master will be kept with the Environmental Control Specialist.
7.1.2 Controlled copies of the Master will be numbered sequentially and
identified as such on the Master Document List.
7.1.3 Changes may be requested by activity to the Environmental
Control Specialist. The Environmental Control Specialist, or his
designee, will make any required changes to the Master and will
update all controlled copies.
7.2 ELECTRONICALLY CONTROLLED DOCUMENTS (ALL EMS
DOCUMENTS EXPECT SPCC PLAN):
7.2.1 The need for a new or revised document will be communicated to
the Environmental Control Specialist.
7.2.2 The Environmental Control Specialist, or designated CFT member,
solicits comments from affected individuals or activities and drafts
the document for CFT review in accordance with Document
Control Procedure.
7.2.3 Upon CFT review and approval, the Environmental Control
Specialist or his designee authorizes the procedure and updates the
Master Document list.
7.2.4 The Environmental Control Specialist or his designee distributes
the notification of a new or revised document to all Salaried
Uncontrolled Document-Verify the latest revision date on Intranet Page:
Authorized by: Environmental Control Specialist Revision Date:
-------
7.2.5
Employees via email. Supervisors, or their designees, of hourly
employees are responsible for communicating any changes
affecting their employees to them via Training Procedure and
Internal Communication Procedure.
The latest revision date for current documents will be tabulated on
the Master Record's List.
J. GENERAL RULES:
8.2
The following must be included on any document on every page:
8.1.1 A title and/or number uniquely identified.
8.1.2 The effective, or latest revision date.
8.1.3 Identity of originating (authorizing) activity.
8.1.4 Page numbering (x of total).
For any document contained within a computer system, that computer
system must be safeguarded to prevent unauthorized use or revision, for
example by use of password protection, or encryption. This requirement
includes master copies as well as controlled copies of documents so
contained.
8.3 A controlled disk copy will be maintained by the Environmental Control
Specialist in the hospital vault.
9 ENVIRONMENTAL RECORDS:
Data and records generated by use of this procedure shall be maintained in
accordance with all Corporate, Division and Plant Records Management guidelines.
10 RECORD OF REVISIONS:
Date:
Description:
Reformatted
Rewrote the procedure to be specific to
a document system controlled on a
computer system
Entire procedure rewritten to reflect
both electronic and hard copy control.
Changes made to reflect division staff
Change Corporate to Global, and add
7.2.5
Text change
Pages affected:
All
All
All
All
All
All
Authorized by:
Uncontrolled Document-Verify the latest revision date on Intranet
Authorized by: Environmental Control Specialist
Page:
Revision Date:
-------
Title: EXHIBIT 1- EMS-4. 4.5-1 MASTER DOCUMENT CONTROL LIST
Document No: EMS-4.4.5-1
Date Approved: 08/12/02
Next Revision Date: 08/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
DOCUMENT
Manual
Distribution List
Glossary
Environmental
Policy
Procedure for
Environmental
Policy
Procedure for
Environmental
Aspects
Significance
Evaluation Criteria
for Environmental
Impacts
Environmental
Aspects & Impacts
Chart
Procedure for
Legal and Other
Requirements
Legislative,
Regulatory and
Other
Requirements for
Health Care
Environmental
Legislation &
Regulations
Procedure for
Objectives and
Targets
Objectives &
Targets Chart
Procedure for
Environmental
Management
Program(s)
Environmental
Management
Program(s)
DOCUMENT
No.
Distribution List
Glossary
EMS-4.2-1
EMS- 4.2
EMS- 4.3.1
EMS-4.3.1-1
EMS-4.3.1-2
EMS 4.3.2
EMS-4.3.2-1
N/A
EMS 4.3.3
EMS- 4.3.3-1
EMS 4.3.4
EMS 4.3.4-1
LOCATION(S)
1. EMS P&P Manual(s) (EMS
Rep's Office, Electronic)
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. EMS Records Binder
3. Main Lobby
4. Cafeteria
5. Administration Building
6. Main Elevator Landing
l.EMSP&PManual(s)
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Environmental Records Binder
(in EMS Rep's Office)
l.EMSP&PManual(s)
2. Environmental Records Binder
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Environmental Records Binder
1. Environmental Law Guide
2. Federal/Provincial Websites
3. Respective Department(s)
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Environmental Records Binder
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Environmental Records Binder
RETENTION
TIME
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain until
updated copy are
available
Retain 2 years
Retain 5 years
Retain 2 years
Retain 2 years
REVIEW
FREQUENCY
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
As Needed
Annually
Semi-Annually
Annually
Semi-Annually
-------
Procedure for
Structure and
Responsibility
Hospital
Organizational
Chart
EMS Roles &
Responsibilities
Chart
Procedure for
Training,
Awareness, &
Competence
Employee EMS
Training &
Awareness
Records Chart
Training Needs
Analysis
Worksheet
Training Records
Procedure for
Communication
Procedure for
Environmental
Management
System
Documentation
Procedure for
Document Control
Master Document
Control List
Procedure for
Operational
Control
Operational
Control &
Training
Requirements
Chart
Operational
Procedures for
Significant
Environmental
Aspects)
Procedure for
Emergency
Preparedness and
Response
Hospital
Emergency
Procedures &
Codes
EMS- 4.4.1
Jan-2002
EMS-4.4.1-2
EMS- 4.4.2
EMS-4.4.2-1
EMS- 4.4.2-2
N/A
EMS- 4.4.3
EMS- 4.4.4
EMS- 4.4.5
EMS-4.4.5-1
EMS- 4.4.6
EMS-4.4.6-1
N/A- Department
Specific
EMS-4.4.7
Code Brown
Code Red
Code Green
Code Orange
Code Black
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Electronic Version
l.EMSP&PManual(s)
l.EMSP&PManual(s)
1 . Electronic Version
l.EMSP&PManual(s)
2. Environmental Records Binder
1. Educational Services
2. Human Resources
l.EMSP&PManual(s)
l.EMSP&PManual(s)
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. EMS Records Binder
l.EMSP&PManual(s)
l.EMSP&PManual(s)
2. Environmental Records Binder
1. Departmental Procedures in
hospital computer system
2. Located in Designated
Departments
l.EMSP&PManual(s)
1. Electronic Version(s)
2. Contingency Binders in each
Department
Retain 2 years
Retain
Retain 2 years
Retain 2 years
Retain
Retain 2 years
Retain
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Retain 2 years
Annually
Annually
Annually
Annually
At Least
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Every 3 years
-------
Procedure for
Monitoring and
Measurement
Monitoring &
Measurement
Documentation
Chart
EMS Audits
Other
Environmental
Audits/Reports
Preventive
Maintenance
Records
Procedure for
Non-Conformance,
Corrective and
Preventive Action
Employee Incident
Report
Procedure for
Records
Procedure for
Environmental
Management
System Audit
EMS Audit
Checklist
Procedure for
Management
Review
Training Records
Audits (EMS,
Waste,
Compliance, etc.)
Waste Manifests
Certificate of
Approval (Air)
Radioisotope
License
Green Team-
Terms of
Reference
Code White
Code Yellow
Code Blue
EMS-4.5.1
EMS-4.5.1-1
N/A
N/A
N/A
EMS- 4.5.2
N/A
EMS- 4.5.3
EMS- 4.5.4
EMS-001
EMS- 4.6.1
N/A
N/A
N/A
N/A
N/A
N/A
l.EMSP&PManual(s)
l.EMSP&PManual(s)
1 . Environmental Audits Binder
(EMS Rep's Office)
1. Associated Departments
2. Environmental Audits Binder
1. Engineering Services
2. Associated Departments
l.EMSP&PManual(s)
1. Occupational Health Center
2. Distributed throughout
Departments
l.EMSP&PManual(s)
l.EMSP&PManual(s)
1. EMS P&P Manual(s)- Appendix
2. Environmental Audits Binder
l.EMSP&PManual(s)
1. Training Records Binder (EMS
Rep's Office)
2. Department Managers/
Supervisors Office
3. Manager, Educational Services
Office
1 . Environmental Audits Binder
(EMS Rep's Office)
1. Housekeeping Office
1. Engineering Services
1. Nuclear Medicine
1. Electronic Hospital Policy and
Procedure Manual
Retain 2 years
Retain 2 years
Retain
Retain
Retain 2 years
Retain 2 years
Retain
Retain 2 years
Retain 2 years
N/A
Retain 2 years
Retain
Retain
Retain
Retain
Retain 1 year
Annually
Annually
As Needed
As Needed
As Needed
Annually
As Needed
Annually
Annually
As Needed
Bi- Annually
As Needed
N/A
N/A
Annually
Annually
Bac . •.
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4.5.3 PROCEDURE RECORDS
Document No: EMS-4.5.3
Date Approved: 15/06/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
I. Purpose
1.1 To ensure that environmental records are established, maintained and disposed of,
in accordance with the standard.
2. Scope
2.1 This policy governs the operations and programs conducted by [hospital name],
located at [insert hospital address].
3. Responsibility
3.1 The EMS Representative is responsible for ensuring that environmental records are
readily retrievable and protected against damage and maintained in a manner
consistent with the requirements of ISO 14001.
4. Procedure
4.1 The EMS Representative and/or designate records the applicable environmental
records requiring control, proper storage, and retention in the "Document Control
Chart" (EMS- 4.4.5-1). Environmental records can include, but are not limited to
the following:
• training records,
• regulatory inspection reports,
• internal/external communication logs,
• legislative and regulatory requirements,
• inspection, calibration and maintenance activity,
• performance indicator data,
• environmental audits and management reviews,
• incident reports.
4.2 Records are located in the Environmental Performance Indicators Binder, Training
Records Binder, The Environmental Legislation and Regulations Binder, The
Environmental Audits Binder and the EMS Records Binder located in the EMS
Representative's office.
4.3 The EMS Representative is responsible for ensuring that records are stored and
maintained in a manner to ensure that they are readily retrievable and protected
against damage.
4.4 The EMS Representative is responsible for ensuring that obsolete documents are
Procedure for Records, EMS-4.5.3 Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
destroyed.
5. Definitions
5.1 Definitions relating to the content of the EMS are contained in the Glossary.
6. References
ISO 14001 - 96 - Environmental Management System Standard
EMS- 4.4.5 - Procedure for Document Control
EMS- 4.4.5-1- Document Control Chart
7. Exhibits
N/A
Procedure for Records, EMS-4.5.3 Page 2 of 2
-------
[HospitalName]
EMS Procedure
Effective Date
Subject
4.4
Records
Purpose
Stepl
Step 2
StepS
Step 4
StepS
This procedure is used to maintain EMS records.
The EMS Manager and other personnel selected by the EMS Manager are
Responsible for identifying records that are maintained by the company as
part of the EMS.
The EMS Manager and other
personnel will maintain all
records in a single location.
The EMS Manager and other
personnel will maintain a
document index of all records
that are maintained as part of
the EMS, the data and person
responsible for the length of
retention for each type of
record.
The EMS Manager and other
facility personnel will identify
and note on the document
index any restrictions on
records necessary for security.
The EMS Manager and other
facility personnel will review
the records and purge obsolete
Records at least every (insert
time frequency appropriate for
your hospital and circumstances).
Types of Records You Might Maintain (Examples):
> Legal, regulatory, and other code requirements
> Results of environmental aspects identification
> Reports of progress toward meeting objectives and
targets
> Permits, licenses, and other approvals
> Job descriptions and performance evaluations
> Training records
> EMS audit and regulatory compliance audit reports
> Reports of identified nonconformities, corrective
action plans, and corrective action tracking data
> Hazardous material spill/other incident reports
> Communications with customers, suppliers,
contractors, and other external parties
> Results of management reviews
> Sampling and monitoring data
> Maintenance records
> Equipment calibration records
Responsible Person:
Signature and Date:
-------
MASTER INDEX OF ENVIRONMENTAL RECORDS
All records are to be stored and retained in accordance with the information stated below. Refer
to the Corporate Records Manual (CRM) for any further guidance. To access the CRM
electronically, type "CRM" at the command line from the main menu on your computer desktop.
Issue Date:
All Records Stored in the Environmental Section unless otherwise noted
TYPE OF RECORD
STORAGE LOG.
RET. TIME
MEETINGS:
• Operating Review Quarterly
• Cross Functional Team
• Management Review
• Incident Management
• Waste Minimization
• Annual Energy
INSPECTIONS
• Self Assessments
• Hazardous Waste Weekly (Satellites)
• Monthly Property (Pollution)
• Agency Visits (Air)
• Agency Visits (Water)
• Hazardous Waste Storage Area
• Outside Aesthetics
File Cabinet 3
EHS Desk 3
EHS Desk 3
Security Office 3
EHS Bookshelf 3
Division Office 3
File Cabinet 3
EHS Bookshelf 3
Bookshelf 3
File Cabinet, Bookshelf 3
File Cabinet, Bookshelf 3
File Cabinet 3
Bookshelf 3
AUDIT REPORTS
• Compliance Assurance Findings/Checklist
• Agency Report
• Internal Audit Reports
* Audit Schedule
* Activity Forms
* CAR's
• Audit Results
File Cabinet 3
Bookshelf, File Cabinet 3
EHS Bookshelf 10
EHS Bookshelf 10
EHS Bookshelf 10
EHS Bookshelf 10
EHS Bookshelf 10
Uncontrolled Document - Verify the latest revision date on the Intranet
Authorized By:
Page:
Revision Date:
-------
AIR RELATED
• Air Reg's applicable to Hospital
• Certificate of Operations
• Annual Emission Statement
• Fees Paid
• Boiler Opacity
• Inspector Safety Checklist
• P.M. on Mist Collectors
• Community Right To Know (SARA)
• CFC's
* Stationary Service Records
* CFC Certifications For Mechanics
* Equipment Inventory
• Title V Permit Application
• FESOP Permit
• Boiler
* Annual Insurance Inspection
* Routine Maintenance Plant
«:« Daily Operator Logs
WATER RELATED
• Pretreatment Permit To Discharge Wastewater
• Monthly Discharge Reports
• Stormwater Permit & Summary
• Stormwater Analyses
• Report of Contact
Bookcase
Bookcase
Computer/bookshelf
Bookshelf
Bookshelf/Powerhouse
Bookshelf
Housekeeping
File cabinet/Bookshelf
Building Maintenance
Bookshelf
Building Maintenance
Book cabinet
Bookshelf
Boiler room
Boiler room
Boiler room
Bookshelf/Waste Plant
Bookshelf
Bookshelf
Bookshelf
File Cabinet/Bookshelf
Until Revised
Until Revised
O
O
3
O
3
3
Until revised
Life of equipmt.
Until revised
Until revised
Until revised
3
Until revised
3
Uncontrolled Document - Verify the latest revision date on the Intranet
Authorized By:
Page:
Revision Date:
-------
WASTE RELATED
• Manifests
* Hazardous Wastes
* Land ban
• Waste Characterizations & Analytical
• List of Industrial Waste
• Special Waste Permits
• Medical Waste Manifest
• Waste Minimization Metrics
PCS RELATED
• Report of Contact
• Notification of PCB Activity
• Annual OCB Logs
• Manifests
• Certificates of Disposal
• Spill Logs
STORAGE TANKS
• USTS
• Listings, Designations, Locations
• Annual Fees
• Release Notifications
• Financial Assurance
• Closure Reports
• Closure Approvals
• Above Ground Storage Tanks
• Listings, Designations, Locations
EMERGENCY PLANNING
• SARA Reports
• Incident Management Plan
• Spill/Emergency Plan
• Mock Incident Logs
• Community Compliant/Inquiry Concerns
FUEL & UTILITIES
• Electric Bills
• Monthly Utilities (Summary)
• Gas Contracts
• Gas Meter Readings
• Gas Nominations
• Water Bills
EHS Desk
EHS Desk
EHS Desk
EHS Desk
EHS Desk
Hospital
Bookshelf, Computer
Book
Book
Book
Book
Book
Book
cabinet
cabinet
cabinet
cabinet
cabinet
cabinet
Bookshelf
Bookshelf
Bookshelf
Bookshelf/Security
Bookshelf/Security
Security
Bookshelf
Powerhouse
Powerhouse
Powerhouse
Powerhouse
Powerhouse
Powerhouse
5
5
Until revised
Until expired
5
3
Life + 3
Life + 3
Life + 3
Life + 3
Life + 3
Life + 3
Life + 5
Life + 5
Life + 5
Life + 5
OwnershipH
Life + 5
Life + 5
Until revised
Until revised
3
Uncontrolled Document - Verify the latest revision date on the Intranet
Authorized By:
Page:
Revision Date:
-------
• Sewer Bills
• Self Reporting Data for Sewer Bills
• Coal Reports to US Department of Energy
TRAINING
• Training Matrix
• Training Content (RCRA)
• Training Attendance (RCRA)
• All Environmental Training Record
GENERAL
• Vendor Information
• Master Agreement Suppliers
• Requests for Toxicology Approval
• Inspection Issue/ Action Plan
• Annual Compliance Assurance Letter
• Environmental Checklist-New machines
• Radioactive Equipment Registrations
• Available Equipment Registration
• Ergonomic Files
• Plant Loss Control Inspections
• ISO 14001 EMS
• ISO 14001 Forms
• Community Complaints/inquiry Log
PLANT DIAGRAMS
• Natural Gas Distribution
• Water Distribution
• Underground Drainage System
• Roof Plan of Exhaust & HVAC
• Department Diagram
• Coolant System
• Industrial Washers
• Underground Electric Utilities
• Fire Loop
• Storm water Distribution
• Site Plan
• Steam Lines / Condensate Lines
• Cooling Tower Water Lines
NOTE: All retention time numbers represent
must be kept indefinitely. Files are located in
unless noted.
Powerhouse
Powerhouse
Powerhouse
Bookshelf
Bookshelf
Bookshelf
Training Dept.
File Cabinet
Bookshelf
Intranet
File Cabinet
File Cabinet
Book Cabinet
File Cabinet
Avail. Equip. Section
Safety
Supervisors
Computer & Intranet
Computer & Intranet
Bookshelf
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
Intergraph System
years and all records involved
3
O
3
3
O
3
Employ ment+3
Until revised
Until revised
3
O
3
O
Life + 3
O
3
1
3
O
3
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
Until Revised
in litigation
Chem and Met Lab Supervisors office
Uncontrolled Document - Verify the latest revision date on the Intranet Page:
Authorized By: Revision Date:
I5v,i-sk to
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
Title: EMS-4. 6 PROCEDURE FOR MANAGEMENT REVIEW
Document No: EMS-4. 6
Date Approved: 06/20/02
Next Revision Date: 06/03
Prepared By:
EMS Representative
Approved By:
EMS Management
Representative
1. Purpose
1.1 To establish a procedure to ensure that the hospital's Environmental Management System is
periodically reviewed and revised, when needed, by hospital management to ensure its
continued suitability, adequacy and effectiveness.
2. Scope
2.1 This procedure applies to all aspects of the EMS associated with the operations and programs
conducted by [insert hospital name], located at [insert hospital address].
3. Definitions
3.1 Definitions relating to the content of the EMS are contained in the Glossary.
4. Responsibility
4.1 It is the responsibility of the EMS Representative and/or designate to ensure that the EMS is
audited on a regular basis and that environmental performance data is included in the
hospital's Annual Environmental Report.
4.2 It is the responsibility of the hospital's senior management team to review, provide feedback,
and when needed, approve EMS documentation and audit findings, on a regular basis.
5. Procedure
5.1 The EMS Representative and/or designate reports on the progress of the EMS, environmental
programs, and other related initiatives to the senior management team or representative
through the hospital's monthly reporting structure.
5.2 The EMS Representative and/or designate summarizes and presents compliance and EMS audit
findings to the hospital's senior management or representative and the Green Team on a
regular basis.
5.3 The EMS Representative and/or designate utilizes the Annual Environmental Report to report
on the progress of environmental objectives and targets (EMS-4.3.3), environmental
performance indicators, and appropriateness of the hospital's Environmental Policy (EMS-
4.2).
5.4 The senior management team provides the initial review and approval of the Annual
Environmental Report. The resulting changes are then incorporated into the report by the EMS
Representative before the report is passed on to other hospital committees and groups.
5.5 Feedback from the Senior Management Team and other interested parties is incorporated into
the process of setting and reviewing environmental objectives and targets (EMS-4.3.3) by the
hospital's Green Team.
Procedure for Management Review, EMS-4.6, Page 1 of 2
-------
SAMPLE HOSPITAL ENVIRONMENTAL PROCEDURE
6. References
ISO 14001 - 96 - Environmental Management System Standard
EMS-4.2 - Procedure for Environmental Policy
EMS- 4.3.3-Procedure for Environmental Objectives and Targets
7. Exhibits
N/A
Procedure for Management Review, EMS-4.6, Page 2 of 2
-------
EMS Procedure: Environmental Management System Audits
I. Purpose
To define the process for conducting periodic audits of the environmental
management system (EME). The procedure defines the process for scheduling,
conducting, and reporting of EMS audits.
II. Scope
This procedure applies to all internal EMS audits conducted at [hospital name].
The scope of EMS audits may cover all activities and processes comprising the EMS
or selected elements thereof.
III. General
Internal EMS audits help to ensure the proper implementation and maintenance of the
EMS by verifying that activities conform with documented procedures and that
corrective action are undertaken and are effective.
All audits are conducted by trained auditors. Auditor training is defines by Procedure
#. Records of auditor training are maintained in accordance with Procedure #.
When a candidate for EMS auditor is assigned to an audit team, the Lead Auditor will
prepare an evaluation of the candidate auditor's performance following the audit.
The ISO Management Representative is responsible for maintaining EMS audit
records, including a list of trained auditors, auditor training records, audit schedules
and protocols, and audit reports.
EMS audits are scheduled to ensure that all EMS elements and plant functions are
audited at least once each year.
The ISO Management Representative is responsible for notifying EMS auditors of
any upcoming audits a reasonable time prior to the scheduled audit date. Plant areas
and functions subject to the EMS audit will also be notified a reasonable time prior to
the audit.
The Lead Auditor is responsible for ensuring that the audit, audit report and any
feedback to the plant areas or functions covered by the audit is completed per the
audit schedule.
The ISO Management Representative, in conjunction with the Lead Audit, is
responsible for ensuring that Corrective Action Notices are prepared for audit finings,
as appropriate.
-------
IV. Procedure
A. Audit Team Selection - One or more auditors comprise an audit team. When the
team consists of more than one auditor, a Lead Auditor will be designated. The
Lead Auditor is responsible for audit team orientation, coordinating the audit
process, and coordinating the preparation of the audit report.
B. Audit Team Orientation - The Lead Auditor will assure that the team is adequately
prepared to initiate the audit. Pertinent policies, procedures, standards, regulatory
requirements and prior audit reports are made available for review by the audit
team. Each auditor will have appropriate audit training, as defined by Procedure #.
C. Written Audit Plan - The Lead Auditor is responsible for ensuring the preparation
of a written plan for the audit. The Internal EMS Audit Checklist may be used as a
guide for this plan.
D. Prior Notification - The plant areas and / or functions to be audited are to be
notified a reasonable time prior to the audit.
E. Conducting the Audit
1. A pre-audit conference is held with appropriate personnel to review the scope,
plan and schedule for the audit.
2. Auditors are at liberty to modify the audit scope and plan if conditions warrant.
3. Objective evidence is examined to verify conformance to EMS requirements,
including operating procedure. All audit findings must be documented.
4. Specific attention is given to corrective actions for audit findings from previous
audits.
5. A post-audit conference is held to present audit findings, clarify any
misunderstandings, and summarize the audit results.
F. Reporting Audit Results
1. The Team Leader prepares the audit report, which summarizes the audit scope,
identifies the audit team, describes sources of evidence used, and summarizes the
audit results.
2. Findings requiring corrective action are entered into the corrective action
database.
G. Audit Report Distribution
1. The ISO Management Representative is responsible for communicating the audit
results to responsible area and / or functional management. Copies of the audit
report are made available by the ISO Management Representative.
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2. The ISO Management Representative is responsible for ensuring availability of
audit reports for purpose of the annual Management review (see Procedure #).
H. Audit Follow-up
1. Management in the affected areas and / or functions are responsible for any
follow-up actions needed as a result of the audit.
2. The ISO Management Representative is responsible for tracking the completion
and effectiveness of corrective actions.
I. Record Keeping
1. Audit reports are retained for at least two years from the date of audit
completion. The ISO Management Representative is responsible for maintaining
such records.
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Hospital Environmental Procedure
Procedure Number: Effective Date:
Title: Management Review of Environmental Systems
1 PURPOSE:
This procedure establishes the [hospital] method of performing management review of the
environmental management system.
2. ACTIVITIES AFFECTED:
All environmental management system components.
3 FORMS USED:
None.
4 REFERENCES:
4.1 EMS Master Document List
4.2 Management Review Procedure
5 DEFINITIONS:
OCM: Operating committee for this process shall include but not necessarily be limited
to Facility Manager, Quality Manager, Engineering Manager, Area Managers, Employee
Relations Manager, Controller, ordesignees.
6 EXCLUSIONS:
None.
7 PROCEDURE:
7.1 The Environmental Management Representative will schedule a meeting for the
CFT to present the Environmental Management System (EMS) for OCM review
at least once each year.
7.2 The CFT will review the following items as appropriate prior to the OCM
management review meeting:
7.2.1 All documents included in the document control procedure.
7.2.2 Regulatory and other requirement which shall include:
7.2.2.1 Any breach of permits
7.2.2.2 Status of agency approvals
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7.2.2.3 Notification of unauthorized releases
7.2.2.4 Compliance with hospital and environmental plan
7.2.2.5 Major incidents
7.2.2.6 Corrective and preventive action status
7.2.3 Progress against objectives, targets and programs.
7.2.4 Complaints and internal and external communications.
7.2.5 Environmental aspects and any trends in significant aspects that alter the
environmental performance at the plant.
7.2.6 Environmental training and awareness initiatives.
7.2.7 Area and site wide summaries of aspects.
7.2.8 Auditing schedule and findings.
7.2.9 Structure and responsibility.
7.2.10 Emergency preparedness and response.
7.2.11 Evaluation and trends of the plant waste matrix such as reductions or
increases in wastes.
7.3 The Cross Functional Team (CFT) shall develop a review presentation of
the EMS for the OCM based upon the above review.
7.4 The OCM shall evaluate the policy, objectives and other elements of the
EMS for continued suitability, adequacy and effectiveness. If changes are
required the OCM shall issue directives to the CFT to identify and
implement corrective and preventive actions as well as assign
responsibilities for implementing of those actions.
7.5 The Environmental Control Specialist shall be responsible for recording
meeting minutes, identifying issues discussed, corrective and preventive
actions and responsibilities.
8 GENERAL RULES:
None.
9 ENVIRONMENTAL RECORDS:
Meeting agendas, attendance records and records of the minutes from the management review
shall be kept in accordance to Corporate Records Management (CRM) Retention Schedule
and kept with CFT meeting minutes.
10 RECORD OF REVISIONS:
Date:
Description:
Reformatted
Add Environmental Management
Representative to 7.1
Change case in 7.2
Modify 7.2.6, add 7.2. 11
Pages affected:
All
All
All
All
Authorized by:
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[HospitalName]
EMS Procedure
Effective Date
Subject
4.6
Administration Review
Purpose The purpose of this procedure is to document the process and primary agenda of
issues to be included in the Administration Review meetings for evaluating the
organization's EMS. The Administration Review process is intended to provide
a forum for discussion and improvement of the EMS and to provide management
with a vehicle for making any changes to the EMS necessary to achieve the
organization's goals.
Step 1 The EMS Manager is responsible for scheduling and conducting a
minimum of two Administration Review meetings during each 12-month period.
The EMS Manager is also responsible for ensuring that the necessary data and
other information are collected prior to the meeting.
Step 2 At a minimum, each Administration Review meeting will consider the
following:
* The suitability, adequacy and effectiveness of the environmental policy.
* The suitability, adequacy and effectiveness of the environmental objectives
(as well as the organization's current status against these objectives)
* The overall suitability, adequacy and effectiveness of the EMS
* The status of corrective and preventive actions and the results of any EMS
audit conducted since the last Administration Review meeting
* The suitability, adequacy and effectiveness of training efforts
* The results of any action items from the previous Administration Review
meeting
Step 3 Minutes will be taken of the Administration Review. These meeting
minutes will include, at a minimum, a list of attendees, a summary of key issues
discussed, and any action items arising from the meeting.
Step 4 A copy of the meeting minutes will be distributed to attendees and any
individuals assigned action items. A copy of the meeting minutes will be
retained on file.
Back to Example List - Page 168
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Continual Improvement
You now know all the EMS components and hopefully have a good beginning to your
EMS. Remember, it all starts with identifying your hospital's environmental aspects and
impacts, determining which are most significant, and then identifying performance-based
objectives and targets. Operational controls such as work instructions help achieve these
objectives and targets and minimize significant impacts. Monitoring and measurement asks you
to track your progress against both of these, making sure you are making positive environmental
progress. Compliance auditing checks your performance against one component of
environmental performance—your regulatory requirements. Your EMS audits are different from
your compliance audits. EMS audits drive continual improvement by checking the system's
performance against how you said the system would work and, in the case of an ISO 14001-
aligned EMS, against the ISO 14001 standard. Audit findings you address through
corrective/preventive action are opportunities for improvement and help improve your system
and environmental performance. As you accomplish objectives and targets, reconsider your list
of aspects. It is a good source of ideas for new objectives and targets, particularly if you are
updating the list to reflect changes in your hospital's activities, products, and services. This
drives continual improvement.
Continual improvement is one of the key differentiators of an EMS from the compliance-
based approach to environmental management. Remember the concept of continual
improvement as you start your system. Your system does not have to be 100% perfect out of the
gate. There will be things you want to change and improve. Your EMS audits can help identify
these opportunities. EMS audits will likely focus more on documentation and things to fix
related to the system, but as your system matures, you should see your audits shift towards
assessment of actual environmental performance. This is key. The system is a means to the end
of improved environmental performance, not an end in and of itself.
Greater employee involvement, particularly beginning with management, is a second key
differentiator of an EMS-based approach to environmental management. Without employee and
top management involvement and support, the EMS will not generate significant environmental
improvement or better results over the current management system. Employees and
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management can be a source of direction for sustainable improvement and long-term value
creation.
Organizations are discovering that their investments in EMSs are leading to improved
environmental performance and compliance with benefits for both the environment, hospital, and
surrounding community. We hope this manual serves as a useful resource in EMS
implementation at your hospital and that you see the same rewards from an EMS as we have
seen in many other organizations.
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Resources
General Pollution Prevention Resources
Articles/Periodicals
"The Mercury Sphygmomanometer Should Be Abandoned Before it is Proscribed."
Journal of Human Hypertension. Volume 14, pages 31 through 36. N.K. Markandu, F.
Whitcher: A.Arnold and C.Carney.
"Pollution Prevention Review: Special Focus: P2 and Hospital Waste." John Wiley &
Sons, Inc. Volume 11, Number 3, Summer 2001.
Books
Nadakavukaren, Anne. Our Global Environment: A Health Perspective. 1995. A
comprehensive survey of the major environmental issues facing healthcare industry.
Written in easy to understand language, with dual emphasis on the ecological impact of
human activities with specific issues of personal and community health.
Check Lists
Environmental Self-Assessment for Health Care Facilities. New York State Department
of Environmental Conservation Pollution Prevention Unit. February, 2000.
A quick and easy checklist of pollution prevention measures for health care facilities.
Fact Sheets
Best Management Practices for Hospitals and Medical Facilities. Palo Alto Regional
Water Quality Control Plant. Ken Torke. September 1994. These best management
practices encompass the metal pollutants of concern in hospitals from the South San
Francisco Bay Area.
Case Studies in Hospital Solid Waste Reduction and Recycling: Reusable Totes, Blue
Bag Wrap Recycling, and Composting: Environmental Best Practices for Health Care
Facilities. Spring 2002. U.S. EPA. Contains three hospital case studies covering
reusable totes, blue sterile wrap and plastic film recycling, and composting.
Eliminating Mercury in Hospitals: Environmental Best Practices for Health Care
Facilities. Spring 2002. U.S. EPA. Excellent fact sheet outlining sources of mercury in
hospitals,efficacy and cost data for mercury-free sphygomanometers, and three case
studies summarizing successes, costs and lessons learned by hospitals accomplishing
mercury reduction.
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Replacing Ethylene Oxide and Glutaraldehyde with Environmentally Preferrable
Sterilants/Disinfectants: Environmental Best Practices for Health Care Facilities. Spring
2002. U.S. EPA. Contains case studies on hospitals reducing use of ethylene oxide and
glutaraldehyde.
Using Microfiber Mops in Hospitals: Environmental Best Practices for Health Care
Facilities. Spring 2002. U.S. EPA. Provides focus on often overlooked aspect of
hospital pollution prevention: janitorial cleaning products. Hospital case studies provide
cost data from water and chemical savings associated with switching to microfiber mops
in hospitals. Labor savings included.
Guides
Environmental Management Guide for Small Laboratories. U.S. EPA Small Business
Division. Washington, DC. May 2000.
Guide to Mercury Assessment and Elimination in Healthcare Facilities
(www.getf.org/file/toolmanager/O16F8459.pdf) Medical Waste Management Program,
Department of Health Services: State of California. September, 2000.
Guide to Pollution Prevention: Selected Hospital Waste Streams: Risk Reduction
Engineering Laboratory. The Center for Environmental Research Information, June 1990,
EPA/625/7/-90/009.
Guidebook for Hospital Waste Reduction Planning and Program Implementation.
American Society for Healthcare Environmental Services of the American Hospital
Association. Chicago, IL. 1996.
Mercury Pollution Prevention in Healthcare. National Wildlife Federation. Guy
Williams. 1997. A guide to help hospitals and their employees in their effort to become
mercury free.
Mercury: In Your Community and the Environment. Wisconsin Department of Natural
Resources. October, 1998.
NYC WasteLe$$: Hospital Waste Prevention and Energy Conservation Guidance
Document. City of New York Department of Sanitation, U.S. EPA, New York State
Energy Research and Development Authority. February 2001.
2000 PBT Program Accomplishments. Office of Pollution Prevention and Toxics. U.S.
EPA. EPA-742-R-01-003. November 2001.
Pollution Prevention Guide for Hospitals (excluding medical wastes), California
Environmental Protection Agency, Department of Toxic Substances Control, Office of
Pollution Prevention and Technology Development, May 1998.
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Manuals
An Organizational Guide to Pollution Prevention. U.S. EPA. Office of Research and
Development. EPA/625/R-01/003. August 2001.
Code Green P2 Strategies for Health Care.
(www.cornet.nf.ca/web/acapha/projects/documents/hospital book.pdf) This manual
provides hospitals a good overview of important pollution prevention areas based on
Canadian resources.
Reducing Mercury Use in Health Care: Promoting a Healthier Environment A "How-to"
Manual, Monroe County Department of Health and the Monroe County Department of
Environmental Services, NY. Manual addresses how to establish a mercury pollution
prevention program in hospitals, a list of mercury-containing products and associated best
management practices, and case studies of successful hospital mercury reduction efforts.
U.S. EPA Buy Clean Training Manual for Eastern Kentucky School Districts. Developed
by the Kentucky Pollution Prevention Center. October 2001.
Waste Management Strategies for Hospitals and Clinical Laboratories. Pollution
Prevention Program, North Carolina Dept. of Environment, Health, and Natural
Resources. May 1992.
Writing a Waste Reduction Plan for Health Care Organization. The University of
Tennessee Center for Industrial Services. This handbook was designed to help your
hospital comply with the Tennessee Hazardous Waste Reduction Act of 1990, Resource
Conservation and Recovery Act (RCRA), and help you identify and assess pollution
prevention and waste reduction options.
Reports
HealthSystem Minnesota Mercury Reduction. Holly J. Baron. Minnesota Technical
Assistance Program. 2000.
Websites
American Hospital Association (www.aha.org).
California Department of Health Services, Medical Waste Management Program.
(http://www.dhs.ca.gov/ps/ddwem/environmental/med_waste/medwasteindex.htm). This
web page provides guidelines for proper handling and disposal of medical waste in
California.
The Candadian Centre for Pollution Prevention (http://www.c2p2online.com)'s
Healthcare Environet is an excellent hospital resource. Healthcare Environet offers
information on management tools including audits, environmental management systems,
health and safety programs, pollution prevention plans and emergency response plans;
-------
numerous case studies; and networks and programs to keep connected with
environmental practitioners and activities in the health care sector.
The Canadian Coalition for Green Healthcare (http://www.greenhealthcare.ca) includes
case studies, an environmentally preferred list of PVC-free and mercury suppliers, and
links to additional green health care web sites.
Complianceinfo.com provides compliance news, newsletters, and other resources to
covering a wide variety of general hospital compliance issues. The website address is
www.complianceinfo.com
Environmental Working Group (www.ewg.org) The Environmental Working Group
(EWG) is a not-for-profit environmental research organization dedicated to improving
public health and protecting the environment by reducing pollution in air, water and food.
Health Care Case Studies in Oregon.
(www.deq.state.or.us/wmc/solwaste/cwrc/cstudy/healthcare.html). Several documented
cases of pollution prevention and cost savings in Oregon.
The Healthcare Compliance Association's (http://www.hcca-info.org/) mission is to
champion ethical practice and compliance standards in the health care community and to
provide the necessary resources for compliance.
Health Care Resource Conservation Coalition (www.albanyonline.com/hrcc/). This site
provides resources to exchange information and establish best management practices in
the relating to healthcare waste
Health Care Without Harm (http://www.noharm.org). This website features new
resources including 'Going Green: A Resource Kit for Pollution Prevention in Health
Care" and links to PVC and mercury publications, videos and web resources.
Hospitals for a Healthy Environment (www.h2e-online.org) is a voluntary partnership of
the US EPA, American Hospital Association, Health Care Without Harm, and the
American Nurses Association pledged to eliminate mercury use by 2005 and reduce all
hospital waste by 50% by 2010. The website offers excellent resources to achieve these
objectives including lists of mercury-containing items, persistent bioaccumulative toxins,
green cleaning products, and links to pollution prevention providers, consultants, mercury
recyclers, and many other resources.
Kentucky Hospital Association (www.kyha.com). The KY Hospital Association
provides information for Kentucky Hospitals.
Medical and Scientific Community Organization Mercury Work Group
(http://www.masco.org/mercury/index.htm) has excellent mercury management and
mercury-free resources including a mercury management guidebook and a searchable
database of mercury-free products.
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Minnesota Technical Assistance Program (http://www.mntap.umn.edu/). This web page
offers answers to questions regarding disposal of some common medical-related waste
streams.
The Nightingale Institute for Health and the Environment (www.nihe.org) web page
provides resources including manuals, news, tools for environmentally responsible
nurses, and a new tool for environmentally preferable health care purchasing called the
HCEPT Tool.
Northwest Guide to Pollution Prevention by the Healthcare Sector
(http://www.pprc.org/pprc/pubs/topics/healthcare.html). This site has an extensive list of
resources in one place.
PBT/mercury reduction resources are accessible through www.kppc.org under Technical
Resource (Links |P2 for Healthcare Organizations.
Pollution Prevention Tips for Healthcare Providers.
(www.montana.edu/~wwwated/healthcare.htm). This Montana Pollution Prevention
Program lists tips, additional resources, and more information about pollution prevention.
Small Business Assistance Programs (SBAPs) were created as a result of the Clean Air
Act Amendments of 1990 requirement that all States develop a program to assist small
businesses in meeting the requirements of the Act. Since then, most of these programs
have expanded to provide assistance in other environmental areas, including waste and
waste issues. SBAPs provide free, non-regulatory environmental compliance and
pollution prevention assistance to small businesses. The program provides small
businesses with partnership-based compliance support, education, outreach and
advocacy. This EPA web link
(http://www.epa.gov/reg3ecej/compliance_assistance/hospitals.htm) provides a listing of
key state contacts for compliance assistance.
Small Business Environmental Assistance Home Page (http://www.smallbiz-
enviroweb.org/ pub sector, asp). Click on 'hospitals/medical' in the search box. While
many articles are dental are pollution prevention-related, there are several focusing on
compliance and disposal options associated with medical waste.
The Sustainable Hospitals website (www.sustainablehospitals.org) provides technical
support to the healthcare industry for selecting products and work practices that reduce
occupational and environmental hazards, maintain quality patient care, and contain costs.
U.S. EPA's Environmentally Preferable Purchasing (EPP) website
(www.epa.gov/oppt/epp) is an excellent resource. Among the tools on this web page
include EPP general training tools, a database of information of contacts for
environmentally preferable products and services, and a practices guide for 'greener'
contracts.' The best one-stop shop for any and all EPP needs.
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U.S. EPA's Mercury web Site, (www.epa.gov/mercury). This site provides background
information, Agency actions taken on mercury, fish advisory information, as well as
downloadable research and technical materials.
U.S. EPA's Mercury in Medical Facilities.
(www.epa.gov/seahome/mercury/src/outmerc.htm). This is an interactive environmental
education software program developed jointly by Purdue University and the U.S. EPA to
provide information on the proper handling and disposal of mercury wastes produced by
medical facilities.
U.S EPA Office of Solid Waste (http://www.epa.gov/epaoswer/osw/ stateweb.htm) This
web page provides link to state solid waste programs.
U.S. EPA's Office of Pollution Prevention and Toxics (OPPT) PBT Program Web site.
www.epa.gov/pbt. A wealth of information on EPA initiatives, goals, regulatory
activities, voluntary partnerships, and links to technical materials and
environmental/health effects associated with PBT's.
U.S. EPA sponsors approximately 89 hotlines and clearinghouses that provide free and
convenient avenues to obtain assistance with environmental requirements. Key hotlines
that may be of interest to include the following:
RCRA/UST/CERCLA Hotline (800) 424-9346
Toxics Substances and Asbestos Information (202) 554-1404
Stratospheric Ozone/CFC Information (800) 296-1996
Clean Air Technical Center (919) 541 -0800
Waste Reduction Activities for Hospitals.
(www.ciwmb.ca.gov/BIZWASTE/factsheets/hospital.htm). This site provides extensive
information in a number of areas related to waste reduction activities for hospitals as well
as many valuable statistics encouraging for hospitals success in waste reduction.
The Waste Reduction Resource Center (http://wrrc.p2pays.org/industry/hospital.htm)
provides resources for hospitals and medical facilities including web sites, manuals,
articles and reports, fact sheets, video tapes, and case studies.
Waste Reduction Tips for Healthcare/Medical.
(www.deq. state.or.us/wmc/solwaste/cwrc/wrstrategy/healthcarestrategy.html) This site
provides waste reduction tips in the pharmacy, x-ray, custodial, purchasing, supplies, and
cafeteria. There are also recycling and composting tips.
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Energy Efficiency Resources
Hospitals exhibit unique energy demands and specifications. Not only do
hospitals operate 24 hours a day, 7 days a week, but also must typically heat and cool
very large areas. Hospitals also have energy-intensive activities such as medical
equipment, laundry and kitchen services, sterilization, and use of large quantities of hot
water. Fulfilling these needs can consume large amounts of energy; consequentially,
energy offers very worthwhile cost savings opportunities. Here are a few resources
focused on hospital energy efficiency.
Energy Efficiency in Health Care Facilities: A Hot Opportunity to Chill. Philip J.
Kercher. September 1999. Available through the American Hospital Association (800)-
242-2626, or visit the American Hospital Association web site at
www.ahaonlinestore.com. Manual describes preventative maintenance, performance
contracting, and energy management teams as component of successful energy
management. Reviews three programs along with costs and benefits.
Managing Utility Cost in a Health Care Facility. Michael Brian Cotton. August, 1999.
Available through the American Hospital Association (800) 242-2626 or visit the
American Hospital Association web site at www.ahaonlinestore.com. Manual describes
energy controls and management opportunities available to hospital facility managers.
Energy Savings in Hospitals. Caddett Analyses Series 20. June 1996. Available for
purchase through the American Council for an Energy Efficient-Economy.
http://www.aceee.org/index.htm
EnergyStar for Hospitals. Among the useful tools at this website are energy and water
efficiency case studies. Also available is a bench mark tool for Cancer Care,
Rehabilitation, and Psychiatric Centers, and Skilled Nursing Facilities. The tool is an
easy way to evaluate and compare energy performance against others across the country.
Environmental Management Accounting
Guides, Articles, and Manuals
Accounting and Capital Budgeting for Pollution Prevention. Martin A. Spitzer, Robert
Pojasek, Francis L. Robertaccio, Judith Nelson. Pollution Prevention in South Carolina.
Winter 1996.
An Introduction to Environmental Accounting As A Business Management Tool: Key
Concepts and Terms. U.S. EPA, Design for the Environment Program, Environmental
Accounting Project.
Set Up a Waste Accounting System to Track Pollution Prevention. Chemical
Engineering Process. Donald C. Nizolek and W. Corey Trench, Mary E. McLearn.
August 1994.
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Total Cost Assessment: Accelerating Industrial Pollution Prevention Through Innovation
Project Financial Analysis. U.S. EPA Office of Pollution Prevent! on. May 1992.
Websites
Environmental Management Accounting Network, (www.uni-lueneburg.de/eman/).
Environmental Management Accounting Research and Information Center.
(www. emaweb site. org/).
Environmental Management Indicators and Environmental Accounting.
(www.kirin.co.jp/english/company/env/p 12_13.html).
EPA Victoria, Australia. Environmental Management Accounting Project.
(http://www.epa.vic.gov.au/Programs/ema.asp).
Environmental Management Initiatives: Minolta. (www.minolta.com/pdf/env_l 1-
16.pdf).
Tellus Institute: Business and Sustainability Group, Introduction to Environmental
Management Accounting. (http://www.tellus.org/b&s/EMA_intro.html).
United Nations Sustainable Development Environmental Accounting Initiative.
(http://www.un.org/esa/sustdev/estemal.htm).
U.S. EPA's Design for the Environment, (http://www.epa.gov/opptintr/dfe/index.htm).
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"
Kentucky Pollution Prevention Center
Environmental Management Systems
(EMS) Auditing Tool
Date:
Audit Team:
Lead Auditor:
Facility Name:
Facility Location:
.Facility Representative:
Opening meeting:
• Brief introduction and background of auditors
• Review scope (this plant)
• Intent is to collect objective evidence to assess whether organization has a EMS.
• Does the system conform to the ISO 14001 standard?
• Is the system documented where required?
• Does the work agree with the documented/undocumented system?
• Do records show the system works?
• Review audit plan and timetable. There will be a closing meeting each day of the audit to review the sections covered. At the end of the audit,
there will be a final closing meeting with a preliminary written report for the plant before the audit team leaves.
• Establish communication links between audit team and auditee.
• Confirm needed resources and facilities are available.
• Confirm date and time of closing meeting.
• Review relevant site safety and emergency procedures with audit team.
KPPC EMS/ISO 14001 AUDITING TOOL
©Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 Section 4.2 - Environmental Policy: Top management shall define the organization's environmental policy and ensure that it:
a) is appropriate to the nature, scale and environmental impacts of its activities, products or services; b) includes a commitment to
continual improvement and prevention of pollution; c) includes a commitment to comply with relevant environmental legislation and
regulations, and with other requirements to which the organization subscribes; d) provides the framework for setting and reviewing
environmental objectives and targets; e) is documented, implemented, maintained and communicated to all employees; f) is available to
the public.
4.2 Environmental policy
This section requires the organization's top management to define, document, maintain, implement, and communicate an environmental policy that
includes a commitment to continual improvement, prevention of pollution, and a commitment to comply with legal and other requirements.
1.1 Has top management defined the organization's environmental policy?
Note(s) Observations and Recommendations Score
Who is top management? Has it been defined in system?
Objective evidence includes meeting minutes showing top
management attendees and policy review and approval.
Signature(s) by top managers) on written policy.
1.2 Is the policy appropriate to the nature and scale of the organization's activities, products, and services?
Note(s) Observations and Recommendations Score
Corporate policies handed down to the facility may not
be appropriate to organization's activities, products, or services.
KPPC EMS/ISO 14001 AUDITING TOOL
©Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.3 Check to ensure the policy includes:
a) A commitment to continual improvement.
b) A commitment to prevention of pollution.
c) A commitment to comply with relevant environmental legislation and regulations and other requirements to which the organization subscribes, that are
applicable to the environmental aspects of its activities, products, or services?
Note(s) Observations and Recommendations Score
1.4 Does the policy provide a framework for setting and reviewing the organization's environmental objectives and targets?
Note(s)
Observations and Recommendations
Score
Score 0=environmental policy does not guide setting
of objectives and targets. Policy written in a way that
leaves readers confused.
Score l=Policy is specific enough to guide setting of
environmental objectives and targets for most aspects;
most of policy understandable to interested parties
Score 2=policy clear and specific to guide setting of
environmental objectives and targets; policy
understandable to interested parties.
1.5 Is the policy documented?
NoteCs)
Observations and Recommendations
Score
KPPC EMS/ISO 14001 AUDITING TOOL
©Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.6 Is the policy implemented and maintained?
Note(s) Observations and Recommendations Score
Is there evidence of discussion of possible need to change
policy? Organization may review policy and progress toward
objectives and targets annually as part of management
review (4.6). Review meetings may have documented
agendas and minutes indicating preventive and corrective
action.
1.7 Is the policy communicated to all employees?
Note(s) Observations and Recommendations Score
Objective evidence that the policy has been
communicated would include employee answers to
questions under 4.4.2 training, awareness, and
competence. Others include documented training
agendas and course materials, policy postings on bulletin
boards throughout production and common areas,
electronic access from workstations, publications, hardhat
stickers, policy on back of ID badges.
KPPC EMS/ISO 14001 AUDITING TOOL
©Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.8 How do you make the policy available to the public?
Note(s) Observations and Recommendations Score
Objective evidence would include policy posted in lobby,
on brochure in lobby, newspaper clippings, handouts at
community events, etc.
KPPC EMS/ISO 14001 AUDITING TOOL
©Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 4.3 - Planning: Section 4.3.1 - Environmental Aspects: The organization shall establish and maintain (a) procedure(s) to
identify the environmental aspects of its activities, products or services that it can control and over which it can be expected to have an
influence, in order to determine those which have or can have significant impacts on the environment. The organization shall ensure that
the impacts related to these significant aspects are considered in setting its environmental objectives. The organization shall keep this
information up-to-date.
4.3.1 Environmental aspects
This section requires the organization to establish and maintain a procedure for the identification of environmental aspects that could have a
significant impact on the environment. Aspect information is required to be kept up-to-date.
2.1 Does the organization have a procedure to identify environmental aspects of plant's activities, products and services, which it can control
and have influence over?
Note(s) Observations and Recommendations Score
1) If no written procedure present, ask how organization
identifies its aspects and assess whether the process
could be duplicated in a controlled and consistent
manner.
2) Relevant records demonstrating application of
procedure include aspect identification worksheets,
meeting minutes from departmental teams identifying
environmental aspects, etc.
3) Are there design, procurement, distribution, product
use and end-of-life issues mentioned in the aspects
procedure?
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2.2 How do you determine significance of aspects/impacts?
Note(s) Observations and Recommendations Score
Was significance of aspects determined in
conformance with the procedure?
2.3 Have environmental aspects which have significant environmental impacts been considered in setting objectives?
Note(s) Observations and Recommendations Score
2.4 Is aspect information up-to-date?
Note(s) Observations and Recommendations Score
1) How frequently is it reviewed (at least annually)?
How are new activities, products, and services
handled within the EMS?
2) Look to see review is occurring as stated and as often
as stated. Examples of objective evidence includes
records of periodic review. This review is commonly
done by environmental staff or functional areas or
Management Review (4.6).
3) New activities, products, and services may be
handled through periodic reviews performed by
environmental staff or functional areas or
Management Review (4.6).
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ISO 14001 4.3 Planning: Section 4.3.2 - Legal and other requirements: The organization shall establish and maintain a procedure to
identify and have access to legal and other requirements which the organization subscribes, that are applicable to the environmental
aspects of its activities, products or services.
4.3.2 Legal and other requirements
Section 4.3.2 requires the organization to have procedures in place to identify and have access to legal and "other" requirements to which the
organization subscribes. 'Other' requirements include industry codes of practice, voluntary waste minimization/pollution prevention programs
such as Project XL, and corporate policies.
3.1 Does the organization have a procedure to identify/have access to legal requirements that relate to environmental aspects of organization's
activities, products, and services?
Note(s) Observations and Recommendations Score
1) If no written procedure present, ask how organization
identifies its legal requirements and assess whether
the process could be duplicated in a controlled and
consistent manner.
2) Choose a requirement that the organization
determined was not applicable. Ask them to show
how they made this determination.
3) Objective evidence that legal requirements have been
identified may include a list/matrix of applicable
regulatory requirements. Pick 2 or 3 legal
requirements and ask auditee to show regulatory text
that is applicable. Is it done how the procedure says
it would be done? Objective evidence for access to
legal requirements includes corporate counsel,
ongoing subscriptions to BNA, CD-ROM's, Internet
bookmarks, corporate headquarters legal staff, CFRs
present during audit, and EPA compliance audits and
results.
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3.2 Does the organization have a procedure to identify/have access to other requirements (relating to environmental aspects of activities,
products, services) to which the organization may subscribe?
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.3.3 - Objectives and Targets: The organization shall establish and maintain documented environmental objectives
and targets, at each relevant function and level within the organization. When establishing and reviewing its objectives, an organization
shall consider the legal and other requirements, its significant environmental aspects, its technological options and its financial,
operational and business requirements, and the views of interested parties. The objectives and targets shall be consistent with the
environmental policy, including the commitment to prevention of pollution.
4.3.3 Objectives and targets
Section 4.3.3 specifies several factors that must be considered for setting objectives and targets. These include, significant environmental aspects,
legal and other requirements, views of stakeholders, technology, financial, operational and other business issues. ISO 14001 also requires the
objectives and targets to link to the environmental policy, and be established at every relevant function and level in the organization.
4.1 Does the organization have documented objectives and targets?
Note(s) Observations and Recommendations
Score
4.2 Are the objectives and targets established at each relevant function and level within the organization?
Note(s)
Observations and Recommendations
Score
This requirement is most commonly addressed in the
documentation through a statement indicating that
objectives and targets apply throughout the organization.
Objective evidence will come through questioning
employees on their knowledge.
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4.3 How were each of the following considered in establishing and reviewing objectives:
a) Legal requirements?
b) Other requirements?
c) Significant environmental aspects?
d) Technological options?
e) Financial requirements?
f) Operational requirements?
g) Business requirements?
h) Views of interested parties?
Note(s) Observations and Recommendations Score
4.4 Who are the organization's external interested parties? How did you consider their views in setting your objectives and targets?
Note(s) Observations and Recommendations Score
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4.5 Has responsibility for establishing and maintaining documented objectives and targets been assigned?
Note(s) Observations and Recommendations Score
1) Tell me how you review your objectives and targets.
How frequently are they reviewed? Who reviews and
approves the objectives and targets?
2) Look to see review is occurring as stated and as often
as stated. Examples of objective evidence includes
records of periodic review of the procedure. This
review is commonly done by environmental staff or
Management Review (4.6) but frequency of review
should be specified.
4.6 Are objectives and targets consistent with the environmental policy, including commitment to prevention of pollution?
Note(s) Observations and Recommendations Score
4.7 Is reasonable progress being made in accomplishing objectives and targets?
Note(s) Observations and Recommendations Score
1) Review quarterly or annual reports on objectives and
targets when auditing Management Review 4.6. Have
they been reviewed by management? Are corrective
actions being implemented that improve the chances
of meeting targets for the objectives?
2) Progress toward objectives and targets may provide
objective evidence of 4.2 Environmental Policy
continual improvement.
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4.8 As objectives and targets are met, are new ones established?
Note(s) Observations and Recommendations Score
1) As objectives and targets are achieved, are new ones
established? This would be objective evidence for
continual improvement under 4.2(b) and (d).
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ISO 14001 Section 4.3.4 - Environmental Management Program(s): The organization shall establish and maintain (a) program(s) for
achieving its objectives and targets. It shall include: a) designation of responsibility for achieving objectives and targets at each relevant
function and level of the organization; b) the means and time frame by which they are to be achieved. If a project relates to new
developments and new or modified activities, products or services, program(s) shall be amended where relevant to ensure that
environmental management applies to such projects.
4.3.4 Environmental management program(s)
This section requires the organization to establish programs for achieving its objectives and targets. The program requirement specifically includes
designation of responsibility at each relevant function and level in the organization, and the means and time frame by which these objectives are to
be achieved. The program is also required to address new activities, products, or services.
5.1 Has the organization established an environmental management program(s) for achieving its objectives and targets?
Note(s) Observations and Recommendations Score
5.2 Has responsibility for achieving objectives and targets at each relevant function and level of the organization been established in the BMP?
Note(s) Observations and Recommendations Score
Pick 2 or 3 objectives and ask auditee to describe which
plant areas are affected by each target/objective.
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5.3 Has the organization specified the time frames by which objectives and targets will be achieved?
Note(s) Observations and Recommendations Score
Do key personnel know relevant timeframes for achieving
objectives and targets? This can be objective evidence of
4.4.2 (d) and 4.4.3 (a).
5.4 Has the organization specified how objectives and targets will be achieved?
Note(s) Observations and Recommendations Score
Objective evidence can include work instructions.
Objective evidence of financial means would include
budgets for EMPs, line item in accounting budget for EMS
or EMP expenditures, staffing plans and vacancies in the
environmental programs.
5.5 How is progress toward objectives and targets measured?
Note(s) Observations and Recommendations Score
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5.6 Does the organization maintain/review programs for achieving objectives and targets?
Note(s) Observations and Recommendations Score
This review may be mentioned under 4.3.3 Objectives and
targets. Examples of objective evidence include records
of periodic review. This review is commonly done by
environmental staff or Management Review (4.6). Look to
see how often review will be conducted.
5.7 When new or modified activities, products or services are implemented, how do you ensure that environmental management applies to these
projects?
Note(s) Observations and Recommendations Score
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ISO 14001 4.4 Implementation and Operation: Section 4.4.1 - Structure and Responsibility: Roles, responsibilities and authorities shall
be defined, documented and communicated in order to facilitate effective environmental management. Management shall provide
resources essential to the implementation and control of the environmental management system. Resources include human resources and
specialized skills, technology and financial resources. The organization's top management shall appoint (a) specific management
representative(s) who, irrespective of other responsibilities, shall have defined roles, responsibilities and authorities for: a) ensuring that
environmental management system requirements are established, implemented and maintained in accordance with this standard; b)
reporting on the performance of the environmental management system to top management for review and as a basis for improvement of
the environmental management system.
4.4.1 Structure and responsibility
This section requires the organization to formally and clearly define, document, and communicate environmental responsibilities, and to assign a
management representative with responsibility for overseeing the overall implementation of the EMS.
6.1 Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done) documented?
If not documented, have environmental roles been defined?
Note(s) Observations and Recommendations Score
6.2 Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done)
communicated?
Note(s) Observations and Recommendations Score
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6.3 Have adequate resources (human, skills, technology, and financial) been provided for the implementation and control of the EMS?
Note(s) Observations and Recommendations Score
How are human, financial, and technological resources
allocated/provided to the EMS? Objective evidence of
financial support would include line item in accounting
budget or an account number for EMS expenditures.
6.4 Has top management appointed an EMS management representative?
Note(s) Observations and Recommendations Score
Be sure to look for documentation/record of appointment
of top management representative (e.g., in a letter or
memo of commitment from President/General Manager or
an organization chart that shows roles and
responsibilities).
6.5 Do the roles and responsibilities of the management's representative(s) fulfill the duties described in Section 4.4.1 a) and b) of the Standard?
Note(s) Observations and Recommendations Score
Top management shall appoint representatives who ensure
EMS requirements are established, implemented, and
maintained" (a) and who report the performance of the EMS
to top management (b). See 6.4 above.
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ISO 14001 Section 4.4.2 - Training, Awareness and Competence: The organization shall identify training needs. It shall require that all
personnel, whose work may create a significant impact upon the environment, receive appropriate training. It shall establish and
maintain procedures to make its employees or members at all relevant levels aware of: a) the importance of conformance with the
environmental policy and procedures and with the requirements of the environmental management system; b) the significant
environmental impacts, actual or potential, of their work activities and the environmental benefits of improved personal performance; c)
their roles and responsibilities in achieving conformance with the environmental policy and procedures, and with the requirements of the
environmental management system including emergency preparedness and response requirements; d) the potential consequences of
departure from specific operating procedures.
Personnel performing tasks which can cause significant environmental impacts shall be competent on the basis of appropriate education,
training and/or experience.
4.4.2 Training, awareness, and competence
This section requires the organization to evaluate and implement specific training activities for those personnel at each relevant function and level,
whose job activities could have a significant impact on the environment. Training is required to include general environmental awareness, and job
specific training.
7.1 Has the organization identified what job functions may have a significant impact on the environment? How does organization identify EMS
training needs?
Note(s) Observations and Recommendations Score
1) Sample-check that personnel (preferably a key line
operator, manager, and supervisor) whose work can
have a significant impact on the environment have
been identified.
2) Objective evidence can include lists of positions
within the organization and associated training needs,
procedures for training, as well as organization charts.
3) Documentation should link personnel whose work can
have a significant impact on the environment to the
training they receive.
4) Was the training delivered? Look at training records
(4.5.3), agendas, class materials/training curricula to
verify what was covered in the training.
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7.2 Has the organization established a procedure to make its employees aware of the following?
a) The importance of conformance with the environmental policy, procedures, and requirements of the EMS.
b) The significant actual and potential impacts of their work and the benefits of improved personal performance.
c) Their roles and responsibilities in achieving conformance with the environmental policy, procedures, EMS, and emergency preparedness and
response procedures.
d) The potential consequences of departure from specified operating procedures.
Note(s) Observations and Recommendations Score
7.3 How does the organization assess competence of personnel whose work can cause significant environmental impacts?
Note(s) Observations and Recommendations Score
7.4 Have training needs for the EMS representative been determined?
Note(s) Observations and Recommendations Score
Verify whether the EMS representative received this
training? Ask for EMS representative's training records
(4.5.3).
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7.5 Who else provides training that is required? How were they trained or qualified to be a trainer?
Note(s) Observations and Recommendations Score
a) Ask to see objective evidence of training received and
competency.
b) If experience is called out as the basis of competency,
follow up with questions: how many years of
experience required? How do you decide 'how much'
experience is enough? What qualifies as experience?
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ISO 14001 Section 4.4.3 - Communication: With regard to its environmental aspects and environmental management system, the
organization shall establish and maintain procedures for: a) internal communication between various functions and levels of the
organization; b) receiving, documenting and responding to relevant communication from external interested parties.
The organization shall consider processes for external communication on its significant environmental aspects and record its decision.
4.4.3 Communication
This section requires the organization to establish and maintain procedures for communicating its aspects and elements of the environmental
management system to external interested parties. It also requires the organization to consider a process for communicating to external parties
about its significant aspects, and record its decision.
8.1 Is there a procedure for internal communication of the EMS and the environmental aspects between the various levels and functions of the
organization?
Note(s) Observations and Recommendations Score
1) If yes, is communication occurred as indicated in the
procedure?
2) Any of the following may be sample items that a
facility may point to as examples of how internal
communication occurs: training-related materials,
agendas, sign-up sheets, and overheads from
environmental meetings.
3) A common nonconformance is that documented
internal communications were required under the
Standard but transmitted verbally.
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8.2 Is there a procedure for receiving, documenting and responding to communications from external interested parties regarding the
organization's environmental aspects and EMS?
Note(s) Observations and Recommendations Score
1) There are three things to look for: how it receives,
documents, and responds to the request.
2) Have you received any external requests for
information? If yes, ask/look to see how these have
been handled in the system. Is it how they said it
would be handled? Was it documented? Responded
to in the required or reasonable period of time? One
test would be to call ahead to ask for significant
aspects. When on-site, verify that your request has
been handled within the system. A common example
of an external request is a sister facility calling for
information on the EMS.
8.3 Has the organization has documented a decision as to whether or not it will communicate information on its aspects and EMS to external
interested parties.
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.4.4 - Environmental Management System Documentation: The organization shall establish and maintain
information, in paper or electronic form, to: a) describe the requirements of the management system and their interaction, b) provide
direction to related documentation.
4.4.4 Environmental management system documentation
This section requires the organization to maintain documentation (electronically or written) which describes the core elements of the EMS, their
interaction, and directions to related documentation.
9.1 Is there documentation describing the core elements of the EMS and their interaction?
Note(s) Observations and Recommendations Score
There are a variety of ways to show interaction among the
elements: references within the procedures (probably
most common), flowcharts, procedural matrices, EMS
table of contents or Master Document Control List.
9.2 Does the scope of the EMS documentation and related documents cover all elements of the ISO 14001 standard? Does documentation
provide direction to related documents?
Note(s) Observations and Recommendations Score
Related documentation may include internal standards
and operational procedures, process information, site
emergency plans, etc.
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ISO 14001 Section 4.4.5 - Document Control: The organization shall establish and maintain procedures for controlling all documents
required by this standard to ensure that: a) they can be located; b) they are periodically reviewed, revised as necessary and approved for
adequacy by authorized personnel; c) the current versions of relevant documents are available at all locations where operations essential
to the effective functioning of the system are performed; d) obsolete documents are promptly removed from all points of issue and points
of use or otherwise assured against unintended use; e) any obsolete documents retained for legal and/or knowledge preservation purposes
are suitably identified. Documentation shall be legible, dated (with dates of revision) and readily identifiable, maintained in an orderly
manner and retained for a specified period. Procedures and responsibilities shall be established and maintained concerning the creation
and modification of the various types of documents.
4.4.5 Document control
This section requires the organization to establish and maintain procedures for controlling documentation related to the EMS.
This section is largely audited while looking at other system requirements.
Generally speaking, if a paper/reference is being used to answer an auditor question, to support the system or to communicate information
regarding the system, it should be in document control and meet document control requirements.
10.1 Does the organization have a procedure for controlling documents required by ISO 14001?
Note(s) Observations and Recommendations Score
10.2 Does the procedure ensure that:
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a) Documents are locatable?
b) Documents are periodically reviewed, revised as necessary, and approved for adequacy by authorized personnel?
c) Current versions of relevant documents are available at all locations where operations essential to the effective functioning of the EMS are
performed?
d) Obsolete documents are promptly removed from all points of issue and use, or otherwise protected from unintended use?
e) Obsolete documents retained for legal and/or knowledge preservation purposes are suitably identified?
Note(s) Observations and Recommendations Score
10.3 Has responsibility for fulfilling document control responsibilities been assigned?
Note(s) Observations and Recommendations Score
10.4 Is documentation legible?
Note(s) Observations and Recommendations Score
10.5 Does documentation have dates of revision?
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Note(s)
Observations and Recommendations
Score
10.6 Is documentation readily identifiable?
Note(s)
Observations and Recommendations
Score
10.7 Is documentation maintained in an orderly manner?
Note(s) Observations and Recommendations
Score
10.8 Is documentation retained for a specific period?
Note(s) Observations and Recommendations
Score
10.9 Are there assigned responsibilities for creating and modifying EMS documents?
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Note(s) Observations and Recommendations Score
10.10 Is there/are there procedure(s) for creating and modifying EMS documents?
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.4.6 - Operational Control: The organization shall identify those operations and activities that are associated with the
identified significant environmental aspects, in line with its policy, objectives and targets. The organization shall plan these activities,
including maintenance, to ensure that they are carried out under specified conditions by: a) establishing and maintaining documented
procedures to cover situations where their absence could lead to deviations from the environmental policy and the objectives and targets
b) stipulating operating criteria in the procedures; c) establishing and maintaining procedures related to the significant environmental
aspects of goods and services used by the organization and communicating relevant procedures and requirements to suppliers and
contractors.
4.4.6 Operational control
This section requires the organization to identify operations and activities that are associated with the significant aspects, then document
procedures whenever the absence of documented procedures could result in deviations from the environmental policy and objectives and targets.
All operational control procedures should have operating criteria spelled out. There should be procedure(s) for communicating applicable and
relevant operational procedures and requirements to suppliers and contractors.
11.1 Has the organization identified operations and activities associated with its identified significant environmental aspects?
Note(s) Observations and Recommendations Score
11.2 Has the organization established documented work instructions and procedures to cover situations where their absence could lead to
deviations from the environmental policy, objectives and targets?
Note(s) Observations and Recommendations Score
Sample several operations and activities associated with
significant aspects. Verify that the procedures tell
"how-to".
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11.3 Has the organization established operating criteria in the work instructions and procedures?
Note(s) Observations and Recommendations Score
11.4 Are relevant documented procedures available at locations where these operations and activities are performed?
Note(s) Observations and Recommendations Score
Is maintenance crew on spill response team? Is
emergency preparedness and response procedure
available at this workstation?
11.5 Has responsibility for implementing these work instructions and procedures been assigned?
Note(s) Observations and Recommendations Score
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11.6 Has responsibility for periodically reviewing and updating these work instructions and procedures been assigned?
Note(s) Observations and Recommendations Score
Tell me how you maintain the procedure. How frequently
is it maintained/reviewed? Look to see review is
occurring as stated and as often as stated. Examples of
objective evidence include records of periodic review.
This review is commonly done by environmental staff or
Management Review (4.6) but frequency of review should
be specified.
11.7 Has the organization established and maintained procedure(s) related to the identifiable significant environmental aspects of goods and
services used by the organization? How are these communicated to suppliers and contractors?
Note(s) Observations and Recommendations Score
1) Show me some of the relevant procedures and
requirements you have for your suppliers and
contractors.
2) Organization should have a procedure that identifies
suppliers (i.e. those whose goods and services are
related to significant aspects) and provides for
communicating relevant procedures and requirements
to these suppliers.
3) Record of this training/external communication could
include mailing of aspect/impact/objectives and
targets/sheet with signed confirmation back to
organization.
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ISO 14001 Section 4.4.7 - Emergency Preparedness and Response: The organization shall establish and maintain procedures to identify
potential for and respond to accidents and emergency situations, and for preventing and mitigating the environmental impacts that may
be associated with them. The organization shall review and revise, where necessary, its emergency preparedness and response
procedures, in particular, after the occurrence of accidents or emergency situations. The organization shall also periodically test such
procedures where applicable.
4.4.7 Emergency preparedness and response
This section requires the organization to establish and maintain procedures for identifying and responding to potential accidents and emergency
situations; preventing and mitigating associated environmental impacts. The organization shall review procedures especially after accidents and
emergency, and revise procedures where necessary.
12.1 Has the organization established a procedure to identify the potential for accidents and emergency situations?
Note(s) Observations and Recommendations Score
Has the organization defined accidents and emergencies?
12.2 Does the procedure address how the organization will respond to accidents and emergency situations so as to prevent and mitigate the
associated environmental impacts?
Note(s) Observations and Recommendations Score
Objective evidence of how the organization would respond
include referenced SPCC Plans, RCRA Hazardous Waste
plans, Stormwater Pollution Prevention Plans, etc.
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12.3 Are emergency preparedness and response procedures available in applicable operational areas?
Note(s) Observations and Recommendations Score
Check during tour, while interviewing key employees.
12.4 Are the procedures maintained, reviewed and updated regularly and when necessary, particularly after the occurrence of accidents or
emergency situations?
Note(s) Observations and Recommendations Score
Have any accidents or emergencies occurred? If so, may
want to see if organization reviewed its procedures. What
would guide decision to review and update the procedure?
Look at incident investigation results and corrective
actions. If one of the potential accidents occurred, what
would be the steps that would be followed for reviewing
and revising the procedures.
12.5 Does the organization periodically test these procedures where practicable? Has responsibility been assigned in these circumstances?
Note(s) Observations and Recommendations Score
Some organizations say: "The organization shall
periodically test such procedures where practicable." How
do you determine if it is practicable to test the procedure?
If practicable, when were they last tested. Look for log of
last test date and time.
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ISO 14001 4.5 Checking and Corrective Action: Section 4.5.1 - Monitoring And Measurement: The organization shall establish and
maintain documented procedures to monitor and measure, on a regular basis, the key characteristics of its operations and activities that
can have a significant impact on the environment. This shall include the recording of information to track performance, relevant
operational controls and conformance with the organization's objectives and targets. Monitoring equipment shall be calibrated and
maintained, and records of this process shall be retained according to the organization's procedures. The organization shall establish and
maintain a documented procedure for periodically evaluating compliance with relevant environmental legislation and regulations.
4.5.1 Monitoring and measurement
This section requires the organization to establish and maintain documented procedures to monitor and measure the key characteristics of
operations and activities that are related to the significant aspects. This should include a requirement for documented procedures for compliance
auditing and monitoring equipment maintenance and calibration.
13.1 Has the organization established documented procedures to monitor and measure on a regular basis the key characteristics (as determined in
4.4.6) of its operations and activities that can have a significant impact on the environment?
Note(s) Observations and Recommendations Score
How do you monitor and measure operations and activities
that can have a significant impact on the environment?
What are the measurements you use that show you are
making progress toward your objectives and targets?
13.2 Does the procedure include requirements for recording information to track performance, relevant operational controls, and conformance
with the organization's objectives and targets?
Note(s) Observations and Recommendations Score
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13.3 Is there a procedure for calibrating and maintaining monitoring equipment?
Note(s) Observations and Recommendations Score
13.4 Are records of calibration and maintenance retained according to the organization's procedures?
Note(s) Observations and Recommendations Score
13.5 Has the organization established a documented procedure for periodically evaluating compliance with relevant environmental legislation and
regulations?
Note(s) Observations and Recommendations Score
1) Procedure should specify how and when compliance
will be evaluated.
2) Verify that compliance evaluations have been
performed as described and at specified time
intervals. Objective evidence includes internal and
external compliance audit reports.
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ISO 14001 Section 4.5.2 - Nonconformance,, Corrective and Preventative Action: The organization shall establish and maintain
procedures for defining responsibility and authority, for handling and investigating nonconformance, taking action to mitigate any
impacts caused by non-conformances and for initiating and completing corrective and preventative action. Any corrective or
preventative action taken to eliminate the causes of actual and potential non-conformances shall be appropriate to the magnitude of
problems and commensurate with the environmental impact encountered.
4.5.2 Nonconformance and corrective and preventive action
This section of the ISO 14001 requires that the organization identify the causes of nonconformance, identify and implement the necessary
corrective action, implement or modify controls necessary to avoid repeating the nonconformance, and record any changes in written procedures
resulting from the corrective action.
14.1 Does the organization have a procedure that defines responsibility and authority for:
a) Handling and investigating nonconformance, including determining root cause of the nonconformance?
b) Taking action to mitigate impacts caused by non-conformances?
c) Initiating and completing corrective and preventive action?
Note(s) Observations and Recommendations Score
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14.2 Has corrective or preventive action (if any) taken been appropriate to the magnitude of the problem and commensurate with the
environmental impacts?
Note(s) Observations and Recommendations Score
If so, was the nonconformance/suggestion handled
according to procedure? Has the organization
implemented and recorded any changes in the
documented procedures resulting from the corrective and
preventive action?
14.3 Has the organization implemented and recorded any changes in the documented procedures resulting from the corrective and preventive
action?
Note(s) Observations and Recommendations Score
1) Have appropriate changes have been carried through
the system and made in documented procedures,
training, relevant work instructions/procedures, etc.
2) If no non-conformances, have there been any
suggestions brought forward to improve the system?
Is there a mechanism, perhaps as part of 4.4.3
Communication, whereby employees can bring
forward suggestions for the EMS? Suggestions
brought forward and handled appropriately in the
system can be objective evidence of a procedure in
place to handle corrective and preventive action. Ask
to see related forms and records. Related records
could include action request forms, action request
logs, etc.
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14.4 Has responsibility for the following been assigned?
a) Handling and investigating nonconformance's
b) Taking action to mitigate impacts of nonconformance's
c) Initiating and completing corrective and preventive action
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.5.3 - Records: The organization shall establish and maintain procedures for the identification, maintenance and
disposition of environmental records. These records shall include training records and the results of audits and reviews. Environmental
records shall be legible, identifiable and traceable to the activity, product or service involved. Environmental records shall be stored and
maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss. Their retention times
shall be established and recorded. Records shall be maintained, as appropriate to the system and to the organization, to demonstrate
conformance to the requirements of this standard.
4.5.3 Records
This section requires the organization to establish and maintain procedures for handling environmental records. Records are used to show that the
organization is doing what procedures said would be done.
15.1 Has the organization established procedures to identify, maintain and dispose of environmental records?
Note(s) Observations and Recommendations Score
Training records, EMS audit records, and management
review records are the minimum system records that must
be kept. See that these are referenced from the
Record(s) procedure.
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15.2 Has responsibility for maintenance and disposition of records been assigned?
Note(s) Observations and Recommendations Score
1. Are records identified, maintained, and disposed of as
indicated in the procedure?
Note: Sample check records to verify that records
are being kept in accordance with the written
retention times.
2. How frequently is it maintained/reviewed? Look
to see review is occurring as stated and as often as
stated. Examples of objective evidence include
records of periodic. This review is commonly done
by environmental staffer Management Review (4.6)
but frequency of review should be specified.
15.3 Do environmental records in the procedure include training records and the results of audits and reviews?
Note(s) Observations and Recommendations Score
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15.4 Are environmental records:
a) Legible?
b) Identifiable?
c) Traceable to the activity, product, or service involved?
d) Readily retrievable?
e) Protected against damage, deterioration, or loss?
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.5.4 - Environmental Management System Audit: The organization shall establish and maintain programs and
procedures for periodic environmental management system audits to be carried out, in order to: (a) determine whether or not the
environmental management system: 1) conforms to planned arrangements for environmental management including the requirements of
this standard; 2) has been properly implemented and maintained; (b) provide information on the results of audits to management. The
audit program, including any schedule, shall be based on the environmental importance of the activity concerned and the results of
previous audits. In order to be comprehensive, the audit procedures shall cover the audit scope, frequency and methodologies, as well as
the responsibilities and requirements for conducting audits and reporting results.
4.5.4 Environmental management system audits
This section requires the organization to establish and maintain procedures and programs for periodic audits of the EMS.
16.1 Has the organization established a procedure/program for periodic EMS audits?
Note(s) Observations and Recommendations Score
16.2 Does the audit procedure/program:
a) Determine whether or not the EMS conforms to planned arrangements for environmental management including ISO 14001?
b) Determine whether the EMS has been properly implemented and maintained?
c) Address how audit information is provided to management?
Note(s) Observations and Recommendations Score
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16.3 Do audit procedures address the following:
a) Audit scope?
b) Audit frequency? (Note: Does the audit program and procedure provide for audit frequency and scope appropriate to the importance of the
activity concerned and results of previous audits? A follow-up question may ask how the organization takes importance of the activity and
results of previous audits into consideration when determining audit frequency.)
c) Audit methodologies?
d) Responsibilities and requirements for conducting and reporting audit results?
Note(s) Observations and Recommendations Score
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ISO 14001 4.6 Management Review: The organization's top management shall, at intervals it determines, review the environmental
management system, to ensure its continuing suitability, adequacy and effectiveness. The management review process shall ensure that
the necessary information is collected to allow management to carry out this evaluation. This review shall be documented. The
management review shall address the possible need for changes to policy, objectives and other elements of the EMS, in the light of
environmental management system audit results, changing circumstances and the commitment to continual improvement.
4.6 Management review
This section requires the organization's top management to periodically review the EMS for suitability and effectiveness, and to make changes to
the system where appropriate. This review must be documented.
17.1 Is there a procedure for top management review to ensure EMS suitability, adequacy, and effectiveness?
Note(s) Observations and Recommendations Score
17.2 Does the procedure address what will be reviewed?
Note(s) Observations and Recommendations Score
17.3 Has top management determined the frequency of the reviews?
Note(s) Observations and Recommendations Score
Look to see where top management determined how often
it meets for management review.
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17.4 Are EMS audit results reviewed during management review?
Note(s) Observations and Recommendations Score
17.5 Does management review address possible need for changes to the environmental policy, objectives, and other elements of the EMS?
Note(s) Observations and Recommendations Score
17.6 Has top management participated in the review?
Note(s) Observations and Recommendations Score
Verify that all procedures to be reviewed during
management review are in fact reviewed at this time.
Verify that possible need for changes to policy, objectives,
etc., have been considered. Make sure these are
documented as having been considered.
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Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
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3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence for
4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
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6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
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8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
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Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
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3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence for
4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
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6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
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8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
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Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
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3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence for
4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
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6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
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8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
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Solid Waste and Emergency Response
(5305W)
EPA530-K-05-012
Introduction to
Hazardous Waste
Identification
(40 CFR Parts 261)
United States
Environmental Protection
Agency
September 2005
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HAZARDOUS WASTE IDENTIFICATION
CONTENTS
1. Introduction 1
2. Regulatory Overview 2
2.1 Hazardous Waste Identification Process 2
2.2 Definition of Hazardous Waste 3
2.3 Listed Hazardous Wastes 5
2.4 Characteristic Hazardous Wastes 13
2.5 Wastes Listed Solely For Exhibiting the Characteristics of Ignitability,
Corrosivity, and/or Reactivity 17
2.6 The Mixture and Derived-from Rules 17
2.7 The Contained-in Policy 21
3. Regulatory Developments 24
3.1 The Hazardous Waste Identification Rules 24
3.2 Final Hazardous Waste Listing Determinations 25
3.3 Proposed Revision of Wastewater Treatment Exemption for Hazardous
Waste Mixtures 25
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Hazardous Waste Identification -1
1. INTRODUCTION
"Is my waste a hazardous waste regulated under the Resource Conservation and Recovery Act
(RCRA)?" This is one of the most common and basic RCRA questions and is the key to the
RCRA hazardous waste program. If something is not a hazardous waste, it is not regulated under
RCRA. Proper identification of a hazardous waste can be a difficult and confusing task, as the
RCRA regulations establish a complex definition of the term "hazardous waste." To help make
sense of what is and is not a hazardous waste, this module presents the steps involved in the
process of identifying, or "characterizing," a hazardous waste.
While introducing the entire hazardous waste identification process, this module will focus on
the final steps, the definition of a hazardous waste. The other steps in the process, including the
definition of solid waste and the solid and hazardous waste exclusions will be discussed in other
modules.
After reading this module, you will be able to explain the hazardous waste identification process
and the definition of hazardous waste, and be familiar with the following concepts:
• hazardous waste listings
• hazardous waste characteristics
• the "mixture" and "derived-from" rules
• the "contained-in" policy
• the Hazardous Waste Identification Rules (HWIR).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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2 - Hazardous Waste Identification
2. REGULATORY OVERVIEW
What is a hazardous waste? In its most basic form, the answer to that question can be quite
simple. A hazardous waste is a waste with a chemical composition or other properties that make
it capable of causing illness, death, or some other harm to humans and other life forms when
mismanaged or released into the environment. Developing a regulatory program that ensures the
safe handling of such dangerous wastes, however, demands a far more precise definition of the
term. EPA therefore created hazardous waste identification regulations that outline a process to
determine whether any particular material is a hazardous waste for the purposes of RCRA.
2.1 HAZARDOUS WASTE IDENTIFICATION PROCESS
Proper hazardous waste identification is essential to the success of the hazardous waste
management program. The RCRA regulations at 40 CFR §262.11 require that any person who
produces or generates a waste must determine if that waste is hazardous. In doing so, §262.11
presents the steps in the hazardous waste identification process:
• Is the waste a "solid waste"?
• Is the waste specifically excluded from the RCRA regulations?
• Is the waste a "listed" hazardous waste?
• Does the waste exhibit a characteristic of hazardous waste?
When faced with the question of whether or not a waste is regulated as hazardous under RCRA,
turn to §262.11. This regulation will remind you of the four steps in the RCRA hazardous waste
identification process.
IS THE WASTE A SOLID WASTE?
Hazardous waste identification begins with an obvious point: in order for any material to be a
hazardous waste, it must first be a waste. But, deciding whether an item is or is not a waste is not
always easy. For example, a material (like an aluminum can) that one person discards could seem
valuable to another person who recycles that material. EPA developed a set of regulations to assist
in determining whether a material is a waste. RCRA uses the term "solid waste" in place of the
common term "waste." Under RCRA, the term "solid waste" means any waste, whether it is a
solid, semisolid, or liquid. The first section of the RCRA hazardous waste identification
regulations focuses on the definition of solid waste. For this module, you need only understand in
general terms the role that the definition of solid waste plays in the RCRA hazardous waste
identification process. Another module, Definition of Solid Waste and Hazardous Waste
Recycling, explains the definition of solid waste in greater detail.
IS THE WASTE EXCLUDED?
Only a small fraction of all RCRA solid wastes actually qualify as hazardous wastes. At first
glance, one would imagine that distinguishing between hazardous and nonhazardous wastes is a
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 3
simple matter of chemical and toxicological analysis. Other factors must be considered,
however, before evaluating the actual hazard that a waste's chemical composition poses.
Regulation of certain wastes may be impractical, unfair, or otherwise undesirable, regardless of
the hazards they pose. For instance, household waste can contain dangerous chemicals, like
solvents and pesticides, but making households subject to the strict RCRA waste management
regulations would create a number of practical problems. Congress and EPA exempted or
excluded certain wastes, like household wastes, from the hazardous waste definition and
regulations. Determining whether or not a waste is excluded or exempted from hazardous waste
regulation is the second step in the RCRA hazardous waste identification process. Only after
determining that a solid waste is not somehow excluded from hazardous waste regulation should
the analysis proceed to evaluate the actual chemical hazard that a waste poses. The module
entitled Solid and Hazardous Waste Exclusions explains which wastes are excluded from
hazardous waste regulation.
IS THE WASTE A LISTED HAZARDOUS WASTE, OR DOES IT EXHIBIT A
CHARACTERISTIC?
The final steps in the hazardous waste identification process determine whether a waste actually
poses a sufficient chemical or physical hazard to merit regulation. These steps in the hazardous
waste identification process involve evaluating the waste in light of the regulatory definition of
hazardous waste. The remainder of this module explains the definition of hazardous waste in
detail.
2.2 DEFINITION OF HAZARDOUS WASTE
A discussion of the definition of hazardous waste should begin with Congress' original statutory
definition of the term. RCRA §1004(5) defines hazardous waste as:
A solid waste, or combination of solid waste, which because of its quantity,
concentration, or physical, chemical, or infectious characteristics may (a) cause,
or significantly contribute to, an increase in mortality or an increase in serious
irreversible, or incapacitating reversible, illness; or (b) pose a substantial present
or potential hazard to human health or the environment when improperly treated,
stored, transported, or disposed of, or otherwise managed.
This broad statutory definition provides a general indication of which wastes Congress intended
to regulate as hazardous, but it obviously does not provide the clear distinctions necessary for
industrial waste handlers to determine whether their wastes pose a sufficient threat to warrant
regulation or not. Congress instructed EPA to develop more specific criteria for defining
hazardous waste. There are therefore two definitions of hazardous waste under the RCRA
program: a statutory definition and a regulatory definition. The statutory definition cited above
is seldom used today. It served primarily as a general guideline for EPA to follow in developing
the regulatory definition of hazardous waste. The regulatory definition is an essential element of
the current RCRA program. It precisely identifies which wastes are subject to RCRA waste
management regulations.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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4 - Hazardous Waste Identification
Congress asked EPA to fulfill the task of developing a regulatory definition of hazardous waste
by using two different mechanisms: by listing certain specific wastes as hazardous and by
identifying characteristics which, when present in a waste, make it hazardous. Following its
statutory mandate, EPA developed a regulatory definition of hazardous waste that incorporates
both listings and characteristics.
HAZARDOUS WASTE LISTINGS
A hazardous waste listing is a narrative description of a specific type of waste that EPA
considers dangerous enough to warrant regulation. Hazardous waste listings describe wastes
from various industrial processes, wastes from specific sectors of industry, or wastes in the form
of specific chemical formulations. Before developing a hazardous waste listing, EPA thoroughly
studies a particular wastestream and the threat it can pose to human health and the environment.
If the waste poses enough of a threat, EPA includes a precise description of that waste on one of
the hazardous waste lists in the regulations. Thereafter, any waste fitting that narrative listing
description is considered hazardous, regardless of its chemical composition or any other potential
variable. For example, one of the current hazardous waste listings reads as: "API separator
sludge from the petroleum refining industry." An API separator is a device commonly used by
the petroleum refining industry to separate contaminants from refinery wastewaters. After
studying the petroleum refining industry and typical sludges from API separators, EPA decided
these sludges were dangerous enough to warrant regulation as hazardous waste under all
circumstances. The listing therefore designates all petroleum refinery API separator sludges as
hazardous. Chemical composition or other factors about a specific sample of API separator
sludge are not relevant to its status as hazardous waste under the RCRA program.
Using listings to define hazardous wastes presents certain advantages and disadvantages. One
advantage is that listings make the hazardous waste identification process easy for industrial
waste handlers. Only knowledge of a waste's origin is needed to determine if it is listed;
laboratory analysis is unnecessary. By comparing any waste to narrative listing descriptions, one
can easily determine whether or not the waste is hazardous. EPA's use of listings also presents
certain disadvantages. For example, listing a waste as hazardous demands extensive study of
that waste by EPA. EPA lacks the resources to investigate the countless types of chemical
wastes produced in the United States - the hazardous waste listings simply cannot address all
dangerous wastes. Another disadvantage of the hazardous waste listings is their lack of
flexibility. Listings designate a waste as hazardous if it falls within a particular category or class.
The actual composition of the waste is not a consideration as long as the waste matches the
appropriate listing description. For instance, some API separator sludges from petroleum
refining might contain relatively few hazardous constituents and pose a negligible risk to human
health and the environment. Such sludges are still regulated as hazardous, however, because the
listing for this wastestream does not consider the potential variations in waste composition.
Thus, the hazardous waste listings can unnecessarily regulate some wastes that do not pose a
significant health threat. It is also possible for industries to substantially change their processes
so that wastes would no longer meet a listing description in spite of the presence of hazardous
constituents. The hazardous waste characteristics provide an important complement to listings
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 5
by addressing most of the shortcomings of the listing methodology of hazardous waste
identification.
HAZARDOUS WASTE CHARACTERISTICS
A hazardous waste characteristic is a property which, when present in a waste, indicates that the
waste poses a sufficient threat to merit regulation as hazardous. When defining hazardous waste
characteristics, EPA does not study particular wastestreams from specific industries. Instead,
EPA asks the question, "what properties or qualities can a waste have which cause that waste to
be dangerous?" For example, EPA found that ignitability, or the tendency for a waste to easily
catch fire and burn, is a dangerous property. Thus, ignitability is one of the hazardous waste
characteristics and a waste displaying that property is regulated as hazardous, regardless of
whether the waste is listed. When defining hazardous waste characteristics, EPA identifies,
where practicable, analytical tests capable of detecting or demonstrating the presence of the
characteristic. For instance, EPA regulations reference a laboratory flash point test to be used
when deciding if a liquid waste is ignitable. Whether or not a waste displays a hazardous
characteristic generally depends on how it fares in one of the characteristics tests. Therefore, the
chemical makeup or other factors about the composition of a particular waste typically determine
whether or not it tests as hazardous for a characteristic.
Using characteristics to define hazardous wastes presents certain advantages over designating
hazardous wastes by listings. One advantage is that hazardous characteristics and the tests used
to evaluate their presence have broad applicability. Once EPA has defined a characteristic and
selected a test for use in identifying it, waste handlers can evaluate any wastestream to see if it is
classified as a hazardous waste. Furthermore, use of characteristics can be a more equitable way
of designating wastes as hazardous. Instead of categorizing an entire group of wastes as
hazardous, characteristics allow a waste handler to evaluate each waste sample on its own merits
and classify it according to the actual danger it poses. Aware of these advantages, EPA
originally planned to use characteristics as the primary means of identifying hazardous waste.
EPA hoped to define and select test methods for identifying all hazardous characteristics,
including organic toxicity, mutagenicity (the tendency to cause mutations), teratogenicity (the
tendency to cause defects in offspring), bioaccumulation potential, and phytotoxicity (toxicity to
plants). EPA encountered problems, however, when trying to develop regulatory definitions of
these properties. One primary problem was that no straightforward testing protocols were
available for use in determining if a waste possessed any of these characteristics. For example,
deciding if a particular wastestream poses an unacceptable cancer risk demands extensive
laboratory experimentation. Requiring such analysis on a routine basis from industrial waste
handlers would be impractical. Therefore, EPA developed a hazardous waste definition that
relies on both listings and characteristics to define hazardous wastes.
2.3 LISTED HAZARDOUS WASTES
EPA has studied and listed as hazardous hundreds of specific industrial wastestreams. These
wastes are described or listed on four different lists that are found in the regulations at Part 261,
Subpart D. These four lists are:
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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6 - Hazardous Waste Identification
• The F list — The F list designates particular solid wastes from certain common
industrial or manufacturing processes as hazardous. Because the processes
producing these wastes can occur in different sectors of industry, the F list wastes
are known as wastes from nonspecific sources. The F list is codified in the
regulations at §261.31.
The K list — The K list designates particular solid wastes from certain specific
industries as hazardous. K list wastes are known as wastes from specific sources.
The K list is found at §261.32.
The P list and the U list — These two lists are similar in that both list pure or
commercial grade formulations of certain specific unused chemicals as hazardous.
Both the P list and U list are codified in §261.33.
These four lists each designate anywhere from 30 to a few hundred wastestreams as hazardous.
Each waste on the lists is assigned a waste code consisting of the letter associated with the list
followed by three numbers. For example, the wastes on the F list are assigned the waste codes
F001, F002, and so on. These waste codes are an important part of the RCRA regulatory system.
Assigning the correct waste code to a waste has important implications for the management
standards that apply to the waste.
LISTING CRITERIA
Before listing any waste as hazardous, the Agency developed a set of criteria to use as a guide
when determining whether or not a waste should be listed. These listing criteria provide a
consistent frame of reference when EPA considers listing a wastestream. Remember that EPA
only uses these criteria when evaluating whether to list a waste; the listing criteria are not used
by waste handlers, who refer to the actual hazardous waste lists for hazardous waste
identification purposes. There are four different criteria upon which EPA may base its
determination to list a waste as hazardous. These criteria are codified in Part 261, Subpart B.
Note that these four criteria do not directly correspond to the four different lists of hazardous
waste. The four criteria EPA may use to list a waste are:
• The waste typically contains harmful chemicals, and other factors indicate that it
could pose a threat to human health and the environment in the absence of special
regulation. Such wastes are known as toxic listed wastes.
• The waste contains such dangerous chemicals that it could pose a threat to human
health and the environment even when properly managed. Such wastes are
known as acutely hazardous wastes.
• The waste typically exhibits one of the four characteristics of hazardous waste
described in the hazardous waste identification regulations (ignitability,
corrosivity, reactivity, or toxicity).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 7
• When EPA has to cause to believe for some other reason, the waste typically fits
within the statutory definition of hazardous waste developed by Congress.
EPA may list a waste as hazardous for any and all of the above reasons. The majority of listed
wastes fall into the toxic waste category. To decide if a waste should be a toxic listed waste,
EPA first determines whether it typically contains harmful chemical constituents. Appendix VIII
of Part 261 contains a list of chemical compounds or elements which scientific studies show to
have toxic, carcinogenic, mutagenic, or teratogenic effects on humans or other life forms. If a
waste contains chemical constituents found on the Appendix VIII list, EPA then evaluates 11
other factors to determine if the wastestream is likely to pose a threat in the absence of special
restrictions on its handling. These additional considerations include a risk assessment and study
of past cases of damage caused by the waste.
Acutely hazardous wastes are the second most common type of listed waste. EPA designates a
waste as acutely hazardous if it contains Appendix VIII constituents that scientific studies show
to be fatal to humans or animals in low doses. In a few cases, acutely hazardous wastes contain
no Appendix VIII constituents, but are extremely dangerous for another reason. An example is
the listed waste P081, which designates unused discarded formulations of nitroglycerine as
acutely hazardous. Although nitroglycerine is not an Appendix VIII hazardous constituent,
wastes containing unused nitroglycerine are so unstable that they pose an acute hazard. The
criteria for designating a waste as acutely hazardous require only that EPA considers the typical
chemical makeup of the wastestream. EPA is not required to study other factors, such as relative
risk and evidence of harm, when listing a waste as acutely hazardous.
To indicate its reason for listing a waste, EPA assigns a hazard code to each waste listed on the
F, K, P, and U lists. These hazard codes are listed below. The last four hazard codes apply to
wastes that have been listed because they typically exhibit one of the four regulatory
characteristics of hazardous waste. You will learn more about the four characteristics of
hazardous waste. The hazard codes indicating the basis for listing a waste are:
Toxic Waste
Acute Hazardous Waste
Ignitable Waste
Corrosive Waste
Reactive Waste
Toxicity Characteristic Waste
(T)
(H)
(I)
(C)
(R)
(E)
The hazard codes assigned to listed wastes affect the regulations that apply to handling the waste.
For instance, acute hazardous wastes accompanied by the hazard code (H) are subject to stricter
management standards than most other wastes.
THE F LIST: WASTES FROM NONSPECIFIC SOURCES
The F list designates as hazardous particular wastestreams from certain common industrial or
manufacturing processes. F list wastes usually consist of chemicals that have been used for their
intended purpose in an industrial process. That is why F list wastes are known as
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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8 - Hazardous Waste Identification
"manufacturing process wastes." The F list wastes can be divided into seven groups, depending
on the type of manufacturing or industrial operation that creates them. The seven categories of
F-listed wastes are:
• spent solvent wastes (F001 - F005)
• wastes from electroplating and other metal finishing operations (F006 - F012,
F019)
• dioxin-bearing wastes (F020 - F023 and F026 - F028)
• wastes from the production of certain chlorinated aliphatic hydrocarbons (F024,
F025)
• wastes from wood preserving (F032, F034, and F035)
• petroleum refinery wastewater treatment sludges (F037 and F038)
• multi source leachate (F039).
Spent Solvent Wastes
Waste codes F001 - F005 apply to wastestreams from the use of certain common organic
solvents. Solvents are chemicals with many uses, although they are most often used in
degreasing or cleaning. The solvents covered by the F listings are commonly used in industries
ranging from mechanical repair to dry cleaning to electronics manufacturing. EPA decided that
only certain solvents used in certain ways produce wastestreams that warrant a hazardous waste
listing. Therefore, a number of key factors must be evaluated in order to determine whether the
F001 - F005 waste codes apply to a particular waste solvent. First, one or more of the 31
specific organic solvents designated in the F001 - F005 listing description must have been used
in the operation that created the waste. Second, the listed solvent must have been used in a
particular manner - it must have been used for its "solvent properties," as EPA defines that
expression. Finally, EPA decided that only a wastestream created through use of concentrated
solvents should be listed. Thus, the concentration of the solvent formulation or product before
its use in the process that created the waste is also a factor in determining the applicability of the
F001 - F005 listing.
The F001 - F005 spent solvent listings provide a good illustration of a principle common to all
listed hazardous wastes. To determine whether a waste qualifies as listed, knowledge of the
process that created the waste is essential, while information about the waste's chemical
composition is often irrelevant. For example, the F005 listing description can allow two
different wastes with identical chemical contents to be regulated differently because of subtle
differences in the processes that created the wastes. A waste made up of toluene and paint is
F005 if the toluene has been used to clean the paint from brushes or some other surface. A waste
with the same chemical composition is not F005 if the toluene has been used as an ingredient
(such as a thinner) in the paint. EPA considers use as a cleaner to be "use as a solvent;" use as an
ingredient does not qualify as solvent use. As you can see, knowledge of the process that created
a waste is the key in evaluating whether a waste can be a hazardous spent solvent or other listed
hazardous waste.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 9
Wastes from Electroplating and Other Metal-Finishing Operations
The listed hazardous wastes F006 - F012 and F019 are wastes commonly produced during
electroplating and other metal finishing operations. Diverse industries use electroplating and
other methods to change the surface of metal objects in order to enhance the appearance of the
objects, make them more resistant to corrosion, or impart some other desirable property to them.
Industries involved in plating and metal finishing range from jewelry manufacture to automobile
production. A variety of techniques can be used to amend a metal's surface. For example,
electroplating uses electricity to deposit a layer of a decorative or protective metal on the surface
of another metal object. Chemical conversion coating also amends the surface of a metal, but
does so by chemically converting (without use of electricity) a layer of the original base metal
into a protective coating. Because each of these processes produces different types of wastes,
EPA only designated wastes from certain metal-finishing operations as hazardous. The first step
in determining whether one of the F006-F012 or F019 listings applies to a waste is identifying
the type of metal finishing process involved in creating the waste:
• F006 - F009 listings only apply to wastes from electroplating operations
• F010 - F012 listings only apply to wastes from metal heat treating operations
• the F019 listing only applies to wastes from the chemical conversion coating of
aluminum.
Dioxin-Bearing Wastes
The listed wastes F020 - F023 and F026 - F028 are commonly known as the "dioxin-bearing
wastes." These listings describe a number of wastestreams that EPA believes are likely to
contain dioxins, which are considered to be among the most dangerous known chemical
compounds. The dioxin listings apply primarily to manufacturing process wastes from the
production of specific pesticides or specific chemicals used in the production of pesticides. The
F027 listing deserves special notice because it does not apply to used manufacturing wastes. It
applies only to certain unused pesticide formulations. F027 is in fact the only listing on the F list
or K list that describes an unused chemical rather than an industrial wastestream consisting of
chemicals that have served their intended purpose. With the exception of F028, all of the dioxin-
bearing wastes are considered acute hazardous wastes and are designated with the hazard code
(H). These wastes are therefore subject to stricter management standards than other hazardous
wastes.
Wastes from the Production of Certain Chlorinated Aliphatic Hydrocarbons
The F024 and F025 listings designate as hazardous certain wastestreams produced in the
manufacture of chlorinated aliphatic hydrocarbons. These listings stand out on the F list (the list
of wastes from nonspecific sources) because they focus on wastes from a very narrow industrial
sector. Many other wastestreams from the manufacture of organic chemicals are listed on the K
list, the list of wastes from specific sources, including two waste codes for chlorinated aliphatic
wastes, K174 and K175.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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10 - Hazardous Waste Identification
Wood Preserving Wastes
The F032, F034, and F035 listings apply to certain wastes from wood preserving operations.
Many types of wood used for construction or other non-fuel applications is chemically treated to
slow the deterioration caused by decay and insects. Such chemical treatment is commonly used
in telephone poles, railroad ties, and other wood products prepared to withstand the rigors of
outdoor use. Wood preservation typically involves pressure treating the lumber with
pentachlorophenol, creosote, or preservatives containing arsenic or chromium. (It should be
noted that after December 31, 2003, many wood treaters will not be using arsenic or chromium
based inorganic preservatives.) The wood preserving process creates a number of common
wastestreams containing these chemicals. For example, once wood has been treated with a
preservative excess preservative drips from the lumber. The F032, F034, and F035 listings
designate this preservative drippage as listed hazardous waste. These listings also apply to a
variety of other residues from wood preserving. Whether the F032, F034, or F035 listings apply
to a particular wood preserving waste depends entirely on the type of preservative used at the
facility. Waste generated from wood preserving processes using pentachlorophenol is F032,
waste from the use of creosote is F034, and waste from treating wood with arsenic or chromium
is F035. The K list also includes a waste code, K001, which applies to bottom sediment sludge
from treating wastewaters associated with processes using pentachlorophenol and/or creosote.
Petroleum Refinery Wastewater Treatment Sludges
The F037 and F038 listings apply to specific wastestreams from petroleum refineries. The
petroleum refining process typically creates large quantities of contaminated wastewater. Before
this wastewater can be discharged to a river or sewer, it must be treated to remove oil, solid
material, and chemical pollutants. Gravity provides a simple way of separating these pollutants
from refinery wastewaters. Over time, solids and heavier pollutants precipitate from wastewaters
to form a sludge. Other less dense pollutants accumulate on the surface of wastewaters, forming
a material known as float. These gravitational separation processes can be encouraged through
chemical or mechanical means. The F037 listing applies to the sludges and float created by
gravitational treatment of petroleum refinery wastewaters. The F038 listing applies to sludges
and float created during the chemical or physical treatment of refinery wastewaters. The K list
also includes waste codes for certain petroleum wastestreams generated by the petroleum
refining industry. These waste codes are K048 through K052 and K169 through K172.
Multisource Leachate
The F039 listing applies to multisource leachate, the liquid material that accumulates at the
bottom of a hazardous waste landfill. Understanding the natural phenomenon known as leaching
is essential to understanding a number of key RCRA regulations. Leaching occurs when liquids
such as rainwater filter through soil or buried materials, such as wastes placed in a landfill.
When this liquid comes in contact with buried wastes, it leaches or draws chemicals out of those
wastes. This liquid (called leachate) can then carry the leached chemical contaminants further
into the ground, eventually depositing them elsewhere in the subsurface or in groundwater. The
leachate that percolates through landfills, particularly hazardous waste landfills, usually contains
high concentrations of chemicals, and is often collected to minimize the potential that it may
enter the subsurface environment and contaminate soil or groundwater. This leachate that
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 11
percolates through hazardous waste landfills and other buried hazardous waste is designated as
F039.
THE K LIST: WASTES FROM SPECIFIC SOURCES
The K list of hazardous wastes designates particular wastes from specific sectors of industry and
manufacturing as hazardous. The K list wastes are therefore known as wastes from specific
sources. Like F list wastes, K list wastes are manufacturing process wastes. They contain
chemicals that have been used for their intended purpose. To determine whether a waste
qualifies as K-listed, two primary questions must be answered. First, is the facility that created
the waste within one of the industrial or manufacturing categories on the K list? Second, does
the waste match one of the specific K list waste descriptions? The 13 industries that can
generate K list wastes are:
• wood preservation
• inorganic pigment manufacturing
organic chemicals manufacturing
• inorganic chemicals manufacturing
• pesticides manufacturing
• explosives manufacturing
• petroleum refining
• iron and steel production
• primary aluminum production
• secondary lead processing
• veterinary pharmaceuticals manufacturing
• ink formulation
• coking (processing of coal to produce coke, a material used in iron and steel
production).
Remember that not all wastes from these 13 industries are hazardous, only those specifically
described in the detailed K list descriptions.
Previously, the K list included waste codes for 17 different industries. However, EPA revoked
the K waste codes applicable to the wastestreams in the primary copper, primary lead, primary
zinc, and ferroalloys industries (K064, K065, K066, K090, and K091) (63 FR 28556, 28579;
May 26, 1998). Currently, there are no K waste codes applicable to these four industries.
In general, the K listings target much more specific wastestreams than the F listings. For
example, EPA added a number of listings to the petroleum refining category of the K list. EPA
estimates that one hundred facilities nationwide produce wastestreams covered by these new K
listings. In contrast, F-listed spent solvent wastes are commonly generated in thousands of
different plants and facilities. You may also notice that industries generating K-listed wastes,
such as the wood preserving and petroleum refining industries, can also generate F-listed wastes.
Typically, K listings describe more specific wastestreams than F listings applicable to the same
industry. For example, K051 and K048 designate as hazardous two very specific types of
petroleum refinery wastewater treatment residues: wastewater treatment sludges created in API
separators and wastewater treatment float created using dissolved air flotation (DAF) pollution
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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12 - Hazardous Waste Identification
control devices. The F037 and F038 listings complement these two K listings by designating as
hazardous all other types of petroleum refinery wastewater treatment sludges and floats. These
petroleum refinery listings illustrate that the K listings are typically more specific than the F
listings. They also illustrate that the two lists are in many ways very similar.
THE P AND U LISTS: DISCARDED COMMERCIAL CHEMICAL PRODUCTS
The P and U lists designate as hazardous pure or commercial grade formulations of certain
unused chemicals. As you will see, the P and U listings are quite different from the F and K
listings. For a waste to qualify as P- or U-listed, a waste must meet the following three criteria:
• the waste must contain one of the chemicals listed on the P or U list
• the chemical in the waste must be unused
• the chemical in the waste must be in the form of a "commercial chemical product," as
EPA defines that term.
The following paragraphs explore these three criteria in detail and examine EPA's rationale in
creating the P and U lists.
You have already learned that hazardous waste listings are narrative descriptions of specific
wastestreams and that a waste's actual chemical composition is generally irrelevant to whether a
listing applies to it. At first glance, the P and U listings seem inconsistent with these principles.
Each P and U listing consists only of the chemical name of a compound known to be toxic or
otherwise dangerous; no description is included. EPA adopted this format because the same
narrative description applies to all P and U list wastes. Instead of appearing next to each one of
the hundreds of P and U list waste codes, this description is found in the regulatory text that
introduces the two lists.
The generic P and U list waste description involves two key factors. First, a P or U listing
applies only if one of the listed chemicals is discarded unused. In other words, the P and U lists
do not apply to manufacturing process wastes, as do the F and K lists. The P and U listings
apply to unused chemicals that become wastes. Unused chemicals become wastes for a number
of reasons. For example, some unused chemicals are spilled by accident. Others are
intentionally discarded because they are off-specification and cannot serve the purpose for which
they were originally produced.
The second key factor governing the applicability of the P or U listings is that the listed chemical
must be discarded in the form of a "commercial chemical product." EPA uses the phrase
commercial chemical product to describe a chemical that is in pure form, that is in commercial
grade form, or that is the sole active ingredient in a chemical formulation. The pure form of a
chemical is a formulation consisting of 100 percent of that chemical. The commercial grade
form of a chemical is a formulation in which the chemical is almost 100 percent pure, but
contains minor impurities. A chemical is the sole active ingredient in a formulation if that
chemical is the only ingredient serving the function of the formulation. For instance, a pesticide
made for killing insects may contain a poison such as heptachlor as well as various solvent
ingredients which act as carriers or lend other desirable properties to the poison. Although all of
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 13
these chemicals may be capable of killing insects, only the heptachlor serves the primary purpose
of the insecticide product. The other chemicals involved are present for other reasons, not
because they are poisonous. Therefore, heptachlor is the sole active ingredient in such a
formulation even though it may be present in low concentrations.
As you can see, the P and U listings apply only to a very narrow category of wastes. For example,
an unused pesticide consisting of pure heptachlor is listed waste P059 when discarded. An unused
pesticide consisting of pure toxaphene is listed waste P123 when discarded. An unused pesticide
made up of 50 percent heptachlor and 50 percent toxaphene as active ingredients, while being just
as deadly as the first two formulations, is not a listed waste when discarded. That is because neither
compound is discarded in the form of a commercial chemical product. Why did EPA choose such
specific criteria for designating P- or U-listed chemicals as hazardous? When first developing the
definition of hazardous waste, EPA was not able to identify with confidence all the different factors
that can cause a waste containing a known toxic chemical to be dangerous. It was obvious,
however, those wastes consisting of pure, unadulterated forms of certain chemicals were worthy of
regulation. EPA used the P and U lists to designate hazardous wastes consisting of pure or highly
concentrated forms of known toxic chemicals. As you will see in the following sections of the
module, wastes that remain unregulated by listings may still fall under protective hazardous waste
regulation due to the four characteristics of hazardous waste.
2.4 CHARACTERISTIC HAZARDOUS WASTES
A hazardous waste characteristic is a property that indicates that a waste poses a sufficient threat to
deserve regulation as hazardous. EPA tried to identify characteristics which, when present in a
waste, can cause death or illness in humans or ecological damage. EPA also decided that the
presence of any characteristic of hazardous waste should be detectable by using a standardized test
method or by applying general knowledge of the waste's properties. EPA believed that unless
generators were provided with widely available and uncomplicated test methods for determining
whether their wastes exhibited hazardous characteristics, this system of identifying hazardous
wastes would be unfair and impractical. Given these criteria, EPA only finalized four hazardous
waste characteristics. These characteristics are a necessary supplement to the hazardous waste
listings. They provide a screening mechanism that waste handlers must apply to all wastes from all
industries. In this sense, the characteristics provide a more complete and inclusive means of
identifying hazardous wastes than do the hazardous waste listings. The four characteristics of
hazardous waste are:
• ignitability
• corrosivity
• reactivity
• toxicity.
The regulations explaining these characteristics and the test methods to be used in detecting their
presence are found in Part 261, Subpart C. Note that although waste handlers can use the test
methods referenced in Subpart C to determine whether a waste displays characteristics, they are
not required to do so. In other words, any handler of industrial waste may apply knowledge of
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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14 - Hazardous Waste Identification
the waste's properties to determine if it exhibits a characteristic, instead of sending the waste for
expensive laboratory testing. As with listed wastes, characteristic wastes are assigned waste
codes. Ignitable, corrosive, and reactive wastes carry the waste codes D001, D002, and D003,
respectively. Wastes displaying the characteristic of toxicity can carry any of the waste codes
D004 through D043.
IGNITABILITY
Ignitable wastes are wastes that can readily catch fire and sustain combustion. Many paints,
cleaners, and other industrial wastes pose such a fire hazard. Most ignitable wastes are liquid in
physical form. EPA selected a flash point test as the method for determining whether a liquid
waste is combustible enough to deserve regulation as hazardous. The flash point test determines
the lowest temperature at which a chemical ignites when exposed to flame. Many wastes in solid
or nonliquid physical form (e.g., wood, paper) can also readily catch fire and sustain combustion,
but EPA did not intend to regulate most of these nonliquid materials as ignitable wastes. A
nonliquid waste is only hazardous due to ignitability if it can spontaneously catch fire under
normal handling conditions and can burn so vigorously that it creates a hazard. Certain
compressed gases and chemicals called oxidizers can also be ignitable. Ignitable wastes carry
the waste code D001 and are among the most common hazardous wastes. The regulations
describing the characteristic of ignitability are codified at §261.21.
CORROSIVITY
Corrosive wastes are acidic or alkaline (basic) wastes which can readily corrode or dissolve
flesh, metal, or other materials. They are also among the most common hazardous wastestreams.
Waste sulfuric acid from automotive batteries is an example of a corrosive waste. EPA uses two
criteria to identify corrosive hazardous wastes. The first is a pH test. Aqueous wastes with a pH
greater than or equal to 12.5, or less than or equal to 2 are corrosive under EPA's rules. A waste
may also be corrosive if it has the ability to corrode steel in a specific EPA-approved test
protocol. Corrosive wastes carry the waste code D002. The regulations describing the
corrosivity characteristic are found at §261.22.
REACTIVITY
A reactive waste is one that readily explodes or undergoes violent reactions. Common examples
are discarded munitions or explosives. In many cases, there is no reliable test method to evaluate
a waste's potential to explode or react violently under common handling conditions. Therefore,
EPA uses narrative criteria to define most reactive wastes and allows waste handlers to use their
best judgment in determining if a waste is sufficiently reactive to be regulated. This is possible
because reactive hazardous wastes are relatively uncommon and the dangers they pose are well
known to the few waste handlers who deal with them. A waste is reactive if it meets any of the
following criteria:
• it can explode or violently react when exposed to water, when heated, or under
normal handling conditions
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 15
• it can create toxic fumes or gases when exposed to water or under normal
handling conditions
• it meets the criteria for classification as an explosive under Department of
Transportation rules
• it generates toxic levels of sulfide or cyanide gas when exposed to a pH range of 2
through 12.5.
Wastes exhibiting the characteristic of reactivity are assigned the waste code D003. The
reactivity characteristic is described in the regulations at §261.23.
TOXICITY CHARACTERISTIC
The leaching of toxic compounds or elements into groundwater drinking supplies from wastes
disposed of in landfills is one of the most common ways the general population can be exposed to
the chemicals found in industrial wastes. EPA developed a characteristic designed to identify wastes
likely to leach dangerous concentrations of certain known toxic chemicals into groundwater. In
order to predict whether any particular waste is likely to leach chemicals into groundwater in the
absence of special restrictions on its handling, EPA first designed a lab procedure that replicates the
leaching process and other effects that occur when wastes are buried in a typical municipal landfill.
This lab procedure is known as the Toxicity Characteristic Leaching Procedure (TCLP). Using the
TCLP on a waste sample creates a liquid leachate that is similar to the liquid EPA would expect to
find in the ground near a landfill containing the same waste. Once the leachate is created in the lab,
a waste handler must determine whether it contains any of 39 different toxic chemicals above
specified regulatory levels. If the leachate sample contains a sufficient concentration of one of the
specified chemicals, the waste exhibits the toxicity characteristic (TC). EPA used groundwater
modeling studies and toxicity data for a number of common toxic compounds and elements to set
these threshold concentration levels. Much of the toxicity data were originally developed under the
Safe Drinking Water Act.
However, there is one exception to using the TCLP to identify a waste as hazardous. The D.C.
Circuit Court, in Association of Battery Recyclers vs. EPA., vacated the use of the TCLP to determine
whether manufactured gas plant (MGP) wastes exhibit the characteristic of toxicity. As previously
stated, the TCLP replicates the leaching process in municipal landfills. The court found that EPA
did not produce sufficient evidence that co-disposal of MGP wastes from remediation sites with
municipal solid waste (MSW) has happened or is likely to happen. On March 13, 2002, in response
to the court vacatur, EPA codified language exempting MGP waste from the toxicity characteristic
regulation (67 FR 11251).
To recap, determining whether a waste exhibits the toxicity characteristic involves two principal
steps: (1) creating a leachate sample using the TCLP; and (2) evaluating the concentration of 39
chemicals in that sample against the regulatory levels listed below in Table 1. If a waste exhibits the
TC, it carries the waste code associated with the compound or element that exceeded the regulatory
level. The following table presents the toxicity characteristic waste codes, regulated constituents,
and regulatory levels. This table and the regulations describing the characteristic of toxicity are
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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16 - Hazardous Waste Identification
codified at §261.24.
Table 1
TOXICITY CHARACTERISTIC CONSTITUENTS AND REGULATORY LEVELS
Waste Code
D004
D005
D018
D006
D019
D020
D021
D022
D007
D023
D024
D025
D026
D016
D027
D028
D029
D030
D012
D031
D032
D033
D034
D008
D013
D009
D014
D035
D036
D037
D038
D010
D011
D039
D015
D040
D041
D042
D017
D043
Contaminants
Arsenic
Barium
Benzene
Cadmium
Carbon tetrachloride
Chlordane
Chlorobenzene
Chloroform
Chromium
o-Cresol*
m-Cresol*
p-Cresol*
Total Cresols*
2,4-D
1 ,4-Dichlorobenzene
1 ,2-Dichloroethane
1 , 1 -Dichloroethylene
2,4-Dinitrotoluene
Endrin
Heptachlor (and its epoxide)
Hexachlorobenzene
Hexachlorobutadiene
Hexachloroethane
Lead
Lindane
Mercury
Methoxychlor
Methyl ethyl ketone
Nitrobenzene
Pentachlorophenol
Pyridine
Selenium
Silver
Tetrachloroethylene
Toxaphene
Trichloroethylene
2,4,5-Trichlorophenol
2,4,6-Trichlorophenol
2,4,5-TP (Silvex)
Vinyl chloride
Concentration
5.0
100.0
0.5
1.0
0.5
0.03
100.0
6.0
5.0
200.0
200.0
200.0
200.0
10.0
7.5
0.5
0.7
0.13
0.02
0.008
0.13
0.5
3.0
5.0
0.4
0.2
10.0
200.0
2.0
100.0
5.0
1.0
5.0
0.7
0.5
0.5
400.0
2.0
1.0
0.2
*If o-, m-, and p-cresols cannot be individually measured, the regulatory level for total
cresols is used.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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Hazardous Waste Identification - 17
2.5 WASTES LISTED SOLELY FOR EXHIBITING THE
CHARACTERISTIC OF IGNITABILITY, CORROSIVITY, AND/OR
REACTIVITY
Hazardous wastes listed solely for exhibiting the characteristic of ignitability, corrosivity, and/or
reactivity are not regulated the same way that other listed hazardous wastes are regulated under
RCRA. When wastes are generated that meet a listing description for one of the 29 wastes listed
only for exhibiting the characteristic of ignitability, corrosivity, and/or reactivity, the waste is not
hazardous if it does not exhibit a characteristic (66 FR 27266, 27283; May 16, 2001). This
concept is consistent with the mixture and derived-from rules, which will be discussed in detail
later in this module. For example, F003 is listed for the characteristic of ignitability. If a waste
is generated and meets the listing description for F003 but does not exhibit the characteristic of
ignitability, it is not regulated as a hazardous waste. However, such wastes are still subject to the
land disposal restrictions unless they do not exhibit a characteristic at the point of generation.
2.6 THE MIXTURE AND DERIVED-FROM RULES
So far, this module has introduced the fundamentals of the hazardous waste identification
process and an overview of the hazardous waste listings and characteristics. You should now be
able to explain in general terms which solid wastes are hazardous wastes. Now we analyze a
new question: "When do these hazardous wastes cease being regulated as hazardous wastes?"
The regulations governing this issue are commonly known as the mixture and derived-from
rules.
BACKGROUND
When EPA first developed the RCRA regulations and the definition of hazardous waste in the
late 1970s, the Agency focused on establishing the listings and characteristics, criteria allowing
industry to identify which wastes deserved regulation as hazardous wastes. Commenters on
EPA's original proposed regulations brought up other key questions about the hazardous waste
identification process. For example, these commenters asked, "once a waste is identified as
hazardous, what happens if that waste changes in some way? If the hazardous waste is changed,
either by mixing it with other wastes or by treating it to modify its chemical composition, should
it still be regulated as hazardous?" Faced with a short time frame for answering this difficult
question, EPA developed a fairly simple and strict answer and presented it in the mixture and
derived-from rules.
LISTED HAZARDOUS WASTES
The mixture and derived-from rules operate differently for listed waste and characteristic wastes.
The mixture rule for listed wastes states that a mixture made up of any amount of a
nonhazardous solid waste and any amount of a listed hazardous waste is considered a listed
hazardous waste. In other words, if a small vial of listed waste is mixed with a large quantity of
nonhazardous waste, the resulting mixture bears the same waste code and regulatory status as the
original listed component of the mixture. This principle applies regardless of the actual health
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
-------
18 - Hazardous Waste Identification
threat posed by the waste mixture or the mixture's chemical composition. The derived-from rule
governs the regulatory status of materials that are created by treating or changing a hazardous
waste in some way. For example, ash created by burning a hazardous waste is considered
"derived-from" that hazardous waste. The derived-from rule for listed wastes states that any
material derived from a listed hazardous waste is also a listed hazardous waste. Thus, ash
produced by burning a listed hazardous waste bears that same waste code and regulatory status
as the original listed waste, regardless of the ash's actual properties.
The net effect of the mixture and derived-from rules for listed wastes can be summarized as
follows: once a waste matches a listing description, it is forever a listed hazardous waste,
regardless of how it is mixed, treated, or otherwise changed. Furthermore, any material that
comes in contact with the listed waste will also be considered listed, regardless of its chemical
composition.
Although the regulations do provide a few exceptions to the mixture and derived-from rules,
most listed hazardous wastes are subject to the strict principles outlined above. Why did EPA
create such a rigid system? To understand the logic behind the mixture and derived-from rules,
one must consider the circumstances under which EPA developed them. If EPA relied solely on
the narrative listing descriptions to govern when a waste ceased being hazardous, industry might
easily circumvent RCRA's protective regulation. For example, a waste handler could simply mix
different wastes and claim that they no longer exactly matched the applicable hazardous waste
listing descriptions. These wastes would no longer be regulated by RCRA, even though the
chemicals they contained would continue to pose the same threats to human health and the
environment. EPA was not able to determine what sort of treatment or concentrations of
chemical constituents indicated that a waste no longer deserved regulation. EPA therefore
adopted the simple, conservative approach of the mixture and derived-from rules, while
admitting that these rules might make some waste mixtures and treatment residues subject to
unnecessary regulation. Adopting the mixture and derived-from rules also presented certain
advantages. For instance, the mixture rule gives waste handlers a clear incentive to keep their
listed hazardous wastes segregated from other nonhazardous or less dangerous wastestreams.
The greater the volume of hazardous waste, the more expensive it is to store, treat and dispose.
CHARACTERISTIC WASTES
As mentioned previously, the mixture and derived-from rules apply differently to listed and
characteristic wastes. A mixture involving characteristic wastes is hazardous only if the mixture
itself exhibits a characteristic. Similarly, treatment residues and materials derived from
characteristic wastes are hazardous only if they themselves exhibit a characteristic. Unlike listed
hazardous wastes, characteristic wastes are hazardous because they possess one of four unique
and measurable properties. EPA decided that once a characteristic waste no longer exhibits one
of these four dangerous properties, it no longer deserves regulation as hazardous. Thus, a
characteristic waste can be made nonhazardous by treating it to remove its hazardous property;
however, EPA places certain restrictions on the manner in which a waste can be treated. You
will learn more about these restrictions in the module entitled Land Disposal Restrictions.
Handlers who render characteristic wastes nonhazardous must consider these restrictions when
treating wastes to remove their hazardous properties.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
-------
Hazardous Waste Identification - 19
WASTE LISTED SOLELY FOR EXHIBITING THE CHARACTERISTIC OF
IGNITABILITY, CORROSIVITY, AND/OR REACTIVITY
All wastes listed solely for exhibiting the characteristic of ignitability, corrosivity and/or
reactivity characteristic (including mixtures, derived-from, and as-generated wastes) are not
regulated as hazardous wastes once they no longer exhibit a characteristic (66 FR 27266, 27268;
May 16, 2001). EPA can list a waste as hazardous if that waste typically exhibits one or more of
the four hazardous waste characteristics. If a hazardous waste listed only for the characteristics
of ignitability, corrosivity and/or reactivity is mixed with a solid waste, the original listing does
not carry through to the resulting mixture if that mixture does not exhibit any hazardous waste
characteristics. For example, EPA listed the F003 spent solvents as hazardous because these
wastes typically display the ignitability characteristic. If F003 waste is treated by mixing it with
another waste, and the resulting mixture does not exhibit a characteristic, the F003 listing no
longer applies. (Be aware, however, that for the land disposal restrictions, the Agency places
certain controls on how hazardous wastes can be treated or mixed with other wastes. Any
hazardous waste mixing must be consistent with these rules.)
If a waste derived from the treatment, storage, or disposal of a hazardous waste listed for the
characteristics of ignitability, corrosivity, and/or reactivity, no longer exhibits one of those
characteristics, it is not a hazardous waste (§261.3(g)(2)(ii)). For example, if a sludge is
generated from the treatment of F003, and that sludge does not exhibit the characteristic of
ignitability, corrosivity, or reactivity, the F003 listing will not apply to the sludge.
MIXTURE RULE EXEMPTIONS
There are a few situations in which EPA does not require strict application of the mixture and
derived-from rules. EPA determined that certain mixtures involving listed wastes and certain
residues from the treatment of listed wastes typically do not pose enough of a health or
environmental threat to deserve regulation as listed wastes. The principal regulatory exclusions
from the mixture and derived-from rules are summarized below.
There are eight exemptions from the mixture rule. The first exemption from the mixture rule
applies to mixtures of characteristic wastes and specific mining wastes excluded under
§261.4(b)(7). This narrow exemption allows certain mixtures to qualify as nonhazardous wastes,
even if the mixtures exhibit one or more hazardous waste characteristics. The module entitled
Solid and Hazardous Waste Exclusions will explain in more detail the mining waste or Bevill
exclusion.
The remaining exemptions from the mixture rule apply to certain listed hazardous wastes that are
discharged to wastewater treatment facilities (§261.3(a)(2)(iv)). Many industrial facilities
produce large quantities of nonhazardous wastewaters as their primary wastestreams. These
wastewaters are typically discharged to a water body or local sewer system after being treated to
remove pollutants, as required by the Clean Water Act. At many of these large facilities, on-site
cleaning, chemical spills, or laboratory operations also create relatively small secondary
wastestreams that are hazardous due to listings or characteristics. For example, a textile plant
producing large quantities of nonhazardous wastewater can generate a secondary wastestream of
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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20 - Hazardous Waste Identification
listed spent solvents from cleaning equipment. Routing such secondary hazardous wastestreams
to the facility's wastewater treatment system is a practical way of treating and getting rid of these
wastes. This management option triggers the mixture rule, however, since even a very small
amount of a listed wastestream combined with very large volumes of nonhazardous wastewater
causes the entire mixture to be listed. EPA provided exemptions from the mixture rule for a
number of these situations where relatively small quantities of listed hazardous wastes are routed
to large-volume wastewater treatment systems. To qualify for this exemption from the mixture
rule, the amount of listed waste introduced into a wastewater treatment system must be very
small (or de minimis) relative to the total amount of wastewater treated in the system, and the
wastewater system must be regulated under the Clean Water Act.
DERIVED-FROM RULE EXEMPTIONS
There are five regulatory exemptions from the derived-from rule. The first of these derived-from
rule exemptions applies to materials that are reclaimed from hazardous wastes and used
beneficially. Many listed and characteristic hazardous wastes can be recycled to make new
products or be processed to recover usable materials with economic value. Such products
derived from recycled hazardous wastes are no longer solid wastes. Using the hazardous waste
identification process discussed at the beginning of this module, if the materials are not solid
wastes, then whether they are derived from listed wastes or whether they exhibit hazardous
characteristics is irrelevant. The module entitled Definition of Solid Waste and Hazardous
Waste Recycling will explain which residues derived from hazardous wastes actually cease to be
wastes and qualify for this exemption.
The other four exemptions from the derived-from rule apply to residues from the treatment of
specific wastes using specific treatment processes. For example, K062 describes spent pickle
liquor from the iron and steel industry. Pickle liquor is an acid solution used to finish the surface
of steel. When pickle liquor is spent and becomes a waste, it usually contains acids and toxic
heavy metals. This waste can be treated by mixing it with lime to form a sludge. This treatment,
called stabilization, neutralizes the acids in the pickle liquor and makes the metals less dangerous
by chemically binding them within the sludge. EPA studied this process and determined that
K062 treated in this manner no longer poses enough of a threat to warrant hazardous waste
regulation. Therefore, lime-stabilized waste pickle liquor sludge derived from K062 is not a
listed hazardous waste. The other exemptions from the derived-from rule for listed wastes are
also quite specific and include: waste derived-from the burning of exempt recyclable fuels,
biological treatment sludge derived-from treatment of K156 and K157, catalyst inert support
media separated from K171 and K172, and residues from high temperature metal recovery of
K061, K062, and F006, provided certain conditions are met.
DELISTING
The RCRA regulations provide another form of relief from the mixture and derived-from rule
principles for listed hazardous wastes. Through a site-specific process known as "delisting," a
waste handler can submit to EPA a petition demonstrating that while a particular wastestream
generated at their facility may meet a hazardous waste listing description, it does not pose
sufficient hazard to deserve RCRA regulation (§260.22). If EPA grants such a petition, the
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
-------
Hazardous Waste Identification - 21
particular wastestream at that facility will not be regulated as a listed hazardous waste. Because
the delisting process is difficult, time-consuming, and expensive, it is not considered a readily
available exception to the mixture and derived-from from rules.
The hazardous waste listings, the hazardous waste characteristics, and the mixture and derived-
from rules are all essential parts of the definition of hazardous waste, but these key elements are
all described in different sections of the RCRA regulations. Only one regulatory section, §261.3,
unites all four elements to establish the formal definition of hazardous waste. This section is
entitled Definition of Hazardous Waste. Section 261.3 states that all solid wastes exhibiting one
of the four hazardous characteristics defined in Part 261, Subpart C, are hazardous wastes. This
section also states that all solid wastes listed on one of the four hazardous waste lists in Part 261,
Subpart D, are hazardous wastes. Finally, this section explains in detail the mixture and derived-
from rules and the regulatory exemptions from these rules. Thus, although §261.3 is entitled
Definition of Hazardous Waste, it serves primarily as a guide to the mixture and derived-from
rules. Substantive rules about the two most crucial elements of the hazardous waste definition,
the listings and characteristics, are found elsewhere.
2.7 THE CONTAINED-IN POLICY
The contained-in policy is a special, more flexible version of the mixture and derived-from rules
that applies to environmental media and debris contaminated with hazardous waste.
Environmental media (singular, "medium") is the term EPA uses to describe soil, sediments, and
groundwater. Debris is a term EPA uses to describe a broad category of larger manufactured and
naturally occurring objects that are commonly discarded (§268.2(g)). Examples of debris
include:
dismantled construction materials such as used bricks, wood beams, and chunks of
concrete
decommissioned industrial equipment such as pipes, pumps, and dismantled tanks
• other discarded manufactured objects such as personal protective equipment (e.g., gloves,
coveralls, eyewear)
• large, naturally occurring objects such as tree trunks and boulders.
Environmental media and debris are contaminated with hazardous waste in a number of ways.
Environmental media are usually contaminated through accidental spills of hazardous waste or
spills of product chemicals which, when spilled, become hazardous wastes. Debris can also be
contaminated through spills. Most debris in the form of industrial equipment and personal
protective gear becomes contaminated with waste or product chemicals during normal industrial
operations. Contaminated media and debris are primary examples of "remediation wastes." In
other words, they are not wastestreams created during normal industrial or manufacturing
operations. They are typically created during cleanups of contaminated sites and during the
decommissioning of factories. Handlers of contaminated media and debris usually cannot
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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22 - Hazardous Waste Identification
control or predict the composition of these materials, which have become contaminated though
accidents or past negligence. In contrast, handlers of "as-generated wastes," the term often used
to describe chemical wastestreams created during normal industrial or manufacturing operations,
can usually predict or control the creation of these wastes through the industrial process.
Examples of as-generated wastes include concentrated spent chemicals, industrial wastewaters,
and pollution control residues such as sludges.
The hazardous waste identification principles you have learned, including the mixture and
derived-from rules, apply to as-generated industrial wastes. EPA decided that a more flexible
version of these principles should apply to the primary remediation wastes: environmental media
and debris. In particular, EPA determined that strict application of the mixture and derived-from
rules was inappropriate for media and debris, especially when listed wastes were involved.
Applying the mixture and derived-from rules to media and debris would present certain
disadvantages, as the following examples illustrate. First, under the traditional mixture and
derived-from rules, environmental media and debris contaminated with any amount of listed
hazardous waste would be forever regulated as hazardous. Such a strict regulatory interpretation
would require excavated or dismantled materials to be handled as listed hazardous wastes and
could discourage environmental cleanup efforts. Second, most spills of chemicals into soil or
groundwater produce very large quantities of these media containing relatively low
concentrations of chemicals. Strict application of the mixture and derived-from principles to
media would therefore cause many tons of soil to be regulated as listed hazardous waste despite
containing low concentrations of chemicals and posing little actual health threat. Finally, one of
the main benefits of the mixture and derived-from rules is not relevant to media and debris. The
mixture and derived-from principles encourage handlers of as-generated wastes to keep their
listed wastes segregated from less hazardous wastestreams to avoid creating more listed wastes.
Handlers of contaminated media and debris generally have no control over the process by which
these materials come into contact with hazardous waste.
For all of the above reasons, EPA chose to apply a special, more flexible, version of the mixture
and derived-from rules to environmental media and debris. Contaminated soil, groundwater, and
debris can still present health threats if they are not properly handled and/or disposed. Therefore,
EPA requires that any medium and debris contaminated with a listed waste or exhibiting a
hazardous characteristic be regulated like any other hazardous waste. Media and debris
contaminated with listed hazardous wastes can, however, lose their listed status and become
nonhazardous. This occurs after a demonstration that the particular medium or debris in question
no longer poses a sufficient health threat to deserve RCRA regulation. The requirements for
making this demonstration are explained below. Once the demonstration is made, the medium or
debris in question is no longer considered to "contain" a listed hazardous waste and is no longer
regulated. In addition, contaminated media that contain a waste listed solely for the
characteristics of ignitability, corrosivity, and/or reactivity, would no longer be managed as a
hazardous waste when no longer exhibiting a characteristic (66 FR 27266, 27286; May 16,
2001). This concept that media and debris can contain or cease to contain a listed hazardous
waste accounts for the name of the policy.
The contained-in policy for environmental media is not actually codified in the RCRA
regulations. In legal terms, it is merely a special interpretation of the applicability of the mixture
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
-------
Hazardous Waste Identification - 23
and derived-from rules to soil and groundwater that has been upheld in federal court. These
principles for the management of contaminated media are therefore known as a policy instead of
a rule. The terms of the contained-in policy are relatively general. In order for environmental
medium contaminated with a listed waste to no longer be considered hazardous, the handler of
that media must demonstrate to EPA's satisfaction that it no longer poses a sufficient health
threat to deserve RCRA regulation. Although handlers of listed media must obtain EPA's
concurrence before disposing of such media as nonhazardous, the current contained-in policy
provides no guidelines on how this demonstration to EPA should be made. The contained-in
policy is a far easier option for eliminating unwarranted hazardous waste regulation for low-risk
listed wastes than the process of delisting a hazardous waste mentioned previously. The
delisting process demands extensive sampling and analysis, submission of a formal petition, and
a complete rulemaking by EPA. A determination that an environmental medium no longer
contains a listed hazardous waste can be granted on a site-specific basis by EPA officials without
any regulatory procedure.
Debris contaminated with hazardous waste has traditionally been governed by the same
nonregulatory contained-in policy explained above. In 1992, EPA codified certain aspects of the
contained-in policy for debris in the definition of hazardous waste regulations in §261.3(f) (57
FR 37194, 34225; August 18, 1992). In particular, EPA included a regulatory passage that
explains the process by which handlers of debris contaminated with listed hazardous waste can
demonstrate that the debris is nonhazardous. This passage also references certain treatment
technologies for decontaminating listed debris so that it no longer contains a listed waste. Thus,
the term contained-in policy is now something of a misnomer for contaminated debris, since a
contained-in rule for debris now exists.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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24 - Hazardous Waste Identification
3. REGULATORY DEVELOPMENTS
The hazardous waste identification process is subject to critical review, and adjusted accordingly
to reflect technology changes and new information. The hazardous waste listings are particularly
dynamic as the Agency conducts further research to incorporate new listings. The following is a
brief discussion of several developments to hazardous waste identification.
3.1 THE HAZARDOUS WASTE IDENTIFICATION RULES
EPA proposed to significantly impact the RCRA hazardous waste identification process through
a rulemaking effort called the Hazardous Waste Identification Rules (HWIR). The first rule,
HWIR-media, was finalized on November 30, 1998, and addressed contaminated media (63 FR
65874). The second rule, HWTR-waste, was finalized on May 16, 2001, and modified the
mixture and derived-from rules, as well as the contained-in policy for listed wastes (66 FR
27266). Both the HWIR-media rule, and the HWIR-waste rule, attempt to increase flexibility to
the hazardous waste identification system by providing a regulatory mechanism for certain
hazardous wastes with low concentrations of hazardous constituents to exit the Subtitle C
universe.
The final HWIR-media rule addresses four main issues. First, the Agency promulgated a
streamlined permitting process for remediation sites that will simplify and expedite the process
of obtaining a permit. Second, EPA created a new unit, called a "staging pile," that allows more
flexibility when storing remediation wastes during cleanups. Third, the Agency promulgated an
exclusion for dredged materials permitted under the Clean Water Act, or the Marine Protection,
Research, and Sanctuaries Act. Fourth, the rule finalized provisions that enable states to more
easily receive authorization when their RCRA programs are updated in order to incorporate
revisions to the federal RCRA regulations. The HWIR-media rule did not incorporate the
provisions that would have removed low risk remediation waste from Subtitle C regulations
because of fundamental disagreements between stakeholders.
On July 18, 2000, the Agency released HWIR-waste exemption levels for 36 chemicals that were
developed using a risk model known as the Multimedia, Multipathway and Multireceptor Risk
Assessment (3MRA) Model (65 FR 44491). EPA is currently reviewing the public comments
and will decide whether further revisions to the model are necessary. After completion of
independent testing, EPA submitted the model to EPA's Science Advisory Board (SAB) for
review during 2003.
The May 16, 2001, HWIR-waste rule revised and retained the hazardous waste mixture and
derived-from rules as previously discussed in this module. In addition, the rule finalized
provisions that conditionally exempt mixed waste (waste that is both radioactive and hazardous),
if the mixed waste meets certain conditions in Part 266 (66 FR 27266).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
-------
Hazardous Waste Identification - 25
3.2 FINAL HAZARDOUS WASTE LISTING DETERMINATIONS
EPA first signed a proposed consent decree with the Environmental Defense Fund (EDF) on
June 18, 1991, following a suit concerning EPA's obligations to take certain actions pursuant to
RCRA. A consent decree is a legally binding agreement, approved by the Court, which details
the agreements of the parties in settling a suit. The proposed consent decree, commonly known
as the "mega-deadline," settles some of the outstanding issues from the case by creating a
schedule for EPA to take action on its RCRA obligations. The consent decree, which has been
periodically updated, requires EPA to evaluate specified wastestreams and determine whether or
not to add them to the hazardous waste listings.
On November 8, 2000, EPA listed as hazardous two wastes generated by the chlorinated
aliphatics industry (65 FR 67068). The two wastes are K174, wastewater treatment sludges from
the production of ethylene dichloride or vinyl chloride monomer (EDC/VCM), and K175,
wastewater treatment sludges from the production of vinyl chloride monomer using mercuric
chloride catalyst in an acetylene-based process. For K174, EPA finalized a contingent-
management listing approach which specifies that the waste will not be listed if it is sent to a
Subtitle C landfill or a non-hazardous landfill licensed or permitted by the state or federal
government.
On November 20, 2001, EPA published a final rule listing three wastes generated from inorganic
chemical manufacturing processes as hazardous wastes (66 FR 58257). The three wastes are
K176, baghouse filters from the production of antimony oxide; K177, slag from the production
of antimony oxide that is speculatively accumulated or disposed; and K178, residues from
manufacturing and manufacturing-site storage of ferric chloride from acids formed during the
production of titanium dioxide using the chloride-ilmenite process.
EPA proposed a concentration-based hazardous waste listing for certain waste solids and liquids
(K180 and K179) generated from the production of paint on February 13, 2001 (66 FR 10060).
Following a review of the public comments and supplemental analyses based on those public
comments, EPA determined that the paint wastes identified in the proposal do not present a
substantial hazard to human health or the environment. Therefore, EPA did not list these paint
production wastes as hazardous. See the April 4, 2002, final determination regarding these
hazardous waste listings (67 FR 16261) for additional information.
On February 24, 2005, EPA published a final rule listing nonwastewaters from the production of
certain dyes, pigments, and food, drug, and cosmetic colorants (70 FR 9138) as hazardous
(K181) using a mass loading-based approach. Under the mass loading approach, these wastes
are hazardous if they contain any of the constituents of concern at annual mass loading levels
that meet or exceed the regulatory levels. The K181 listing focuses on seven hazardous
constituents: aniline, o-anisidine, 4-chloroaniline, p-cresidine, 1,2-phenylenediamine, 1,3-
phenylenediamine, and 2,4-dimethylaniline. Waste that contains less than the specified threshold
levels of constituents of concern are not hazardous. The K181 listing is EPA's final obligation
under the consent decree.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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26 - Hazardous Waste Identification
3.3 PROPOSED REVISION TO WASTEWATER TREATMENT
EXEMPTION FOR HAZARDOUS WASTE MIXTURES
On April 8, 2003, EPA proposed to add benzene and 2-ethoxyethanol to the list of solvents
whose mixtures with wastewater are exempted from the definition of hazardous waste (68 FR
17234). EPA is proposing to provide flexibility in the way compliance with the rule is
determined by adding the option of directly measuring solvent chemical levels at the headworks
of the wastewater treatment system. In addition, EPA is proposing to include scrubber waters
derived from the combustion of spent solvents to the headworks exemption. Finally, EPA is
proposing to extend the de minimis exemption to wastes listed in §§261.31 and 261.32 when
released in de minimis quantities and to non-manufacturing facilities if certain conditions are
met. The final rule is scheduled to be published in the Fall of 2005.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
But is an introduction to the topic used for training purposes.
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NAVOSHENVTRACEN
INCOMPATIBLE MATERIALS CHART
MATERIAL GROUP
EXAMPLES
INCOMPATIBLE MATERIALS EXAMPLES
HMUG
GROUP
Batten/Acid
Paint Removers
De-Rust Sprays
Epoxies
Isocyanales
Dielhylenelnamine
_ Ammonia
Sodium Hydroxide
Sodium Bicarbonate
Cleaners/Detergents
Degreasers
Carbon Removers
Antifogging Compounds
"pasoti
COMPRESSED
GASES
Acolylono
o» Holtum
Propane
Amrn ' i
Oxygon
FLAMMABLiS/COMBUSTtBLES
G GttOUPS ? 3 S. /, rJ to II 1? 13 u. t5 17. Ifl. !••.
ACIDS
IHMUG GROUPS 1 3 181
ACIDS.' Batl«(YAcid.
FLAMMABLES/COMBUSTIBLES '
-OOPS 1.2.« 8. S. 10, n 12. n. - • ' ' •<•
15 " >« 19. 20 at t>WMSt*ntfa
IMMIXJOROUP57 1B|
• , '
SwaumNMIt,
... . , . ,
HEAT SOURCES
•.'..,•. ,i - i . I..: . .
'OH SPECIfIC MMJDI.INGAND STOWAGE OUIOANCE
CORROSION
PREVENTIVE
COMPOUNDS
Corrosion Inhibitors
Chemical Conversion
Compounds
ACIDS
IMMuG GROUPS 1 3. t«l
DelOfgenl5, Diitfifectarrt. Scouring
PotKMo Sodium HydroMto
Tnsodium Phospnaln. Potassium
(AlkaUexBnos'ClluMKS)
ACID-CONTAINING
IMPOUNDS
<
18
OXKXZSt
CNcnw Uunoy SMC
OWourn Hypocnonte
HEAVY METALA
[HMUG GROUPS I J 18. Ml
19
FUELS
PETROLEUM BASED MATERIALS
FUELS. SOLVENTS.
HEAT
(MMUG GROUPS 1 2. J 4 5. 0. a. 9 to II
1? u. 15 tT 19.20.21 22)
JP4, JP5,
Gasoline
! . '
IHMUG GROUPS 1,3 III)
20
HEAVY
METALS
. C^vomtum. Copper.
l,«ad. Magnouum, Mercury.
Nkrkol. Slfonti
Tm. inc
21
BATTERIES
.-
Lilh-um
17 IH ?tt
SOLVEN
IHMUG GROUPS IS !• JO!
22
PESTICIDES
•, ,
(HMUO GROUPS I 3 l«l
1 This Chart is lo be used as a Guide Only!
2. Compare the desired HMUG Group in the Left Column with the Incompatible
Material(s) ol that Group in Ihe Center Column, on Ihe same row.
3. Should Ihe Matenal(s) in the Center Column be mixed with Ihg desired Group in
the Lett Column, the Expected Reaction(s) can be see in the Right Column.
4. For specific information on storage ol Hazardous Materials, consult Ihe MSDS.
HMUG. OPNAVINST 5100.19 (Series), NSTM 670. Ships Ha2ardous Material
List (SHML). and NAVSUP PUB 573
REACTION IF MIXED
HEAT VIOLENT
GAS GENERATION REACTION
HEAT
FIRE HAZARD
HEAT
VIOLENT
GASGENEHATION REACTION
HEAT
FIRE HAZARD
FIRE HAZARD
EXPLOSION HAZARD
FIRE HAZARD
VIOLENT REACTION
HEAT
FIRE HAZARD
HEAT
VIOLENT REACTION
EXPLOSION HAZARD
HEAT
FIRE HAZARD
HEAT
FIRE HAZARD
HEAT, FIRE HAZARD
VIOLENT REACTION
HEAT
FIRE HAZARD
NO REACTION
HEAT
VIOLENT REACTION
FIRE HAZARD
TOXIC GAS GENERATION
FIRE HAZARD
TOXIC GAS GENERATION
VIOLENT REACTION
GENERATION OF TOXIC AND FLAMMABLE GAS
HEAT
VIOLENT REACTION
TOXIC GAS GENERATION
TOXIC GAS GENERATION
ProducsO tar COMNAVSUPSVSCOM
By
NAVAL OCCUPATIONAL SAFETY AND HEALTH.
AND ENVIRONMENTAL TRAINING CENTER
9080Br«izyPI Cra9can.NoiloA.VA23Stl.3998
COM 1804) M5-S77B DSN1365-3778 EXTENSION 345 or 343
REV 1/JANUARY 1996
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[47 FR 32367, July 26, 1982]
APPENDIX V TO PART 264—EXAMPLES OF POTENTIALLY
INCOMPATIBLE WASTE
Many hazardous wastes, when mixed with other waste or materials at a
hazardous waste facility, can produce effects which are harmful to
human health and the environment, such as (1) heat or pressure, (2) fire
or explosion, (3) violent reaction, (4) toxic dusts, mists, fumes, or gases,
or (5) flammable fumes or gases.
In the lists below, the mixing of a Group A material with a Group B
material may have the potential consequence as noted.
GROUP 1-A
Acetylene sludge
Alkaline caustic liquids
Alkaline cleaner
Alkaline corrosive liquids
Alkaline corrosive battery fluid
Caustic wastewater
Lime sludge and other corrosive alkalies
Lime wastewater
Lime and water
Spent caustic
GROUP 1-B
Acid sludge
Acid and water
Battery acid
Chemical cleaners
Electrolyte, acid
Etching acid liquid or solvent
Pickling liquor and other corrosive acids
Spent acid
Spent mixed acid
Spent sulfuric acid
Heat generation; violent reaction.
GROUP 2-A
Aluminum
Beryllium
Calcium
Lithium
Magnesium
Potassium
Sodium
Zinc powder
Other reactive metals and metal hydrides
GROUP 2-B
Any waste in Group 1-A or 1-B
Fire or explosion; generation of flammable hydrogen gas.
GROUP 3-A
Alcohols, Water
GROUP 3-B
Any concentrated waste in Groups 1-A or 1-B
Calcium
Lithium
Metal hydrides
Potassium
S02 C12, SOC12, PC13, CH3 SiCl3
Other water-reactive waste
Fire, explosion, or heat generation; generation of flammable or
toxic gases.
GROUP 4-A
Alcohols
Aldehydes
Halogenated hydrocarbons
Nitrated hydrocarbons
Unsaturated hydrocarbons
Other reactive organic compounds and solvents
GROUP 4-B
Concentrated Group 1-A or 1-B wastes
Group 2-A wastes
Fire, explosion, or violent reaction.
GROUP 5-A
Spent cyanide and sulfide solutions
GROUP 5-B
Group 1-B wastes
Generation of toxic hydrogen cyanide or hydrogen sulfide gas.
GROUP 6-A
Chlorates, Chlorine, Chlorites
Chromic acid
Hypochlorites
Nitrates
Nitric acid, fuming
Perchlorates
Permanganates
Peroxides
Other strong oxidizers
GROUP 6-B
Acetic acid and other organic acids
Concentrated mineral acids
Group 2-A wastes
Group 4-A wastes
Other flammable and combustible wastes
Fire, explosion, or violent reaction.
-------
Produced by
as part of the Local Hazardous
Waste Management Program
King County in King County
Publication Number SQG-LABS-1 (9/94) REV. 7/05
July 2005
Final Report
Laboratory Waste
Management Guide
Dave Waddell
Local Hazardous Waste Management Program in King County
Technical Assistance and Pollution Prevention Team
-------
This report was prepared by the Local Hazardous Waste Management Program in King
County, Washington. The program seeks to reduce hazardous waste from households
and small quantity generator businesses in King County by providing information and
technical assistance to protect human health and the environment.
For more information or to order additional copies of this report contact:
Produced by
King County
as part of the Local Hazardous
Waste Management Program
in King County
130 Nickerson Street, Suite 100
Seattle, WA 98109
206-263-3050 TTY Relay: 711
Fax 206-263-3070
www.govlink.org/hazwaste/
Publication Number SQG-LABS-1 (9/94) REV. 7/05
Waddell, Dave. Laboratory Waste Management Guide, Final Report. Seattle, WA: Local
Hazardous Waste Management Program in King County, 2005.
Alternate Formats Available
Voice: 206-263-3050 or TTY Relay: 711
LabGuidelines 05.doc
Oa
..... V
'-t Printed on Recycled Paper
-------
CONTENTS
Introduction 1
Facility Management 2
Drain Protection 2
Safety Showers 2
Chemical Storage 3
Components of a Safe and Effective Chemical Storage Area 3
Storing and Handling Chemicals 3
Systematic Storage of Lab Chemicals 4
Preparing Your Laboratory for Earthquakes 6
Planning for Renovation and New Construction 7
Water Conservation 8
Training 8
Chemical Spill Management 10
Managing Hazardous Chemicals On Site 11
Incompatible Chemicals 11
Acids and Bases 11
Oxidizing Chemicals 11
Water-Reactive Compounds 11
Potentially Explosive Chemicals 12
Metal Azides 12
Ethers and Other Peroxide-forming Chemicals 13
Metal Picrates and Picric Acid 13
Ammoniacal Silver Staining Solutions 14
Hazardous Waste Reduction and Disposal 16
Acetone Used in Glassware Cleaning 17
High Pressure Liquid Chromatography Waste 17
Ethidium Bromide Management 18
Disposal of Pure Ethidium Bromide 18
Disposal of Electrophoresis Gels 18
Disposal of Contaminated Gloves, Equipment and Debris 18
Disposal of Ethidium Bromide Solutions 18
Treatment of Ethidium Bromide Waste 18
Deactivating EtBr Solutions 19
Decontamination of Ethidium Bromide Spills 19
Alternatives to Ethidium Bromide 20
Disposal of Alcohols 20
Disposal of 3,3-Diaminobenzidine (DAB) 21
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DAB Detoxification Procedure 21
Disposal of Wastes Containing Sodium Azide 21
Enterococcus Agar 21
Alkaline Iodide Azide (AIA) Reagent for the Winkler Dissolved Oxygen Titration 22
Management of Aldehyde Wastes 22
Formalin 22
Chemical Treatment of Formalin 23
Alternatives to Formalin 24
Glutaraldehyde 24
Chemical Treatment of Glutaraldehyde 24
Ortho-Phthalaldehyde 24
Chemical Treatment of Ortho-Phthalaldehyde 25
Aldehyde Spill Management 25
Management of Scintillation Fluid Wastes 25
Pollution Prevention (P2) 26
P2 Example: Liquid Chromatography 26
P2 Example: Western Blotting 27
On-site Treatment of Laboratory Wastes 27
Specific Standards for On-site Treatment of Wastes 27
Carbon Adsorption 27
Evaporation 28
Separation 28
Elementary Neutralization 28
Treatment by Generator Counting Requirements 29
Permit by Rule 29
Conditions to Qualify for Permit by Rule (PER) Exemption 29
Example: PER for Lab Sample Destruction 30
Example: PER for Managing Acidic Glass-Washing Solutions 30
Wastewater and Solid Waste Disposal Guidelines 31
For More Information 32
Industrial Materials Exchanges 32
Hazardous Waste Management—In King County 32
Hazardous Waste Management— Outside King County 32
King County Industrial Waste Program 32
Air Quality Management 32
Health and Safety Programs 33
Resources for Reducing the Scale of Experiments and Analyses 33
Appendix A King County Guidelines for Sewer Disposal 34
Appendix B Seattle & King County Guidelines for Solid Waste Disposal 37
Appendix C Proper Disposal of Fixatives & Stains 39
Appendix D Solid Waste Disposal - Common Questions 47
Selected Bibliography 49
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INTRODUCTION
The first edition of this management guide, published in 1994, was prepared by
representatives from several groups: the King County Water and Land Resources Division,
the Local Hazardous Waste Management Program in King County, the Northwest Laboratory
Coalition, and the Washington Biotechnology Association. Baz Stevens from King County's
Industrial Waste Section (formerly the Municipality of Metropolitan Seattle) was one of the
original authors.
The management guide is part of a comprehensive program to reduce the amount of
hazardous waste generated by businesses and the metals and chemical contaminants
improperly disposed into waters and landfills. This is the fourth edition of the management
guide.
This edition addresses a broader range of issues and waste streams than was covered in the
original document. The practices recommended in these guidelines will help analytical,
medical, teaching, and biotechnology labs properly manage hazardous materials and reduce
hazardous waste.
The guidelines also help businesses and agencies in King County decide whether their waste
may be acceptable for discharge to the sewer. For more help, see the contacts listed in the
For More Information section of this report. Though the specific focus is King County, many
of the recommendations are applicable to labs anywhere in the United States.
These guidelines do not provide authorization under Permit by Rule (WAC 173-303-802) to
allow discharge of hazardous chemicals to the sewer. They serve, in part, as a guideline to
assist businesses and agencies in King County in determining whether their waste may be
acceptable for discharge to the sewer.
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FACILITY MANAGEMENT
Drain Protection
Solutions discharged into the sewer system flow to wastewater treatment facilities that have
limited capacity to remove chemical contaminants. Most areas in King County discharge to
facilities that are maintained and operated by King County Department of Natural Resources
and Parks. Rain and other runoff into storm drains usually flow directly to creeks and
waterways that drain to Puget Sound with no treatment. It is important to protect both storm
drains and the sewer system from chemicals and other pollutants. In a sense, all the best
management practices in this handbook are intended to provide "drain protect on"—or water
quality protection.
To protect your drains:
• Do not hold or store chemicals in sinks. Use tubs, containers or storage lockers instead.
• Post laminated signs by sinks listing wastes that cannot be poured down the drain from
nearby lab processes.
• Provide spill and leak protection around all sinks, especially cup sinks on countertops and
under hoods where hazardous materials are used or stored.
• Provide secondary containment trays or tubs for reagents being temporarily stored in fume
hoods with cup sink drains.
• Block floor drains in areas where chemicals are used or stored.
• Keep enough material on hand to prevent and clean up spills. These supplies may include
absorbents, drain plugs, acid and base neutralizers, goggles, gloves, respirators with
chemical specific cartridges, and waste collection containers. Make sure clean-up
materials and copies of the emergency response plan and emergency phone numbers are
readily available.
• Provide secondary containment for carboys and bottles on floors holding analytical
reagents and wastes from analytical instruments.
• Periodically flush cup sink drains with water to keep sewer gases from passing through a
dry p-trap.
Safety Showers
Prevent spilled chemicals from reaching safety shower drains. Possible methods include:
• Eliminate the drain.
• Cover or plug the drain when not in use to prevent accidental discharge.
King County - Lab Waste Management Guide
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• Install a temporary plug that opens automatically when the safety shower is turned on (this
can be done by linking the lever action that activates the shower to one that lifts the plug.)
• See the Spill Management section for information on preventing spilled chemicals from
spreading.
Should contaminants washed off a per son during emergency use of a safety shower be
allowed in a drain? When hazardous chemicals are spilled on a worker, the first priority is to
flush the contaminants off the person. If steps can be taken to limit the amount of hazardous
chemicals entering the floor drain without interfering with speedy emergency response, do so.
If not, as soon as possible notify the local sewer agency that there has been a release. Post the
local sewer agency's phone number near the safety shower and in your spill response guide.
Check in the blue pages of your phone book for this phone number and look for the words
"Sewer" or "Wastewater" under the name of your city or county.
Chemical Storage
Laboratories generally use a variety of toxic, corrosive, reactive and flammable materials. If
these are stored close together in fragile containers, there is a risk of breakage and spills that
release materials to the environment. Proper storage of chemicals requires the use of prudent
handling and storing practices and a well-constructed lab facility.
Components of a Safe and Effective Chemical Storage Area
• Maintain an inventory of chemicals stored in each lab.
• Anchor hazardous material storage cabinets to walls.
• Close and latch doors on storage cabinets.
• Provide separate corrosion-free cabinets for flammable liquids, concentrated inorganic
acids and caustic liquid bases.
• Keep a Class ABC fire extinguisher near locations where chemicals are stored or used and
train employees in its operation.
• Provide secondary containment for chemicals stored on counters and near drains.
Storing and Handling Chemicals
• Store incompatible materials separately. Several concentrated organic acids are
combustible and are more safely stored with flammable liquids than with sulfuric acid and
nitric acid that are powerful oxidizers. Refer to the Incompatible Chemicals section below
for further information on safer chemical storage.
• Reduce the risk of bottle breakage. Whenever possible, order concentrated acids and
flammable solvents in plastic-coated bottles. Small containers are more durable and less
King County - Lab Waste Management Guide
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likely to break than large ones. Use rubber or plastic bottle carriers or bottle jackets when
transporting glass containers.
• Keep containers closed when not in use so contents cannot evaporate or escape a tipped
container.
• Return chemicals to their proper place after use or at least before leaving the work station
at the end of the day.
• Properly label containers with the name of the compound and its primary hazards.
Chemical symbols alone are insufficient identification.
• Regularly check expiration dates on chemicals. Dispose of them or use them promptly
and properly.
• Write the date received on each chemical container that arrives and the date opened on all
containers of peroxidizable solvents.
• Avoid storing chemicals in fume hoods. They interfere with the air flow, clutter work
space and could potentially spill into cup sink drains.
• Avoid storing chemicals on bench tops.
• Properly store or dispose of all hazardous materials before leaving the workstation.
• Avoid storing chemicals under sinks.
• Do not store flammable liquids in domestic refrigerators or freezers. Use only "lab-safe"
equipment with external thermostats, manual defrosting, etc.
Systematic Storage of Lab Chemicals
We suggest following the storage and handling guidelines found in Prudent Practices in the
Laboratory by the National Research Council's Committee on Hazardous Substances in the
Laboratory (National Academy Press, Washington, DC, 1995).
Many universities publish diagrams of their chemical storage system on their Web sites.
These are often based on the storage system published in the National Research Council's
Prudent Practices in the Laboratory. Two chemical supply companies, J.T. Baker and Flinn
Scientific Inc., also have popular systems for chemical storage that incorporate the concept of
"related and compatible storage groups" found in Prudent Practices.
These systems are based on a series of codes for functional classes of chemicals. Organic and
inorganic chemicals are separated, with sub-groups further separated. The "related and
functional storage groups listed in Prudent Practices'" and the shelf storage codes often
assigned to these groups are listed below. ("I" refers to inorganic compounds and "O" refers
to organic compounds.)
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1-1 Metals, hydrides
1-2 Halides, sulfates, sulfites, thiosulfates, phosphates, halogens
1-3 Amides, nitrates (except ammonium nitrate), nitrites, azides
1-4 Hydroxides, oxides, silicates, carbonates, carbon
1-5 Sulfides, selenides, phosphides, carbides, nitrides
1-6 Chlorates, perchlorates, chlorites, hypochlorites, peroxides
1-7 Arsenates, cyanides, cyanates
1-8 Borates, chromates, manganates, permanganates
1-9 Inorganic acids
I-10 Sulfur, phosphorus, arsenic, phosphorus pentoxide
O-l Organic acids anhydrides, peracids
O-2 Alcohols, glycols, amines, amides, imines, imides
O-3 Hydrocarbons, esters, aldehydes
O-4 Amines, imines, pyridine
O-5 Ethers, ketones, ketenes, halogenated hydrocarbons, ethylene oxide
O-6 Epoxy compounds, isocyanates
O-7 Organic peroxides, hydroperoxides, azides
O-8 Sulfides, polysulfides, sulfoxides, nitriles
O-9 Phenols, cresols
Flammable liquids must be stored in flammable storage cabinets or fire safety cans.
Alphabetical storage is discouraged except within compatible groups.
Most guidelines have adapted this list to create a systematic shelf storage system.
Unfortunately, this system is confusing to implement. For example, many of the listed
chemicals are hazardous liquids that should be stored in specialized cabinets rather than on
shelves. The system is also difficult to implement for secondary schools and other labs with
limited storage space: most stockrooms are too small to accommodate a system that has 19
separated shelves (plus storage cabinets.)
For labs with restricted storage spaces, compatible storage can be provided by grouping
chemicals with similar hazards together. These labs could use a simplified system like the
one illustrated in Table 1.
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Table 1 -Shelf Storage Pattern for Small Stockrooms
Inorganic Shelves
1-1 & 1-10 - Sulfur, phosphorus, arsenic, metals, hydrides
(store all away from water!)
1-2 - Halides, sulfates, sulfites, thiosulfates, phosphates,
halogens
1-5 & 1-7 - Sulfides, selenides, phosphides, carbides,
nitrides, arsenates, cyanides
1-4 - Dry hydroxides, oxides, silicates, carbonates
1-3, 1-6 & 1-8 - Nitrates, nitrites, borates, chromates,
manganates, permanganates, chlorates, chlorites,
inorganic peroxides
Corrosive Acid Storage Cabinet - Inorganic acids. Nitric
acid stored separately in this or another cabinet
Organic Shelves
O-1 - Dry and dilute organic acids, anhydrides,
peracids
O-5 & O-7 - Organic peroxides, azides
O-6 & O-8 - Epoxy compounds, isocyanates,
sulfides, sulfoxides, nitriles
O-9 - Miscellaneous organics: Powdered and
alcohol-free stains and indicators.
Flammable Storage Cabinet - Hydrocarbons,
ethers, ketones, amines, halogenated
hydrocarbons, aldehydes, alcohols, glycols,
phenol, cresol, combustible organic acids,
combustible anhydrides
Corrosive Base Storage Cabinet or Cupboard
- Concentrated inorganic hydroxides
Notes: Keep water reactive metals away from aqueous solutions and alcohols. Use secondary containers to
separate yellow and white phosphorus, which are stored under water, from water-reactive metals.
Preparing Your Laboratory for Earthquakes
• Lips on shelves provide some restraint for bottles in an earthquake, but are inadequate
when there is violent shaking. Having doors on chemical storage cupboards is
recommended. Unsecured cupboard doors can open during earthquakes. They should be
fitted with locking latches.
• Shelf lips should be between one and two inches in height. Excessively high lips can
make it difficult to remove bottles, increasing the risk of losing one's grip on them. Lips
that are too low do little to restrain bottles from falling off shelves.
• Some shelf anchors can fail. They should be designed to restrain full, rather than empty,
shelves. Additionally, many shelf clips become corroded over time due to exposure to
acid vapors. Inspect shelf anchors annually. Those with more than a patina of rust should
be promptly replaced.
• Anchor large laboratory equipment and shelves to walls. Incubators, biosafety cabinets,
corrosive and flammable storage cabinets, freezers and refrigerators, and storage shelves
can fall over or collapse. In addition, these items also have "movement" potential, and can
prevent emergency access to, and egress from, occupied spaces.
• On a side note: here's a recommendation from the Stanford School of Medicine's website:
"A word about biological cultures: Any earthquake that requires the evacuation of a
building can put valuable research material at risk. Very little is more frustrating than to
King County - Lab Waste Management Guide
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come back to a building (perhaps after several days or a week) to find the infrastructure
sound, equipment in good shape, but cultures non-viable. Loss of culture material can set
back both research and careers if steps are not taken to back up material whenever
possible. If lyophilization (and storage off site) is not possible, try to work out a "deal"
with out-of-state colleagues to store duplicates of each other's cultures (fires and other
Acts-of-God do not respect geographical boundaries). "
• Small anchoring devices are available, from "thumb-locking" clips to industrial strength
Velcro-like strips to assist with anchoring computer printers and other equipment.
• Secure distillation apparatus and other elaborate glassware with straps and install
refrigerator door clasps.
• Following an earthquake, use caution when entering rooms with closed doors and when
opening cabinets and cupboards. Containers may have broken, and toxic, flammable or
corrosive vapors may be in the cabinet, cupboard or room. The first assessment of
damage to rooms containing chemicals should be done by personnel trained in emergency
response and wearing appropriate personal protective equipment.
Planning for Renovation and New Construction
• Avoid putting chemical storage shelves or cabinets over sinks. Accidental spills or
breakage could release chemicals to the sewer.
• If you install a house vacuum system, use dry-seal or non-contact water pumps. Pumps
that use contact water may discharge chemicals to the sewer.
• If a safety shower discharges to a laboratory floor drain, construct the drain in an
appropriately-sized sump with a standpipe to prevent spilled chemicals from going down
the drain while allowing water from the shower to drain. Check with your local building
code to determine whether such sumps must be double-contained.
• If available, select a sink that has a lip to provide spill protection.
• Contact the local plumbing inspector early in the process to clearly communicate to them
where acidic wastes could accidentally enter drains and where they could not. This could
save time and costs from having to stop the process to replace cast-iron piping with acid-
resistant piping.
• Passive acid-treatment tanks are often recommended by architects in classrooms and
laboratory spaces. For most situations, these systems are very difficult to manage and
maintain. Sulfuric acid creates a "slime" layer in contact with limestone that requires
physical agitation or high pressure rinsing to remove. Once the slime layer is in place, the
limestone chips no longer neutralize acidic wastewaters. This could damage downstream
side-sewer lines and lead to very expensive pavement-cutting and sewer repair projects.
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Water Conservation
Structural measures, such as those listed below, can significantly reduce water use. In
addition, well-trained lab workers can use their ingenuity to save water on the job.
• Install water-saving devices (such as flow restrictors) on sinks and rinse tanks.
• Reduce rinse times if possible (without affecting product quality).
• Recycle water - for example, to air scrubbers and cooling towers.
• Eliminate one-pass or continuous flow cooling systems. Consider installing heat
exchangers or re-circulating cooling water systems to conserve waste cooling water.
• Overhaul faulty steam traps on steam sterilizers.
• Reverse osmosis (RO) water is commonly used in lab experiments, but the RO process is
very wasteful with as much as 90 percent of the water discharged as wastewater. Some
universities have recirculated this water back through the RO system or used the discarded
water as non-potable water in other areas. Possible uses include flushing toilets, watering
landscape plants or as cooling water for autoclaves.
Training
All laboratory staff should understand the importance of using Best Management Practices for
waste reduction and environmental protection. Training for new employees and refresher
training for all staff are important.
• Keep your lab's Spill Response Plan updated and available to employees.
• Post emergency numbers.
• Train lab workers in the components of the Chemical Hygiene Plan covering proper
chemical handling, storage and disposal.
• Emphasize a commitment to waste prevention and proper chemical management.
• Encourage employees to develop waste prevention and waste stream efficiency ideas and
then to implement them.
• Provide regular training in water conservation.
Under Chapter 296-824 WAC, any business using hazardous chemicals must develop an
emergency plan that anticipates and develops responses to emergencies. The plan must be
written and must address pre-emergency planning and coordination with all potential
responders. The plan must also define personnel roles and ensure that employees working
with hazardous chemicals receive the minimum mandatory training required for awareness of
chemical hazards and/or responding to spills. See WAC 296-824-30005 for more information
King County - Lab Waste Management Guide
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about these requirements. They are enforced by the Washington Department of Labor and
Industries.
The Laws and Agency Rules section of the Washington Legislature's Web site at
http://www.leg.wa.gov/WAC/index.cfm?section=296-824-100&fuseaction=section links to a
flow chart that helps define when training is mandated under Chapter 296-824 WAC.
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CHEMICAL SPILL MANAGEMENT
Spill management plans are very dependent on the size and complexity of the facility and the
diversity and comparative hazards of the chemicals being used in the lab. Excellent examples
of spill management plans are available from many university's environmental health and
safety program websites. A few key components should be part of every laboratory's spill
response procedures:
• Differentiate between major and minor chemical spills.
• Major spills require immediate emergency response assistance. They are typically
identified as difficult to contain, likely to harm personnel or posing an immediate and
serious fire risk.
• Prepare for major spills by working with your local emergency responders to develop a
notification and evacuation plan. At some facilities, initial response to major spills may
be by the facility's trained emergency response team. For many other labs, these spills are
beyond the capacity of their staff.
• Minor spills typically will be cleaned up by laboratory staff or facility-based emergency
response teams.
• Only clean up minor spills when you know the chemical's name and hazards and have
protective equipment and spill kits that can handle it. This points out the importance of
proper labeling and spill response training.
• Spill response training should be carefully designed to distinguish between major and
minor spills and between similar chemicals with different hazards. Many lab staff can
easily clean up a spill of 500 milliliters of 25 percent sodium hydroxide solution. Few lab
staff can safely clean up a similar spill of ammonium hydroxide. Both are corrosive
bases, but ammonium hydroxide's intensely irritating vapors pose a unique hazard.
• Small labs, such as a high school science lab, should have simple, easy-to-use spill kits.
The kit should contain citric acid for spills of liquid bases, sodium carbonate for acids, and
granular absorbent for organic solvents. Sand is sometimes applied to increase traction in
spills of slippery compounds like sulfuric acid and sodium hydroxide.
• Contact your local sewer agency to learn when they should be notified of a spill entering
the sanitary sewer.
10 King County - Lab Waste Management Guide
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MANAGING HAZARDOUS CHEMICALS ON SITE
Incompatible Chemicals
When they come in contact with each other, incompatible chemicals could react by releasing
toxic or flammable gases, exploding or spontaneously igniting. Segregate and store chemicals
by hazard class to minimize the risk of reactions between incompatible chemicals and label
storage cabinets and cupboards with the hazard class of the stored materials. Material safety
data sheets (MSDSs) should be available for all chemicals on site. Review them for
information about incompatibilities. The following is a partial list of common incompatible
chemicals that can react with each other.
Acids and Bases
Store strong acids and bases separately in enclosures made of corrosion-resistant materials.
Oxidizing Chemicals
Oxidizers are materials that yield oxygen readily to stimulate the combustion of organic
matter. When oxidizers come in contact with flammable solvents, they can start or fuel fires.
Typical oxidizing agents found in laboratories include chromates and dichromates, halogens
and halogenating agents, peroxides and organic peroxides, nitric acid and nitrates, chlorates
and perchlorates, and permanganates and persulfates.
• Store oxidizers away from alkalis, azides, nitrites, organic compounds (including acetic
acid), powdered metals and activated carbon.
• Avoid contact between oxidizers and common combustible materials such as paper, cloth
and wood.
Water-Reactive Compounds
Water-reactive compounds include alkali earth metals such as lithium, potassium and sodium,
sodium borohydride, calcium carbide and sodium peroxide. Solutions containing water, such
as inorganic acids and alcohols, should be kept separated from these chemicals during storage
and use.
• Store water-reactive compounds away from aqueous solutions, inorganic acids, base
solutions and alcohols. Though many chemical storage systems recommend water-
reactive solids be stored in the flammable storage cabinets, in many cases this would not
be prudent since these cabinets often contain alcohols with 30 percent water.
• Keep a Class D fire extinguisher near storage and use areas for these compounds.
• Store these compounds in locations protected from automated sprinklers.
King County - Lab Waste Management Guide 11
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• Alkali metals should be stored in areas where they are free of moisture, contact with
oxygen, and, in the case of lithium, nitrogen gas.
• Only the amount of water-reactive materials necessary to perform the work should be
removed from storage. Spare materials should be returned to the appropriate storage
container, and the container to its appropriate location.
• Storage containers should be labeled with their contents, hazardous properties and type of
oil or gas used to inert the metal. Furthermore, these containers should be stored
individually or in a manner that allows visual inspection for container integrity.
• Storage areas should be free of combustibles and of ignition sources.
• The portions of the building dedicated as storage area for alkali metals should not be
equipped with automatic sprinklers. No other source of water (e.g., showers, sinks) should
be in the immediate proximity of the metal.
• Storage areas should be prominently labeled to indicate the presence of alkali metals.
We suggest following the storage and handling guidelines found in Prudent Practices in the
Laboratory by the National Research Council's Committee on Hazardous Substances in the
Laboratory (National Academy Press, Washington, DC, 1995).
Both J.T. Baker and Flinn have established systems for chemical storage.
Potentially Explosive Chemicals
Several classes of chemicals may become explosive when they react with other compounds or
may become unstable during storage. Seriously question whether you need these compounds
in your facility. These include peroxidizable solvents, potentially explosive dinitro- and
trinitro- organic compounds and elemental potassium.
Metal Azides
Inorganic azide compounds, such as sodium azide, can react with metals and their salts to
produce explosive metal azide crystals. For example, when azide solutions are poured down
drains the dilute solution can react with lead solder and copper pipes to produce explosive
lead or copper azide salts.
• If you must use azide solutions, replace metal pipes with PVC or other non-metal piping
materials.
• If sodium azide solutions have been discharged to drains having metallic pipes or solder,
you should assume your pipes may be contaminated with metal azide salts. Contact the
Business Waste Line at 206-296-3976 or Washington Department of Ecology (Ecology) at
425-649-7000 for assistance in determining the proper disposal procedures.
12 King County - Lab Waste Management Guide
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Ethers and Other Peroxide-forming Chemicals
Certain ethers are more susceptible to peroxide formation than others. Peroxides are formed
by oxygen that reacts with ethers: R-O-R is ether; R-O-O-R is peroxide. It is the oxygen-to-
oxygen bond that makes ether unstable. Generally, the larger the alkyl group (R), the more
readily the ether will form peroxides. Ethyl ether and isopropyl ether can react with air to
form explosive peroxide crystals. Other solvents such as tetrahydrofuran and dioxane can also
produce peroxides.
Peroxides can explode when subjected to heat, friction or shock. Do not disturb or open
containers in which peroxides may have formed. A good rule of thumb is to dispose of any
container holding a peroxide-forming compound one year after the date it was opened. Label
these containers with the words "DATE OPENED" and add the date.
To prevent the formation of peroxides:
• Avoid using peroxide-forming solvents if possible.
• Purchase ether with butylhydroxy toluene (BHT) or ethanol added as an anti-oxidant.
• Label ether containers with the dates they are opened.
• Purchase ether in containers small enough to use all the solvent within six months.
• Check the MSDSs for your solvents to see if any are prone to creating peroxides.
Elemental potassium is a peroxide-former that is commonly used in school laboratories to
demonstrate characteristics of period 1 earth metals. Potassium is a water-reactive earth metal
that reacts with moisture in air to start the peroxidation process. This process can be observed
by physical changes in the color of the potassium sticks. Originally a dull silver color,
potassium will oxidize and form white crystals on its surface. As these crystals progressively
turn yellow, orange, red and purple, the peroxidation process is advancing and the compound
is increasingly at risk of exploding when handled. [Blair, 2000]
Metal Picrates and Picric Acid
Metal picrate compounds and picric acid can become dangerously unstable as a dry powder.
Picric acid can dry out and form explosive picrate crystals when exposed to air, especially
when contaminated with even minute amounts of metals.
To prevent the formation of explosive picrate crystals:
• Always keep picric acid wet or in solution.
• Avoid contact between picric acid and metals. Metal picrate salts are prone to explode
when subjected to friction or shock.
• Never purchase or store picric acid in containers with metal lids.
• Avoid flushing picric acid solutions down drains at concentrations above 0.01 percent.
King County - Lab Waste Management Guide 13
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• Dispose of more concentrated picric acid solutions as dangerous waste.
• Bouin's Fixative contains picric acid and formaldehyde solution (formalin.) Be sure to
keep this fixative hydrated with water. Bouin's 2000 is a picric acid and formalin-free
alternative available from American Master*Tech Scientific, Inc. 800-860-4073.
• If picric acid solutions have been discharged to drains with metallic pipes or soldered
joints, assume the piping is contaminated with explosive metal picrate salts. Contact the
Business Waste Line at 206-296-3976 or Ecology at 425-649-7000 for help in finding
proper disposal procedures.
Perchloric Acid
Perchloric acid is highly corrosive and typically occurs as a 70 percent solution. When
warmed above 150 degrees Fahrenheit, it is a powerful oxidizer. Perchloric acid can form
explosive metal perchlorate crystals in combination with heavy metals. Any work with
perchloric acid must be done in a specially-designed fume hood with a water wash down
system designed to prevent the buildup of metal perchlorates in the duct work. If you have
been performing perchloric acid digestions in a fume hood not specifically designed for
perchloric acid, contact the Business Waste Line at 206-296-3976 or Ecology at 425-649-
7000 immediately for assistance in locating a contractor to evaluate the hood for perchlorate
contamination.
• Spills and other emergencies: In the event of a perchloric acid spill, neutralize with soda
ash (sodium carbonate) or another appropriate neutralizing agent. Soak up the spill with
an inorganic based absorbent. Do NOT use rags, paper towels, or sawdust and then put
them aside to dry out, as such materials may spontaneously ignite. Likewise, spills on
wood may present a fire hazard after the liquid dries.
• If you must use perchloric acid solutions, replace metal pipes with PVC or other non-
metal piping materials.
• If perchloric acid solutions have been discharged to drains having metallic pipes or solder,
you should assume that your pipes may be contaminated with metal azide salts. Contact
the Business Waste Line at 206-296-3976 or Ecology at 425-649-7000 for assistance in
determining the proper disposal procedures.
• Regularly inspect your containers of perchloric acid for discoloration. If the acid has
turned a dark color and has crystals forming around the bottom of the bottle, there is a
potential explosion hazard. Notify an emergency response agency and secure the area.
White crystals around the cap are typically an ammonium salt, and small amounts may be
washed off the bottle to the sewer using copious amounts of water.
Ammoniacal Silver Staining Solutions
Ammoniacal silver staining solutions are hazardous because they can form explosive silver
salts. Whether disposed or deactivated, these wastes are counted against your generator
status. See Appendix C for information on these and other stains.
14 King County - Lab Waste Management Guide
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Safe use of these staining solutions includes the following procedures:
• Don't allow silver nitrate to remain in ammonium solutions for more than two hours.
• Keep silver nitrate solutions separate from ammonium hydroxide solutions.
• Deactivate these waste solutions by diluting 15:1 with water. Then, while stirring
frequently, slowly add 5 percent hydrochloric acid to the solution until the pH reaches 2.
• Add ice if the solution heats up.
• Silver chloride will precipitate out when the pH reaches 2.
• Filter out the precipitate and dispose as hazardous waste, adjust the pH of the solution to 6
to 7 with sodium bicarbonate, then discharge to the sanitary sewer.
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HAZARDOUS WASTE REDUCTION AND DISPOSAL
A hazardous waste is a solid, liquid or gas that could pose dangers to human health or the
environment. In Washington State, hazardous waste is called dangerous waste and is
primarily regulated by the Department of Ecology (Ecology). Several other federal, state and
local agencies may regulate a laboratory's hazardous materials and wastes. These include the
federal Environmental Protection Agency, the state Department of Labor and Industries, the
local fire department, the local air quality authority and the local sewer district.
Not complying with hazardous waste regulations can lead to significant fines and penalties. It
is important that laboratory managers take steps to avoid violating regulatory requirements.
• The manager of a laboratory should establish, follow and support a laboratory waste
management policy.
• The policy should include written procedures and defined responsibilities.
• Laboratories should have a staff member responsible for coordinating hazardous materials
management and ensuring regulatory compliance.
The Occupational Health and Safety Administration (OSHA) requires all laboratories to
implement a written Chemical Hygiene Plan. These plans are monitored for compliance with
OSHA requirements by the state Department of Labor and Industries. In 29 CFR Part 1910 §
191.1450, Appendix A, OSHA lists the National Research Council's recommendations
concerning chemical hygiene in laboratories. Important topics that should be addressed
include rules and procedures about:
• Chemical procurement, distribution and storage
• Environmental monitoring
• Housekeeping, maintenance and inspections
• Medical program
• Personal protective apparel and equipment
• Records
• Signs and labels
• Training and information
• Waste disposal
OSHA recommends that a laboratory's Chemical Hygiene Plan include a waste disposal
program. The following are specific recommendations (29 CFR 1910 §191.1450):
• Comply with Department of Transportation regulations (CFR 49) when transporting
wastes.
16 King County - Lab Waste Management Guide
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• Promptly dispose of unlabeled containers. If partially used, they should not be opened.
• Remove waste from laboratories to a central waste storage area at least once a week and
from the central waste storage area at regular intervals.
• Avoid indiscriminate disposal by pouring waste chemicals down the drain or adding them
to mixed refuse for landfill burial. This is unacceptable and often illegal.
• Do not use fume hoods to dispose of volatile chemicals.
• Dispose of wastes by recycling, reclamation or chemical deactivation whenever possible.
• Avoid stocking over 2.2 pounds or 1.0 kilograms of "P-listed" chemical products (WAC
173-303-9903.) This could help you stay below large quantity hazardous waste generator
status.
• Limit the size of samples you accept and guarantee your ability to return samples to the
supplier.
Hazardous waste disposal is a complex issue. Before you attempt to deactivate hazardous
wastes for sewer or solid waste disposal, check with the regulating agency to see if the
process is acceptable. Written documentation of chemical deactivation activities may be
required. Several resources are available to provide guidance in managing your laboratory
wastes. The following sections provide guidance on specific waste streams that labs often
find challenging to properly manage.
Acetone Used in Glassware Cleaning
Analytical laboratories often use acetone when cleaning glassware. Acetone is ignitable and
is a federally-regulated F003 dangerous waste. It may not be rinsed off the glassware and put
down the drain. (Flammable liquids are prohibited from sewer disposal.) Instead, collect
acetone rinsate and dispose of it as ignitable dangerous waste.
High Pressure Liquid Chromatography Waste
High pressure liquid chromatography (HPLC) analyses are typically done with a mixture of
water, acetonitrile and methanol. Both acetonitrile and methanol are flammable solvents.
Some methods add 0.1 percent trifluoroacetic acid to the mixture. Acetonitrile concentrations
in the resulting liquid waste range from 10 to 40 percent and are prohibited from discharge to
the sewer.
There are a number of ways to reduce the volume of solvent waste from HPLC analyses.
These include modifying the size of columns used in the process, distilling and reusing
acetonitrile, and separating water from the solvent waste. If the water remaining after
separation contains <100 milligrams/liter of acetonitrile, it may be discharged to the sewer in
King County.
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Ethidium Bromide Management
Ethidium bromide (EtBr) is commonly used in molecular biology research and teaching
laboratories. While it is not regulated as dangerous waste, the mutagenic properties of this
substance may present a hazard when poured down the drain or placed in the trash.
Based on these considerations, the following disposal procedures for ethidium bromide are
recommended:
Disposal of Pure Ethidium Bromide
Unused Ethidium Bromide (EtBr) should be collected for disposal with a hazardous waste
vendor.
Disposal of Electrophoresis Gels
Trace amounts of EtBr in electrophoresis gels should not pose a hazard. Higher
concentrations, e.g., when the color of the gel is dark pink or red, should not be placed in
laboratory trash. The disposal recommendations for gels are:
• Less than 0.1% EtBr: dispose as solid waste with approval from Public Health - Seattle &
King County
• More than or equal to 0.1% EtBr: place in sealed bags and label for disposal as hazardous
waste.
Disposal of Contaminated Gloves, Equipment and Debris
Gloves, test tubes, paper towels, etc., that are contaminated with more than trace amounts of
EtBr should be placed in sealed bags and labeled for hazardous waste disposal.
Disposal of Ethidium Bromide Solutions
Aqueous solutions with <10|ig/ml (<10 ppm) EtBr can be discharged to the sewer.
Aqueous solutions containing >10|ig/ml (>10 ppm) EtBr: Chemically treat using the
decontamination procedures listed below and dispose to the sewer or collect for disposal as
dangerous waste. All aqueous solutions released to the sewer must meet local sewer
discharge requirements for metals, pH, etc.
Solvent solutions containing any amount of EtBr; or EtBr mixed with a radioactive isotope are
restricted from discharge to the sewer and should be disposed as ignitable dangerous waste.
Treatment of Ethidium Bromide Waste
Ethidium bromide waste solutions can be treated to increase their concentration before
disposal, thereby reducing disposal costs, or deactivated to eliminate their hazardous
characteristics before discharge to the sewer. Most universities recommend filtration over
deactivation as the safer method.
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Filtering aqueous EtBr waste solutions through activated charcoal is simple and effective. The
filtrate may be poured down the drain. Commercially available filtration systems include
Fluor Away™, the S&S Extractor™ and The Green Bag® Kit.
• Filter the EtBr solution through charcoal filter.
• Pour filtrate down the drain.
• Place charcoal filter in a sealed bag (e.g., zip-lock) and collect for disposal as hazardous
waste.
A safety note: if using house vacuum to speed filtration, do not use a standard Erlenmeyer or
side-arm filtering flask. A filtration flask capable of withstanding vacuum must be used to
prevent implosion.
Deactivating EtBr Solutions
All EtBr solutions that are deactivated should be neutralized and poured down the drain with
copious amounts of water. Deactivation may be confirmed using ultraviolet (UV) light to
detect fluorescence. There are two recognized methods for deactivation, the Lunn and
Sansone Method [Lunn and Sansone, 1994, p. 185] using hypophosphorus acid and sodium
nitrate, and the Armour Method that uses household bleach. [Armour, 1996, p. 214] Though
the Armour Method is the simplest, it is somewhat controversial since found traces of
mutagenic reaction mixtures using this method. [Lunn and Sansone, Analytical Biochemistry,
1987, vol. 162, p. 453]
Decontamination of Ethidium Bromide Spills
EtBr spills can be decontaminated with a solution of 20 ml of hypophosphorus acid (50%)
added to a solution of 4.2 g of sodium nitrate in 300 ml water. Prepare fresh solution the day
of use in a fume hood. Wear rubber gloves, lab coat, and safety glasses. Turn off electrical
equipment before decontamination.
• Soak paper towel in decontamination solution, place on contaminated surface, and scrub.
• Scrub five more times with paper towels soaked in water, using fresh towel each time.
• Place all towels in a container and soak in fresh decontamination solution for one hour.
• Test squeezings from final towel scrub and mixture for fluorescence; repeat procedure
with fresh decontamination solution if fluorescence is present.
• Neutralize with sodium bicarbonate and discard as nonhazardous aqueous waste.
• This procedure has been validated for EtBr-contaminated stainless steel, Formica, glass,
vinyl floor tile surfaces, and filters of transilluminators.
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Alternatives to Ethidium Bromide
Ethidium bromide (EtBr) is a dangerous compound due to its mutagenicity. SYBR Safe™ is
a potentially safer alternative. Data on mutagenicity and EcoToxicity show SYBR Safe™ is
much less mutagenic than EtBr and is acceptable for discharge to the sanitary sewer.
Several major institutions have switched from EtBr to SYBR Safe™ with good results in
DNA analysis. However, SYBR Safe™ is less effective than the traditional EtBr staining for
RNA analysis.
Disposal of Alcohols
Alcohols, such as ethanol, methanol and isopropanol, are common organic solvents used in
laboratories. All are flammable and are regulated as ignitable hazardous waste at
concentrations above 24 percent in water. Additionally, methanol and isopropanol are
category D toxic hazardous wastes under the Washington Dangerous Waste Regulations and
are considered hazardous waste at a concentration above 10 percent in water.
Alcohol solutions that characterize as hazardous wastes are prohibited from discharge to the
sewer. Dilution of waste alcohol solely to bring its concentration below these levels is
prohibited. Dilution of alcohol that is done as part of the "industrial process" at the lab is
allowed and its concentration is not evaluated for waste characterization until the process is
complete.
For example, in teaching laboratories, what would be considered "waste" ethanol can be
mixed with water to demonstrate the Particle Theory. The final volume of the solution is less
than the predicted sum of the volumes of the separate solutions because the alcohol and water
molecules arrange in a different geometry that is more closely packed. At the point the
demonstration is completed, the ethanol concentration is determined. If the final ethanol
concentration is below 24 percent, it will not be considered an ignitable waste and would be
acceptable for discharge to the sewer.
Technologies are available for removing stains, dyes and cell debris from reagent grade
ethanol, methanol and isopropanol used in Cytology and Histology stain lines, thus permitting
the same alcohol to be reused indefinitely. In addition, these systems will remove lipids (fats)
and marker inks commonly found in tissue processor waste alcohol. Commercially available
systems include the filtration-based Benchtop Alcohol Recycling System™ from Creative
Waste Solutions and fractional-distillation-based systems from B/R Instruments, CBG
Biotech and CMT Environmental Services. Suncycle Systems has also developed an alcohol
cartridge recycling system for tissue processors.
Descriptions of these systems can be found by visiting the Sustainable Hospitals website at
http://www.sustainablehospitals.org/cgi -bin/DB_Report.cgi?px=W&rpt=Cat&id=30
Isopropanol is often used as a disinfectant in medical labs. Surfaces are wiped down with a
cloth or paper towel holding isopropanol, with much of the isopropanol evaporating off the
cloth and counter. When the cloth wiper is no longer useful, put the rag in your shop towel
collection container for laundering, or wring out the free liquids into an ignitable hazardous
20 King County - Lab Waste Management Guide
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waste collection container. The remaining cloth or paper wiper will typically be acceptable
for disposal as solid waste. See Appendix E, Solid Waste Disposal Common Questions, for
important information on receiving clearance for disposal of solid waste in King County.
Disposal of 3,3-Diaminobenzidine (DAB)
3,3-Diaminobenzidine lacks toxicity data to allow characterization as a dangerous waste. It is
a potent mutagen and should be handled very carefully. Contact with the skin causes burning
pain and itching. Inhalation can cause cyanosis (bluish lips.) Because it poses a serious risk
to health on contact, DAB is not permitted to be discharged to the sewer or septic tank. It is
recommended that DAB be disposed as a hazardous waste or be detoxified prior to discharge
to the sewer.
Do not try to detoxify DAB with chlorine bleach (sodium hypochlorite) because the products
remain toxic. There are two methods to detoxify DAB. One method is described as follows:
[Dapson, 1995, p. 162]
DAB Detoxification Procedure
1. Prepare the following aqueous stock solutions
• 0.2 M potassium permanganate (31.6 g KMnO4 /liter)
• 2.0 M sulfuric acid (112 ml concentrated acid/liter)
2. Dilute the DAB solution until its concentration does not exceed 0.9 mg/ml.
3. For each 10 ml of DAB solution, add:
• 5 ml 0.2 M potassium permanganate
• 5 ml 2.0 M sulfuric acid
4. Allow mixture to stand for at least 10 hours. It is now non-mutagenic.
Disposal of Wastes Containing Sodium Azide
Some commonly used laboratory reagents contain sodium azide. Sodium azide is a category-
B toxic compound due to oral-rat LD50 data, so in a mixture it will designate at a
concentration of 0.1%. Any waste containing over 0.1% sodium azide must either be treated
to remove the toxicity characteristic or disposed as a hazardous waste. It also can form
explosive metal azides, as is discussed in the Managing Hazardous Chemicals On-site section
below.
Enterococcus Agar
Here is a common list of constituents and concentrations, expressed in amount per liter.
Enzymatic Digest of Casein 13.0 g
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Enzymatic Digest of Soybean Meal 5.0 g
Yeast Extract 6.0 g
Dextrose 3.0 g
Dipotassium Phosphate 4.0 g
Sodium Azide 0.4 g
Agar 10.0 g
Through this calculation: 0.4 grams/liter = 400 mg/L = 400 ppm = 0.04%, we find the final
sodium azide concentration to be below the 0.1% concentration where it would designate as a
hazardous waste. Therefore, waste Enterococcus agars do not have to be counted or disposed
as hazardous waste.
Alkaline Iodide Azide (AIA) Reagent for the Winkler Dissolved Oxygen Titration
Here is a common list of constituents and concentrations in the AIA reagent before being
added to a water sample for dissolved oxygen analysis.
Water 50.0 percent
Potassium Hydroxide 40.0 percent
Potassium Iodide 9.0 percent
Sodium Azide 0.6 percent
Since the sodium azide concentration is over 0.1% with a pH greater than 12.5, expired or
unused stock reagent will be regulated as a corrosive, Washington-state-only toxic hazardous
waste. When used as a titrant, it is sufficiently diluted during the analytical process to fall
below the 0.1% concentration limit. The waste solution generated by the Winkler Method
must be counted as a corrosive hazardous waste if its final pH is over 12.5, but it can then be
neutralized under the treatment-by-generator guidelines and disposed to the sewer.
Management of Aldehyde Wastes
The most common aldehyde wastes coming from labs are ten-percent buffered formalin (3.7
percent formaldehyde solution,) two-to-four percent glutaraldehyde solutions and 0.5 percent
ortho-phthalaldehyde (OPA) solutions (typically Cidex® OPA.) Formalin is used as a tissue
preservative. Ortho-phthalaldehyde and glutaraldehyde are used as cold sterilants.
Formalin
Formaldehyde solutions are regulated in Washington State as category C toxic compounds.
Based on equivalent concentration criteria, formaldehyde solutions designate as hazardous
wastes at concentrations of 1.0 percent or more in water. However, due to concerns about
worker exposure to formaldehyde vapors, the discharge limit to the King County sewer
22 King County - Lab Waste Management Guide
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system is 0.1 percent formaldehyde in water. Formaldehyde solutions can never go into
septic systems or storm drains. Solutions that are more than 1.0 percent formaldehyde must
either be disposed as hazardous waste or chemically treated to reduce the formaldehyde
concentration to acceptable levels for sewer discharge.
Chemical Treatment of Formalin
Formalin is readily treatable. Solutions should be diluted with water to fewer than five percent
formaldehyde before chemical treatment. Commercially available chemical treatment
products that will "detoxify" formalin are listed below (although this list may not be
exhaustive):
• "Neutralex™" - produced by Scigen/Tissue Tek 800-725-8723 ext. 7268 (certified as a
treatment technology in California)
• VYTAC™ 10F" - by Baxter Healthcare Corp 800-964-5227 (certified as a treatment
technology in California)
• "Aldex®" - by Waste & Compliance Management, Inc. 866-436-9264 (turns the formalin
into a solid for disposal as solid waste)
• "Formalex®" - by S&S SASCO 800-624-8021 (notes: requires filtering and may require
pH adjustment; decertified as a treatment technology in California)
• "D-Formalizer®" - by Surgipath 800-225-3035 (not recommended due to release of low
levels of hydrogen sulfide gas)
• "Trans*Form™" - by American Master*Tech Scientific 800-860-4073.
Note that California's treatment technology certification program is no longer funded at the
time this edition was written.
According to product data, these compounds will reduce the concentration of a treated sample
of formalin to under 0.1 percent formaldehyde, though the times required for this vary.
According to product literature, both "Neutralex™" and "D-Formalizer®" will reduce the
concentration to less than 25 parts per million (ppm) in 15 minutes.
Since the sewer limit is 0.1 percent residual formaldehyde, the treatment compounds can be
diluted below the manufacturer's recommended concentration. For Neutralex™, one packet
is described as treating one gallon of buffered formalin to 15 ppm. However, since the sewer
limit is 1000 ppm, the packet can actually treat 50 times as much formalin and still have the
resulting solution meet the local sewer limit.
Formalin treatment is covered under the treatment by generator guidelines, so log sheets must
be kept indicating the amount of formalin treated and the dates the treatment occurred. The
amount of formalin generated before treatment must continue to be counted toward your
generator status.
King County - Lab Waste Management Guide 23
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Alternatives to Formalin
Another option is to request less hazardous preservatives from suppliers. Safer substitutes for
formaldehyde can reduce the risk of harmful exposures and potentially eliminate disposal
problems. Be sure to check with the Business Waste Line at 206-296-3976 before purchasing
a "safer substitute" to ensure that it really is less hazardous.
Propylene glycol-based solutions are often used for soaking solutions on specimens that have
been preserved in formalin. In histology settings, Prefer® or Safe-Fix® have been used as
effective substitute preservatives to formalin on small specimens but have been found to be
less effective on larger tissues due to their slower penetration rate. Other formalin alternatives
include ExCell Plus™ and Optimal *Fix™
Glutaraldehyde
Glutaraldehyde solutions are regulated in Washington State as category C toxic compounds.
Based on equivalent concentration criteria, glutaraldehyde solutions designate as hazardous
wastes at concentrations of 1.0 percent in water. However, research on biodegradability tests
found that two-to-four percent glutaraldehyde sterilant solutions broke down readily to non-
hazardous by-products in the sewer system. [Balogh, 1997] Therefore, cold sterilant solutions
containing less than four percent glutaraldehyde are acceptable for discharge to the King
County sewer system. Glutaraldehyde solutions can never go into septic systems or storm
drains. Solutions of over 4.0 percent glutaraldehyde must either be disposed as hazardous
waste or chemically treated to reduce the glutaraldehyde concentration to acceptable levels for
sewer discharge.
Chemical Treatment of Glutaraldehyde
Glutaraldehyde is readily treatable using the same methods described above for formalin.
Dilute solutions with water to less than five percent glutaraldehyde prior to chemical
treatment.
Ortho-Phthalaldehyde
O-phthalaldehyde solutions are regulated in Washington State as category C toxic
compounds. Based on equivalent concentration criteria, o-phthalaldehyde solutions designate
as hazardous wastes at concentrations of 1.0 percent in water. Therefore, cold sterilant
solutions containing less than one percent o-phthalaldehyde are acceptable for discharge to
the King County sewer system. O-phthalaldehyde solutions can never go into septic systems
or storm drains.
One of the most commonly used o-phthalaldehyde-based cold sterilants is Cidex® OPA.
Cidex® OPA contains 0.55 percent o-phthalaldehyde and therefore is acceptable for
discharge to the sewer at its working strength.
Research has recently been done on the aquatic toxicity of o-phthalaldehyde. Preliminary
data indicates that o-phthalaldehyde may be highly toxic to fish, which could lead to it being
prohibited from discharge to the sewer untreated.
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Chemical Treatment of Ortho-Phthalaldehyde
O-phthalaldehyde is readily treatable by adding the amino acid glycine to it at a rate of 25
grams per gallon of waste o-phthalaldehyde. Treating spent o-phthalaldehyde-based solutions
with glycine prior to discharge to the sewer is currently recommended as a best management
practice by the Washington Department of Ecology. [Fernandes, 2005]
Aldehyde Spill Management
Glutaraldehyde and formalin spills can be deactivated with one of the commercially-available
treatment chemicals listed above. O-phthalaldehyde spills can be deactivated by adding 25
grams of the amino acid glycine to each gallon of spilled material.
Management of Scintillation Fluid Wastes
Scintillation fluids are used to detect weak alpha and beta-emitting radionuclides. This is
typically done by mixing the fluid with the radionuclide, which contaminates the fluid.
If the stock fluid contains hazardous materials, the waste produced is by definition mixed
waste (both hazardous and low-level radioactive waste.) If the radioactive material
concentration is sufficiently low, the fluid can be disposed as a hazardous waste.
In guidance published between 1993 and 1995, the Department of Ecology approved three
scintillation fluids for discharge to the sewer:
• Packard / Perkin Elmer (PE) Microscint™ O
• Packard / PE Optifluor™
• National Diagnostic's Ecoscint
At this time, no other products have been approved by Ecology for discharge to the sewer.
Generally, if the samples turn out to be radioactive, they are disposed as either a mixed waste
or a radioactive waste. Those samples which do not have radioactivity detected (or very low
amounts of radioactivity) would be disposed in the sewer if non-hazardous or disposed as a
chemical waste or mixed waste if toxic.
Many other products are in the market. The compounds listed below designate as dangerous
waste and are prohibited from discharge to the sewer. The surfactants in many scintillation
cocktails contain alkyl phenoxy ethoxylates (APEs) or tergitol. Both of these compounds are
Category D toxic hazardous wastes. Other cocktails contain xylene, pseudocumene or other
solvents that cause them to be regulated as ignitable hazardous wastes.
• Packard / Perkin Elmer: Microscint™ 20, Ultima Gold, OptiPhase HiSafe, OptiPhase
HiSafe 2 and OptiPhase PolySafe
• National Diagnostics: Ecoscint™ A, Ecoscint™ O and Ecoscint™ H, Uniscint BD
• Beckman Coulter: Ready Safe, Ready Protein+, Ready Gel, Ready Value, Ready Organic,
Ready Flow III and Ready Solv HP
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Pollution Prevention (P2)
Activities that reduce waste and prevent pollution are strongly encouraged by Ecology, King
County Water and Land Resources Division and the Local Hazardous Waste Management
Program in King County. Reducing use of chemicals reduces chemical waste. Basic pollution
prevention techniques include product substitution, reduced product usage, recycling and
reuse of chemicals, modified operations, careful inventory tracking and water conservation.
Pollution prevention best management practices include the following:
• Use analytical methods that do not require hazardous chemicals.
• Substitute hazardous chemicals with less toxic alternatives.
• Use the least amount of chemical required for each experiment or process so that there is
less to dispose of as waste.
• Ask if your suppliers offer chemicals in small volumes and buy them in small lots. This
can reduce waste and leftover materials in case procedures are changed, expiration dates
pass or spills occur.
• Use microscale techniques when available to reduce analytical wastes. Contact the
National Microscale Chemistry Center for more information and assistance.
• Microscale chemistry often is too expensive for high school and middle school
laboratories. Small-scale chemistry is a less expensive alternative that has been adopted
by many schools. Stock solution concentrations are typically reduced to less than 1.0
molar, volumes are measured in drops rather than milliliters and inexpensive plastic
equipment is used rather than expensive glassware. Contact the National Small Scale
Chemistry Center for more information and assistance.
• Date containers when they arrive so you can see how quickly they are used (if at all). Bar
coding systems are now available to track inventory.
• Consolidate or coordinate purchasing authority to reduce duplicate purchases of chemicals
and improve inventory tracking.
• Check with suppliers of your laboratory standards. Some will allow you to ship standards
back for reuse after the expiration dates have passed. If yours does not, dispose of them
properly.
P2 Example: Liquid Chromatography
Solvent recycling in liquid chromatography (LC and HPLC) can be done by the
microprocessor controlled S3 Solvent Saver System®. It uses a sensitive level sensing circuit
to shunt the eluant to waste whenever the output from the system detector exceeds a user set
level. After the contaminant (normally a component from the sample) has passed and the
output from the system detector drops below the programmed level, the uncontaminated
26 King County - Lab Waste Management Guide
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solvent will be returned to the solvent reservoir to be used again, reducing both solvent
disposal and purchasing costs.
P2 Example: Western Blotting
Western blotting is a technique used by biochemists to electrophoretically transfer proteins
from polyacrylamide gels onto a more stable membrane substrate, such as nitrocellulose. The
standard conducting solution used during western blotting contains 20% methanol, resulting
in the generation of a listed hazardous waste. For many protein transfer applications,
particularly those involving high molecular weight proteins, it is possible, and even helpful, to
replace 20% methanol, a hazardous waste, with 20% ethanol, a non-hazardous waste, in the
conducting solution.
On-site Treatment of Laboratory Wastes
Laboratories are uniquely qualified to treat some of their wastes to eliminate their hazards or
reduce the amount of waste needing disposal, thereby cutting costs. Unlike the situation in
many other states, the Washington Department of Ecology encourages on-site treatment of
hazardous wastes by generators. Six focus sheets have been published by Ecology to provide
treatment-specific guidance on carbon adsorption, elementary neutralization, evaporation,
filtration, separation and solidification. Ecology's Technical Information Memorandum 96-
412 provides guidance on how to conduct these activities.
Specific Standards for On-site Treatment of Wastes
• Before initiating treatment, verify the resulting wastes are acceptable for disposal as solid
waste or to the sewer and that the treatment process cannot pose a risk to human health or
the environment.
• The container in which treatment occurs must be marked with the date was first
accumulated in it and emptied every 180 days for medium quantity generators or 90 days
for large quantity generators.
• The containers must be in good condition, compatible with their contents, properly
labeled, kept closed and inspected weekly.
• Secondary containment should be provided for wastes awaiting treatment.
The following criteria are condensed from Ecology's Treatment by Generator (TBG) Fact
Sheets. [Ecology, 2004]
Carbon Adsorption
• It works well with aromatic solvents, chlorinated organics, phenols, polynuclear
aromatics, organic pesticides, chlorinated non-aromatics, high molecular weight
aliphatics, chlorine, halogens, antimony, arsenic, bismuth, chromium, tin, silver, mercury
and cobalt.
King County - Lab Waste Management Guide 27
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• It works poorly with alcohols, low molecular weight ketones, organic acids, aldehydes,
low molecular weight aliphatics, nitrates, phosphates, chlorides, bromides, iodides, lead,
nickel, copper, cadmium, zinc, barium and selenium.
• It is allowed when treated effluent and backwash are properly managed and disposed,
spent carbon is regenerated or disposed properly, spills and releases are promptly cleaned,
equipment is decontaminated as needed and sufficient time is provided for the carbon to
adsorb contaminants.
Evaporation
• It is allowed if only inorganic waste mixed with water is treated, all organic vapors from
organic solutions are captured, some water content is left to prevent "over-cooking" of
sludges, remaining sludges are properly disposed and secondary containment is provided
for the evaporator.
• Many schools can evaporate water from waste copper sulfate and other metal solutions as
a waste-reduction and cost-cutting technique. By lining the evaporation container with a
closable plastic bag, the waste sludge can be easily removed and placed in a small
hazardous waste collection container for eventual removal.
Separation
• All separation processes must not change a waste's structure, except to form a precipitate,
and cannot generate toxic or flammable gases unless all vapors are captured.
Elementary Neutralization
• This process can only be used on wastes that are regulated solely because they exhibit the
characteristic of corrosivity from having a pH of less than or equal to 2.0 or greater than
or equal to 12.5.
• The resulting waste must have a pH between 6 and 9 and meet the sewer discharge
guidelines listed in Appendix A prior to discharge
• Neutralizing large volumes of concentrated mineral acids is discouraged, since it
generates significant heat and fumes which pose serious safety risks.
• Passive limestone acid-neutralization tanks are not recommended. These tanks are hard to
maintain, sulfuric acid can significantly reduce their effectiveness and hard-to-reach
sediments must be removed and characterized before disposal.
28 King County - Lab Waste Management Guide
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Treatment by Generator Counting Requirements
• Regulated generators must notify Ecology on their Form 2 and in their Dangerous Waste
Annual Report that they are conducting treatment by generator activities and whether it is
being done in accordance with a specific fact sheet. This notification must occur before
initiating treatment.
• TBG activities will not reduce a lab's hazardous waste generator status, but it will
typically reduce disposal costs significantly. For annual reporting and generator status
determinations, the total quantity (as wet weight) of waste generated prior to treatment
and the weight of any remaining material that designates as hazardous waste after
treatment must be counted. The waste before treatment and materials remaining after the
process must be designated and managed properly.
• Generators must maintain a written log of the quantity of each dangerous waste managed
on site, the treatment method and the date treatment occurred.
Permit by Rule
Permit by rule is a second regulatory allowance for on-site treatment of wastes before
disposal. One of the common areas of regulatory confusion regards the difference between
permit by rule and treatment by generator. Both are available options for laboratories wishing
to manage wastes on site.
There are two primary benefits derived from receiving a permit or written authorization that
qualifies a process for permit-by-rule exemption.
• The waste that is treated under Permit by Rule is exempt from being counted toward your
generator status.
• Waste disposal costs are less because your waste is not hauled off-site
Conditions to Qualify for Permit by Rule (PBR) Exemption
• You must have written permission to discharge the waste to the sewer from the Publicly
Owned Treatment Works (POTW.) NOTE: This document does not constitute permission under the
PBR guidance in WAC 173-303-802.
• Wastes must be properly designated at point of generation, before mixing with any other
waste streams.
• If treatment will be in an elementary neutralization unit, wastes must designate as
hazardous only because of the corrosivity characteristic.
• In order to qualify as an elementary neutralization unit, treatment must take place in a tank
or container.
• The waste must be treated immediately upon being generated. This requires a "hard-
piped" system connecting the process that generated the waste to the treatment tank. There
King County - Lab Waste Management Guide 29
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can be no break between the point where the waste was generated and the treatment tank,
such as by emptying the waste into a bucket and then pouring it into the treatment tank.
• The generator must notify Ecology that wastes are being treated on-site and indicate on
the annual report that PER activity is being conducted.
• The facility must have a contingency plan and emergency procedures.
• Weekly inspections of the treatment tank's integrity must be done and good housekeeping
practiced in the area.
• Staff training must be documented.
Example: PBR for Lab Sample Destruction
• You must meet all the requirements listed above under Conditions to Qualify for Permit
by Rule (PBR) Exemption. NOTE: This document does not constitute permission under the PBR
guidance in WAC 173-303-802.
• Laboratory samples are kept under chain-of-custody protocols for an established length of
time before being disposed. Some of these samples are of water which has been acidified
before analysis to preserve the sample.
• When the protocol no longer requires a sample be stored, it can be disposed. If the sample
is hazardous only for the corrosivity characteristic, it can be neutralized and discharged to
the sewer. This neutralization can be viewed as treatment by generator or permit by rule
depending on the circumstances.
• When treated in batches by adding a neutralizing solution to the sample, it is considered
treatment by generator (TBG) and the waste must be counted towards the lab's generator
status. This is because the sample becomes a waste as soon as it begins to be treated and
the treatment is done in a batch process. For larger labs doing water quality analyses, this
could move their generator status up to large quantity generator.
• It is considered immediate treatment under PBR if an entire acidified liquid sample is
poured or siphoned directly into a neutralization tank that already contains a basic
neutralizing solution. This is considered PBR, and does not count as generated hazardous
waste, because the liquid is a viable reference sample until it comes into contact with the
neutralizing liquid via a continuous "hard-piped" system.
Example: PBR for Managing Acidic Glass-Washing Solutions
• You must meet all the general requirements listed above to qualify for PBR consideration.
NOTE: This document does not constitute permission under the PBR guidance in WAC 173-303-802.
• Laboratory glassware is often acid-washed in tubs. This acidic wastewater must be
neutralized before discharge to the drain. It is subject to regulation as dangerous waste if
its pH is less than 2.0.
30 King County - Lab Waste Management Guide
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• This wastestream, which can also be a significant portion of a lab's entire generated
waste, can be viewed as treatment by generator or permit by rule depending on the
circumstances.
• If the wastewater from the glass washing tub is directly piped to an elementary
neutralization tank, neutralized, then directly piped to the sewer, it will qualify as
immediate treatment under PER and not be counted as generated waste.
• If the glass washing wastewater is treated in batches by adding a neutralizing compound
to it, the process is considered TBG and counts towards the lab's generated hazardous
waste.
Wastewater and Solid Waste Disposal Guidelines
All wastewater discharged to the sewer system must comply with local, state and federal
standards. These are designed to protect surface waters and to maintain the quality of
biosolids from wastewater treatment plants. Discharge to a septic tank system is regulated as
if the discharge was directly to groundwater, so virtually no wastes may go to a septic tank.
Do not discharge laboratory wastes to a septic system. Laboratory operations often generate
hazardous wastes that contain dilutions and mixtures of chemicals in very low concentrations
or in small quantities. See Appendix A for King County guidelines for disposal of non-
hazardous wastes to the sewer system.
Solid waste guidelines are designed to protect local and regional landfills, transfer stations,
their customers and their employees. Appendix B lists King County guidelines for solid waste
disposal. In general, each component of a waste stream must meet all criteria listed in the
relevant appendix to be accepted for discharge to the King County sewer system or disposal
as a solid waste.
The guidelines in the appendices are offered as a starting point for proper sewer and solid
waste disposal and should not be considered definitive. Many aspects of the dangerous waste
regulations, Chapter 173-303 WAC (listed wastes, off-spec chemicals, mixtures,
formulations, etc.), are not covered in Appendices A and B. Please refer to WAC 173-303-
070 through 173-303-110 for waste designation procedures. The generator has full
responsibility for waste characterization and regulatory compliance.
Certain wastes that fail the criteria listed in Appendix A may be suitable for discharge to the
sewer under special rules. Under all conditions, obtain written authorization from the King
County Industrial Waste Program at 206-263-3000 or a local sewer utility to discharge
wastewater that falls outside these criteria. For information on solid waste disposal, call the
Waste Characterization Program at Public Health - Seattle & King County at 206-296-4633.
Again, these guidelines do not provide authorization under Permit by Rule to allow discharge
of hazardous chemicals to the sewer. They serve, in part, as a guideline to assist businesses
and agencies in King County in determining whether their waste may be acceptable for
discharge to the sewer.
King County - Lab Waste Management Guide 31
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FOR MORE INFORMATION
Industrial Materials Exchanges
For materials management alternatives, contact the Industrial Materials Exchange (IMEX) at
206-296-4899. IMEX is a free service designed to help businesses find markets for industrial
by-products and surplus materials. Through IMEX, businesses with materials they can no
longer use can be matched with others who may need the materials. Materials are advertised
at no cost.
Hazardous Waste Management-ln King County
The Local Hazardous Waste Management Program in King County provides on-site
consultation services to businesses in King County. The services are at no charge to the
customer and do not have the regulatory authority of enforcement. Information is kept strictly
confidential. Call 206-263-3080.
The Business Waste Line provides answers to questions about hazardous waste management.
The caller may remain anonymous. Call 206-296-3976 or e-mail bwl@metrokc.gov
The Waste Characterization Program at Public Health - Seattle & King County provides
answers about what can go into the landfills. Call 206-296-4633 or e-mail wc@metrokc.gov
Hazardous Waste Management- Outside King County
The Northwest Regional Office of the Washington Department of Ecology provides technical
and regulatory assistance to businesses throughout Washington State. In the northwest part of
the state, they can be reached at 425-649-7000. Ask to speak to a hazardous waste technical
assistance staff person.
King County Industrial Waste Program
For more information on sewer guidelines in King County, call the King County Industrial
Waste Program at 206-263-3000 or your local sewer utility.
Air Quality Management
For more information on air quality guidelines in the Puget Sound region, call the Puget
Sound Clean Air Agency at 206-343-8800.
32 King County - Lab Waste Management Guide
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Health and Safety Programs
For more information on health and safety regulations, call the Washington State Department
of Labor and Industries, Voluntary Services Program at 206-281-5470. The Voluntary
Services Program provides educational assistance to businesses at no charge and does not
have the regulatory authority of enforcement. All information is kept strictly confidential.
Resources for Reducing the Scale of Experiments and Analyses
The National Microscale Chemistry Center offers workshops, seminars and publications on
the operation and advantages of converting labs to the microscale level. Contact them via
phone at 508-837-5137 or at their website at
http://www.microscale.orgsilvertech.com/microscale/.
The National Small-Scale Chemistry Center is located at Colorado State University with
regional centers across the United States. The focus of small-scale chemistry is the teaching
lab. It is currently in use at secondary schools, community colleges and universities. Small
scale differs from microscale in its use of inexpensive plastic materials in place of traditional
glass apparatus. Both the volumes and concentrations of chemicals are reduced with these
substantial benefits:
• Lower costs of materials and chemicals
• Increased safety from use of unbreakable plastic and nonhazardous solutions
• Reduced lab set-up and clean-up times, which allows more hands-on chemistry
education
Visit their website at http://www.smallscalechemistry.colostate.edu/ for more information and
a free video demonstrating the benefits of small-scale chemistry.
King County - Lab Waste Management Guide 33
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APPENDIX A
KING COUNTY GUIDELINES FOR SEWER DISPOSAL
King County Guidelines for Sewer Disposal
Characteristic or
Criteria
1. FlashPoint
2. Boiling Point
3. Corrosivity (pH)
4. Solubility
5. Reactivity
6. Radioactivity
7. Persistence
(WAC 173-303-100)
8. Toxicity
(WAC 173-303-1 00)
9. Toxic Mixtures
(WAC 173-303-1 00)
Acceptable to sewer if meets
ALL of these criteria
>65 degrees C or 140 degrees F
>65 degrees C or 140 degrees F
5.5 to 12.0
Water soluble
Non-reactive
Meets WA Dept. of Health limitations1
Halogenated organic compounds <0.01%
Polycyclic aromatic hydrocarbons <1.0%2
Category X <0.001%
Category A <0.01%
Category B <0.1%
Category C <1.0%
Category D <10 %
No evidence or Category E =100%
Equivalent concentration <0.001%
Unacceptable to sewer if exhibits
ANY of these criteria
<65 degrees C or 140 degrees F
<65 degrees C or 140 degrees F
<5.5 or>12.0
Water insoluble
Water or air reactive; explosive;
polymerizer
Creates toxic gas or nuisance stench
Does not meet Dept of Health limits
Halogenated organic compounds >0.01%
PAH concentration >1.0%2
Category X >0.001%
Category A >0.01%
Category B >0.1%
Category C >1.0%
Category D >10%
Equivalent concentration >0.001%
Important Note: These guidelines for sewer disposal are not definitive. Many aspects of Chapter 173-303 WAC (e.g., listed wastes,
off-spec chemicals, mixtures, formulations, etc.) could not be covered in this table. Please refer to WAC 1 73-303-070 through -
1 1 0 for waste designation procedures. These guidelines are offered as a starting point for proper sewer disposal. The discharger
must take full responsibility for waste characterization and regulatory compliance. Certain wastes that fail the criteria listed in the
above table may be suitable for discharge to the sewer under rules promulgated by the Washington State Department of Ecology.
Under all conditions, obtain written authorization from King County's Industrial Waste Program to discharge wastewater that falls
outside these criteria.
1 Chapter 246 WAC. For specific guidance, contact the Washington Dept. of Health at 425-576-8945
2
Polycyclic aromatic hydrocarbons (PAHs) include acenaphthene, acenaphthylene, fluorene, anthracene, fluoranthene,
benzo(a)anthracene, benzo(b)fluoranthene, benzo(k)fluoranthene, pyrene, chrysene, benzo(a)pyrene, dibenz(a,h)anthracene,
indeno (1,2,3-c,d)pyrene, benzo(g,h,l)perylene, dibenzo [(a,e), (a,h), (a, I), and (a, I)] pyrenes, and dibenzo (a,j) acridine. Also,
carcinogens are not separately regulated.
Small quantity generators of hazardous waste should contact their sewer agency to see if they are partially exempt from the Toxic
Mixtures discharge requirements
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Toxic Category Table (WAC 173-303-100)
Data can be found in the Registry of Toxic Effects of Chemical Substances (RTECS), NIOSH
Category
X
A
B
C
D
Fish Oral (rat)
LC50 (mg/L) LD50 (mg/kg)
O.01 <0.5
0.01 -<0.1 0.5-<5.0
0. 1 - <1 .0 5 - <50
1.0 -<10 50-<500
10-100 500-5000
Inhalation (rat) Dermal (rabbit)
LC50 (mg/L) LD50 (mg/kg)
O.02 <2
0.02 - <0.2 2 - <20
0. 2 - <2.0 20 - <200
2.0 - <20 200 - <2000
20 - 200 2000 - 20,000
Example Compounds
Organophosphate
Insecticides
Fuming Nitric Acid,
Aflatoxin
Phenol, Sodium Azide
Sodium Cyanide
Stannic Chloride,
Sodium Fluoride
Methanol, Stannous
Chloride
King County Local Sewer Limits4
Substance
Arsenic
Cadmium
Chromium
Copper
Cyanide
Lead
Mercury
Nickel
Silver
Zinc
Temperature
Hydrogen
sulfide
Polar fats, oil and
grease (FOG)6
Nonpolar FOG6
Grab Sample Max (mg/L)
4
0
5
8
3
4
0
5
3
0
6
0
0
0
0
2
0
0
10.0
<150°F
10.0
No visible FOG floating on surface
100
Daily Average Max (mg/L)
1.0
0.5
2.75
3.0
2.0
2.0
0.1
2.5
1.0
5.0
100
4 Important note: Your sewer district may have local limits that are different than those listed above. Contact your local
sewer district to learn their limits
Daily average is calculated from three samples taken at least five minutes apart. Businesses discharging over 5,000
gallons a day must meet the standards for daily average maximum and grab sample maximum.
Polar FOG is from animal or vegetable sources. Nonpolar FOG is from mineral or petroleum sources. Important note:
Many sewer districts will have FOG limits that are lower than 1 00 mg/L. Contact your local sewer district to learn their limits
and to verify whether their FOG limits are for Total FOG (polar + nonpolar) or for only nonpolar FOG.
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Additional King County Sewer Guidelines
Substance
Glutaraldehyde7
Formaldehyde
Formalin (treated)9
Ethanol
Methanol
Isopropanol
Barium
Beryllium
Selenium
Thallium
Discharge Limits
One percent in water7
0.1 percent in water8
None once formaldehyde concentration is under limit
pH is adjusted as necessary
and
24 percent in water
Ten percent in water
Ten percent in water
100 mg/L
10mg/L
1.0 mg/L
1 0 mg/L
6 Important note: These guidelines are designed for small discharges of under 50 gallons. Your sewer district may
have local limits that are different than those listed above. Contact your local sewer district to learn their limits
7 Cold sterilant solutions containing no more than four percent glutaraldehyde may be discharged to the King County
sewer provided appropriate BMPs are followed. Contact King County Industrial Waste for a copy of the "Policy
regarding discharge of 2-4% glutaraldehyde disinfectant solutions to King County Sanitary Sewer".
Formaldehyde is a category B toxic compound and therefore designates as a hazardous waste at concentrations
above 0.1 percent.
g
See section on formaldehyde treatment options.
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APPENDIX B
SEATTLE & KING COUNTY GUIDELINES
FOR SOLID WASTE DISPOSAL
Characteristic or Criteria
1. Physical State
2. Corrosivity (pH)
3. Reactivity
4. Radioactivity
5. Toxicity Characteristic
Leaching Procedure
(WAC 173-303-090)
6. Persistence
(WAC 173-303-1 00)
7. Toxicity
(WAC 173-303-1 00)
8. Formalin Preserved
Tissues & Specimens
9. Toxic Mixtures
(WAC 173-303-1 00)
Unacceptable for solid waste disposal at sites in King County
Liquid
<2.0or>12.5
Water or air reactive; explosive; polymerizer.
Creates toxic gas or nuisance stench
Does not meet Dept of Health limits1
Must be less than Dangerous Waste limits for TCLP-listed metals and organics.
Halogenated organic compounds >0.01%
PAH concentration >1.0%2
Category X>0. 001%
Category A >0. 01%
Category B >0.1%
Category C >1.0%
Category D >10%
Residual formaldehyde concentration >1.0 %
Equivalent concentration >0.001%
Important Note: These guidelines for solid waste disposal are not definitive. Many aspects of Chapter 173-303 WAC
(e.g., listed wastes, off-spec chemicals, mixtures, formulations, etc.) could not be covered in this table. Please refer to
WAC 173-303-070 through -110 for waste designation procedures. The guidelines provided here are offered as a starting
point for proper solid waste disposal. The generator must take full responsibility for waste characterization and regulatory
compliance. Under most conditions you should obtain a written clearance from Public Health Seattle & King County prior
to disposal of contaminated or questionable solid waste. Call 206-296-4633 or e-mail wc@metrokc.gov for more help.
1 Chapter 246 WAC. For specific guidance, contact the Washington Dept. of Health at 425-576-8945
2Polycyclic aromatic hydrocarbons (PAHs) include acenaphthene, acenaphthylene, fluorene, anthracene, fluoranthene,
benzo(a)anthracene, benzo(b)fluoranthene, benzo(k)fluoranthene, pyrene, chrysene, benzo(a)pyrene,
dibenz(a,h)anthracene, indeno (1,2,3-c,d)pyrene, benzo(g,h,l)perylene, dibenzo [(a,e), (a,h), (a,I), and (a,I)] pyrenes, and
dibenzo (a,j) acridine. Carcinogens are not separately regulated.
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Toxic Category Table (WAC 173-303-100)
Data can be found in the Registry of Toxic Effects of Chemical Substances (RTECS), NIOSH
Category
X
A
B
C
D
Fish
LC50 (mg/L)
<0.01
0.01 -O.1
0. 1 -<1.0
1.0-<10
10-100
Oral
(rat)
LD50 (mg/kg)
<0.5
0.5-<5.0
5-<50
50 - <500
500 - 5000
Inhalation
(rat)
LC50 (mg/L)
<0.02
0.02 - <0.2
0. 2-<2.0
2.0 - <20
20 - 200
Dermal
(rabbit)
LD50 (mg/kg)
<2
2-<20
20 - <200
200 - <2000
2000 - 20,000
Example Compounds
Organophosphate
Insecticides
Mercuric chloride
Arsenic,
Sodium Cyanide
Phenol,
Sodium Fluoride
Sodium Chloride, Stannous
Chloride
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APPENDIX C
PROPER DISPOSAL OF FIXATIVES & STAINS
Stain Solutions
Constituents
Disposal Option
Acid Fast Stain (for Mycobacteria)
• Solution 1
• Solution 2
• Working solution
• Decolorizing solution
• Methylene blue
counterstain
Ethanol, basic fuchsin
Organic cleaner
Mix of solution 1 and 2
Ethanol, hydrochloric acid
Methylene blue, acetic acid
Ignitable Hazardous Waste
Not regulated as HW
Ignitable HW
Ignitable HW, check pH for
corrosivity
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Alcian Blue Pas Stain
• 1% Alcian blue solution
• 0.5% Periodic acid
solution
• IN Hydrochloric acid
• Shiff reagent
• 0.55% Potassium
metabisulfate solution
Alcian blue, acetic acid,
thymol
Periodic acid
Hydrochloric acid
Basic fuchsin, sodium
metabisulfate, IN
hydrochloric acid
Potassium metabisulfate
Alcian Blue Stain, pH 2.5
• 3% Acetic acid solution
• 1% Alcian blue solution
• Nuclear fast red
counterstain solution
Acetic acid
Alcian blue, acetic acid,
thymol
Nuclear fast red, aluminum
sulfate
Bluing Solution for Hematoxylin Stain
• Ammonia solution
• Lithium carbonate
solution
• Celloidin
• Glycerin water
mounting medium
Ammonium hydroxide
Lithium carbonate
Ethanol, ethyl ether,
celloidin (nitrocellulose,
parlodion)
Glycerin, phosphate
buffered solute
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Test for oxidizer, otherwise
not regulated as HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated as HW
Corrosive HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated as HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Toxic HW
Ignitable HWas a liquid,
Flammable Solid HWor
Explosive IF DRY
Not regulated as HW
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Stain Solutions
Constituents
Disposal Option
Congo Red Stain (Amyloid)
• 80% Alcohol & sodium
chloride (saturated)
• Alkaline salt solution
• Stock Congo red
staining solution
Sodium chloride, ethanol
80% alcohol, sodium
hydroxide
Congo red, 80% alcohol
Ignitable HW
Ignitable HW, check pH for
corrosivity
Ignitable HW
Elastic Van Gieson Stain
• Acid fuchsin - 1%
• Picric acid, saturated
solution
• Van Gieson's solution
Acid fuchsin
Picric acid
Acid fuchsin, picric acid
Not regulated as HW
Corrosive, Flammable Solid
HW
Corrosive, Flammable Solid
HW
Fite's Acid Fast Stain
• Ziehl-Neelsen carbol-
fuchsin solution
• Decolorizing solution
• Methylene blue
counterstain
Phenol, absolute alcohol,
basic fuchsin
70% Ethanol, hydrochloric
acid
Methylene blue, acetic acid
Toxic HW
Ignitable HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Fontana-Masson Stain
• 10% Silver nitrate
• Fontana's silver
solution
• 0.2% Gold chloride
solution
• 5% Sodium thiosulfate
solution
• Nuclear fast red
counterstain solution
Silver nitrate
Silver nitrate, ammonium
hydroxide
Gold chloride
Sodium thiosulfate
Nuclear fast red, aluminum
sulfate
Oxidizer HW
Corrosive, Oxidizer HW
Not regulated as HW (but
reclaim the gold if possible)
Not regulated as HW
Not regulated as HW
Giemsa (Modified Max-Gruenwald) Stain
• Stock Jenner solution
• Working Jenner
Solution
• Stock giemsa solution
• Working giemsa
solution
• 1 % Acetic water
solution
Jenner dye, methanol
Stock Jenner solution
Giemsa powder, glycerin,
methanol
Stock giemsa solution
Glacial acetic acid
Ignitable and Toxic HW
Ignitable and Toxic HW
Ignitable, Toxic and
Persistent HW
Not regulated as HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
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Stain Solutions
Constituents
Disposal Option
Gram (Modified Brown-Brenn) Stain
• 1% Crystal violet
solution
• Grams iodine solution
• Stock basic fuchsin
solution
• Working basic fuchsin
solution
Crystal violet
Iodine, potassium iodide
Basic fuchsin
Stock basic fuchsin solution
Toxic HW
May be regulated as tissue
corrosive
Persistent HW
Not regulated as HW
Gridley's Ammoniacal Silver Nitrate Solution
• Ammoniacal silver
nitrate solution
• 1% Periodic Acid
• 2% Silver Nitrate
• Formalin Solution
• 0.2% Gold Chloride
• 5% Sodium Thiosulfate
Sodium hydroxide, silver
nitrate, ammonium
hydroxide,
Periodic acid
Silver nitrate
Formaldehyde
Gold chloride
Sodium thiosulfate
Corrosive, Oxidizer HW.
Potentially Explosive HW, can
deactivate prior to disposal
Test for oxidizer, otherwise
not regulated as HW
Toxic, Oxidizer HW
Toxic HW
Not regulated but reclaim
gold if possible
Not regulated as HW
Grocall's Methenamine Silver (GMS) Stain
• 5% Chemical acid
solution
• Silver nitrate solution
• 3% Methenamine
solution
• 5% Borax solution
• Stock Methenamine-
silver nitrate solution
• Working methenamine-
silver nitrate solution
• 1% Sodium bisulfite
solution
• 0.1% Gold chloride
solution
• 2% Sodium thiosulfate
solution
• Stock light green
solution
• Working light green
solution
Chromium trioxide
Silver nitrate
Hexamethylenetetramine
Sodium borate
3% Methenamine, 5% silver
nitrate solutions
5% Borax solution,
methenamine-silver nitrate
stock
Sodium bisulfite
Gold chloride
Sodium thiosulfate
Light green SF (yellowish),
glacial acetic acid
Stock light green solution
Toxic HW, test for oxidizer,
check pH for corrosivity
Toxic Oxidizer HW
Flammable Solid HW
Not regulated as HW
Toxic Flammable Solid HW
Toxic Flammable Solid HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated but reclaim
gold if possible
Not regulated as HW
Not regulated as HW
Not regulated as HW
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Stain Solutions
Constituents
Disposal Option
Hypo (Sodium Thiosulfate)
• 3% Sodium thiosulfate
solution
• Lugol's iodine for
mercury removal
• 2% Hydrochloric acid
• Nuclear-fast red
solution
Sodium thiosulfate
Iodine, potassium iodide
Hydrochloric acid
Nuclear-fast red, aluminum
phosphate, thymol
Not regulated as HW
Corrosive HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated as HW
Iron Stain (Prussian Blue)
• 2% Potassium
ferricyanide solution
Potassium ferricyanide
Jones Silver Stain
• 0.5% Periodic acid
solution
• 3% Methenamine
solution
• Borate buffer solution
• 5% Silver nitrate
solution
• Working methenamine
silver solution
• 0.2% Gold chloride
solution
• 3% Sodium thiosulfate
Periodic acid
Hexamethylenetetramine
Boric acid, sodium borate
Silver nitrate
3% Methenamine solution,
5% silver nitrate solution,
borate buffer solution
Gold chloride
Sodium thiosulfate
Not regulated as HW but not
allowed to sewer
Test for oxidizer, otherwise
not regulated as HW
Flammable Solid HW
Check pH for corrosivity
Toxic, Oxidizer HW
Test for oxidizer, then test for
toxicity
Not regulated but reclaim
gold if possible
Not regulated as HW
Mucicarmine Stain
• Mucicarmine stock
solution
• Mucicarmine working
solution
• Weigert's iron
hematoxylin, solution A
• Weigert's iron
hematoxylin, solution B
• Weigert's iron
hematoxylin solution
• 0.25% Metanil yellow
solution
Carmine alum lake,
aluminum hydroxide,
ethanol, aluminum chloride
Mucicarmine stock solution
Hematoxylin, ethanol
Hydrochloric acid, ferric
chloride
Hematoxylin solution A and
solution B
Metanil yellow, acetic acid
Ignitable HW, check pH for
corrosivity
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Ignitable HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Ignitable HW, check pH for
corrosivity
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
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Stain Solutions
Constituents
Disposal Option
Oil Red O Stain
• Oil red O stock solution
• Oil red O working
solution
Oil red O, 98% isopropanol
Oil red O stock solution
Toxic, Ignitable HW
Toxic, Ignitable HW
Periodic Acid Sch iff Stain (PAS)
• 0.5% Periodic acid
solution
• IN hydrochloric acid
• Schiff reagent
• 0.55% Potassium
metabisulfite solution
Periodic acid
Hydrochloric acid
Basic fuchsin, sodium
metabisulfite,
IN hydrochloric acid
Potassium metabisulfite
Test for oxidizer, otherwise
not regulated as HW
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated as HW
Periodic Acid Shift Digested Stain (PAS-D)
• 0.55% Potassium
metabisulfite solution
• Malt diastase solution
• Phosphate buffer
Potassium metabisulfite
Diastase of malt, pH 6.0
phosphate buffer
Sodium chloride, sodium
phosphate monobasic
Not regulated as HW
Not regulated as HW
Not regulated as HW
Phosphotungstic Acid Hematoxylin (PTAH)
• PTAH working solution
• Eosin Y working
solution
Hematoxylin,
phosphotungstic acid,
potassium permanganate
Eosin Y, 95% ethanol ,
glacial acetic acid
Test for corrosivity & oxidizer,
otherwise not regulated as
HW. Must meet sewer limits
Ignitable HW
Reticulin Stain (Gomori's Method)
• 10% Silver nitrate
solution
• 10% Potassium
hydroxide solution
• Ammoniacal silver
solution
• 0.5% Potassium
permanganate solution
• 2% Potassium
metabisulfite solution
• 2% Ferric ammonium
sulfate solution
• Formalin solution
• 0.2% Gold chloride
solution
Silver nitrate
Potassium hydroxide
Sodium hydroxide, silver
nitrate, ammonium
hydroxide,
Potassium permanganate
Potassium metabisulfite
Ferric ammonium sulfate
Formaldehyde
Gold chloride
Oxidizer HW
Corrosive HW
Corrosive, Oxidizer HW.
Potentially Explosive HW, can
deactivate prior to disposal
Test for oxidizer, otherwise
not regulated as HW
Not regulated as HW
Not regulated as HW
Toxic HW
Not regulated but reclaim
gold if possible
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Stain Solutions
Constituents
Disposal Option
Reticulin Stain (Gomori's Method) -continued
• 2% Sodium thiosulfate
solution
• Nuclear-fast red
(Kernechtrot) solution
Sodium thiosulfate
Nuclear-fast red, aluminum
sulfate
Not regulated as HW
Not regulated as HW
Spirochete Stain (Steiner & Steiner Method)
• 1% Uranyl nitrate
solution
• 1% Silver nitrate
solution
• 0.04% Silver nitrate
solution
• 2.5% Gum mastic
solution
• 2% Hydroquinone
solution
• Reducing solution
Uranyl nitrate
Silver nitrate
Silver nitrate
Gum mastic, absolute
alcohol
Hydroquinone
Gum mastic solution,
hydroquinone solution,
absolute alcohol
Not regulated as HW or
radioactive waste. Meets
DOH guidelines for sewer
discharge.
Oxidizer HW
Toxic HW. Test for oxidizer.
Ignitable HW
Toxic HW
Ignitable HW
Trichrome Stain - Masson's Method
• Bain's solution
• Weigert's iron
hematoxylin, solution A
• Weigert's iron
hematoxylin, solution B
• Weigert's iron
hematoxylin, working
solution
• Biebrich scarlet - acid
fuchsin solution
• Phosphomolybdic-
phosphotungstic acid
solution
• Aniline blue solution
• 1 % Acetic acid solution
• Toluidine blue stain
solution (for mast cells)
Picric acid, glacial acetic
acid, formaldehyde
Hematoxylin, 95% alcohol
Ferric chloride, glacial
acetic acid
Solution A, solution B
1% Biebrich scarlet
solution, 1% acid fuchsin,
acetic acid
Phosphomolybdic acid,
phosphotungstic acid
Aniline blue, acetic acid
Glacial acetic acid
Toluidine blue
Toxic HW, test pH for
corrosivity
Ignitable HW
Corrosive HW
Ignitable HW, test pH for
corrosivity
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Test for oxidizer, test pH for
corrosivity, otherwise not
regulated as HW, must meet
sewer limit
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Check pH for corrosivity,
otherwise not regulated as
HW, must meet sewer limit
Not regulated as HW
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King County - Lab Waste Management Guide
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Stain Solutions
Constituents
Disposal Option
Vonkossa Stain for Calcium
• 5% Silver nitrate
solution
• 5% Sodium thiosulfate
• Nuclear-fast red
solution
Fixative
Silver nitrate
Sodium thiosulfate
Nuclear-fast red, aluminum
sulfate
Constituents
Miscellaneous Fixatives
• Alcohol fixatives
Methanol, ethanol
B-5 Fixative
• Stock solution
• Working solution
• Bouin's fixative solution
Mercuric chloride, sodium
acetate (anhydrous)
B-5 stock solution,
formaldehyde solution
Picric acid (saturated), 37%
formaldehyde solution,
acetic acid
Carnoy's Fixatives
• Carnoy's fixative 1
• Carnoy's fixative II2
• Propionic acid -
ethanol solution
Acetic acid, ethanol
Chloroform, acetic acid,
ethanol
Propionic acid, ethanol
Formalin Fixatives
• 1 0% Aqueous formalin
solution
• 10% Aqueous saline
formalin solution
• 10% Neutral buffered
formalin
• Formalin alcohol
solution
• Hollande's fixative
solution
Formaldehyde
Formaldehyde, sodium
chloride
Formaldehyde, sodium
phosphate monobasic,
sodium phosphate dibasic
Formaldehyde, ethanol
Copper acetate, picric acid,
formaldehyde, acetic acid
Zenker's Fixative Solutions
• Stock solution
• Working solution
Mercuric chloride,
potassium dichromate,
sodium sulfate
Zenker's stock solution,
acetic acid
Oxidizer HW
Not regulated as HW
Not regulated as HW
Disposal Option
Methanol is Toxic Ignitable
HW, Ethanol is Ignitable HW
Toxic HW
Toxic HW
Toxic HW, check for
corrosivity
Corrosive, Ignitable HW
Corrosive, Ignitable, Toxic
HW
Ignitable HW
Toxic HW
Toxic HW
Toxic HW
Ignitable Toxic HW
Toxic HW
Toxic HW, test to see if oxidizer or
corrosive
Toxic HW, test to see if
oxidizer or corrosive
1 Ammoniacal silver staining solutions are hazardous due to their potential to form explosive silver
salts. Whether disposed or deactivated, these wastes are counted against your generator status.
• Don't allow silver nitrate to remain in ammonium solutions for more than two hours.
King County - Lab Waste Management Guide
45
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• Keep silver nitrate solutions separate from ammonium hydroxide solutions.
• Deactivate these waste solutions by diluting 15:1 with water. Then, while stirring frequently,
slowly adding 5% hydrochloric acid to the solution till the pH reaches 2.
• Add ice if the solution heats up. Silver chloride will precipitate out when the pH reaches 2.
• Filter out the precipitate and dispose as hazardous waste, adjust the pH of the solution to 6 to 7
with sodium bicarbonate, then discharge to the sewer.
2 A chloroform-free alternative, Carney's 2000™, is available from American Master*Tech Scientific,
Inc.
46 King County - Lab Waste Management Guide
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APPENDIX D
SOLID WASTE DISPOSAL - COMMON QUESTIONS
What is "Solid Waste?"
• "Solid Waste" refers to materials allowed in local municipal collection systems for
garbage and recycling.
Who do I call to find out if my waste is acceptable for disposal as solid waste?
• Contact the Public Health - Seattle & King County Waste Characterization Program at
206-296-4633 or e-mail wc@metrokc.gov.
Who do I call to get my waste cleared for disposal as solid waste?
• Contact the Waste Characterization Program at 206-296-4633 or e-mail wc@metrokc.gov.
What are the guidelines for disposal of biomedical wastes? Who do I call for info?
• Untreated medical wastes are NOT allowed in the landfill. For more information on
biomedical waste disposal, contact the medical waste coordinator for Public Health -
Seattle & King County at 206-296-4831. See
http://www.metrokc.gov/health/hazard/solidwaste.htmtfbiomedical
Where does my solid waste go for disposal?
• Wastes generated within the Seattle city limits are disposed at Columbia Ridge Landfill,
Oregon.
• Wastes generated in King County, outside the Seattle city limits, go to Cedar Hills
Landfill near Issaquah
What process must I go through to get a clearance for questionable solid waste?
• Contact the Waste Characterization program at 206-296-4633 or e-mail wc@metrokc.gov,
describe your waste and ask for instructions about the information needed to determine its
acceptability.
• They will answer your questions and send you a two-page Waste Characterization Form.
Download the form on-line at http://www.metrokc.gov/health/hazard/wcform.doc
• Complete the form and submit it with the appropriate data (typically material safety data
sheets and/or results of laboratory analyses).
• If the waste is from Seattle, they'll review the information and, if it is acceptable, issue a
permit.
• If the waste is from King County, outside Seattle, they'll review the information and issue
a technical report. If the waste is acceptable, King County Solid Waste will issue a
permit.
King County - Lab Waste Management Guide 47
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Can I dispose of "Special Wastes" at King County or Seattle solid waste facilities?
• Not at this time. Special Wastes are defined in WAC 173-303-040 as state-only
dangerous waste that is solid only and is either:
A. Corrosive;
B. Category D toxic;
C. PCB Waste; or
D. Persistent waste that is not extremely hazardous.
Note: Some "special dangerous wastes" are allowed for local landfill disposal, generally only
if they are toxic category D and a solid. Contact the Waste Characterization program at 206-
296-4633 or e-mail wc@metrokc.gov for potential approval.
There are now some firms offering direct haul service for "special wastes." Call the Waste
Characterization Program at 206-296-4633 or e-mail wc@metrokc.gov for more information.
What common solid wastes from labs may not be acceptable?
• Buffers consisting of more than 10% toxic category D substances (e.g., potassium
hydroxide)
• Drier packages with over 10% potassium chloride, sodium chloride or copper chloride
• Soil samples with these characteristics:
A. Contains three percent (3%) or more total petroleum hydrocarbons;
B. Contains contaminants which occur at concentrations at or above a dangerous waste
threshold in the toxicity characteristics list (see WAC 173-303-090 [8] [c])
• Many lab stains and dyes can designate because they are halogenated organic compounds
(e.g., bromophenol blue).
48 King County - Lab Waste Management Guide
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SELECTED BIBLIOGRAPHY
American Chemical Society, Task Force on Laboratory Waste Management. Less Is Better.
Washington, DC: American Chemical Society, 1993.
Armour, Margaret-Ann. Hazardous Laboratory Chemicals Disposal Guide, 2nd Edition. Boca Raton,
FL: Lewis Publishers. 1996.
Balogh, Cynthia. Policy regarding discharge of 2-4% glutaraldehyde disinfectant solutions to King
County Sanitary Sewer. Seattle, WA: King County Department of Natural Resources. 1997.
Blair, David. 2000 (October). Personal communication. Focus Environmental Services.
College of the Redwoods. No-Waste Lab Manual for Educational Institutions. Sacramento, CA:
California Dept. of Toxic Substances Control. 1989.
Davis, Michelle, E. Flores, J. Hauth, M. Skumanich and D. Wieringa. Laboratory Waste Minimization
and Pollution Prevention, A Guide for Teachers. Richland, WA: Battelle Pacific Northwest
Laboratories. 1996.
King County Industrial Waste Program. Discharging Industrial Wastewater in King County. Seattle,
WA:2001.
Environmental Protection Agency. Labs for the 21st Century. Washington, DC:
http://www.labs2 lcentury.gov/ 2005.
Fernandes, Arianne. 2005 (June). Personal communication, Washington Department of Ecology.
Field, Rosanne A Management Strategies and Technologies for the Minimization of Chemical Wastes
from Laboratories. Durham, NC: N.C. Department of Environment, Health, and Natural
Resources Office of Waste Reduction, 1990.
Flinn Scientific Inc. Chemical and Biological Catalog Reference Manual 2000. Batavia, IL: Flinn
Scientific Inc. 2000.
Lunn, George and Eric B. Sansone. Destruction of Hazardous Chemicals in the Laboratory, 2nd
Edition. New York, NY: John Wiley and Sons. 1994.
Lunn, George and Eric Sansone. Ethidium bromide: destruction and decontamination of solutions.
Analytical Biochemistry 162, pp. 453-458. 1987
National Research Council, Committee on Hazardous Substances in the Laboratory. Prudent
Practices in the Laboratory. Washington, DC: National Academy Press, 1995
Reinhardt, Peter, K. Leonard and P. Ashbrook. Pollution Prevention and Waste Minimization in
Laboratories. Boca Raton, FL: Lewis Publishers. 1996.
Rowe, Bill, University of Washington. Stain Solutions Guide. Seattle, WA: Unpublished handout from
the King County Medical Industry Waste Prevention Roundtable (MIRT) Seminar #4., 2000.
University of Washington. Laboratory Spill Guide. Seattle, WA:
http://www.ehs.washington.edu/Services/Spill Response.htm 2002.
King County - Lab Waste Management Guide 49
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Vanderbilt Environmental Health and Safety Program. "Guide to Laboratory Sink/Sewer Disposal of
Wastes." http://www.safety.vanderbilt.edu/resources/hazard_factsheet_sewer.htm 2005.
Washington State Department of Ecology. Dangerous Waste Regulations, Chapter 173-303 WAC.
Publication No. 92-91 Olympia, WA: Department of Ecology Publications, 2003.
Washington State Department of Ecology. Step-by-Step Guide to Better Laboratory Management
Practices. Publication No. 97-431 Olympia, WA: Department of Ecology Publications, 1999.
Washington State Department of Ecology. Treatment by Generator Fact Sheet. Publication No. 96-
412 Olympia, WA: Department of Ecology Publications, 2004.
http://www.ecy.wa.gov/biblio/96412.html
JO King County - Lab Waste Management Guide
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Solid Waste and Emergency Response
(5305W)
EPA530-K-05-013
Introduction to
Land Disposal
Restrictions
(40 CFR Part 268)
United States
Environmental Protection
Agency
September 2005
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LAND DISPOSAL RESTRICTIONS
CONTENTS
1. Introduction 1
2. Regulatory Summary 2
2.1 History of the LDR Program 2
2.2 LDR and EPA's Groundwater Protection Strategy 4
2.3 Applicability 5
2.4 Treatment Standards 6
2.5 Alternative Treatment Standards 8
2.6 Variances, Extensions, and Exemptions 10
2.7 Storage and Dilution Prohibitions 13
2.8 Tracking and Recordkeeping Requirements 15
2.9 Characteristic Hazardous Wastes 17
3. Special Issues 20
3.1 Point of Generation 20
3.2 Dioxin-Containing Waste 20
3.3 LDR Applicability and Remediation Wastes 20
4. Regulatory Developments 21
4.1 Burden Reduction Initiative 21
4.2 Dyes and Pigments 21
4.3 Macroencapsulation of Radioactive Lead Solids 22
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Land Disposal Restrictions - 1
1. INTRODUCTION
The primary goal of the Resource Conservation and Recovery Act (RCRA) Subtitle C program
is to protect human health and the environment from the dangers associated with generation,
transportation, treatment, storage, and disposal of hazardous waste. Disposal of hazardous waste
on the land is a practice of particular concern to the RCRA program. Land disposal units, such
as landfills and surface impoundments, must comply with stringent requirements for liners, leak
detection systems, and groundwater monitoring. The land disposal restrictions (LDR) provide a
second measure of protection from threats posed by hazardous waste disposal. The LDR
program ensures that hazardous waste cannot be placed on the land until the waste meets specific
treatment standards to reduce the mobility or toxicity of the hazardous constituents in the waste.
This training module presents an overview of the land disposal restrictions program.
When you have completed this module, you will be able to describe the LDR requirements.
Specifically, you will be able to:
• define the basic terms and describe the structure of the LDR regulations
• identify the statutory basis for LDR
describe the applicability of LDR
explain how EPA sets treatment standards
• identify treatment standards for wastes subject to land disposal restrictions and cite the
CFR section
• describe and identify how extensions and variances from treatment requirements are
obtained
define generator and treatment, storage, and disposal facility (TSDF) requirements under
the LDR program
• summarize the schedule of existing restrictions and the plan for restricting newly
identified wastes.
Use this list of objectives to check your knowledge of this topic after you complete the training
session.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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2 - Land Disposal Restrictions
2. REGULATORY SUMMARY
The LDR program found in 40 CFR Part 268 requires waste handlers to treat hazardous waste or
meet specified levels for hazardous constituents before disposing of the waste on the land. This
is called the disposal prohibition. To ensure proper treatment, EPA establishes a treatment
standard for each type of hazardous waste. The Agency lists these treatment standards in Part
268, Subpart D. The Agency expresses treatment standards either as required treatment
technologies that must be applied to the waste or contaminant concentration levels that must be
met. EPA bases treatment standards on the performance of the best demonstrated available
technology (BDAT) that is able to substantially diminish the toxicity of a waste or to reduce the
mobility of the hazardous constituents in a hazardous waste. Wastes that do not meet treatment
standards cannot be land disposed unless EPA has granted a variance, extension, exclusion, or
the waste is managed pursuant to an approved "no migration" petition. In addition to the
disposal prohibition, there are prohibitions and limits in the LDR program regarding the dilution
and storage of wastes. The program also requires tracking and recordkeeping to ensure proper
management and safe land disposal of hazardous wastes.
2.1 HISTORY OF THE LDR PROGRAM
The Hazardous and Solid Waste Amendments of 1984 (HSWA) established EPA's authority for
the LDR program. Due to the large number of hazardous waste codes that existed prior to
HSWA, EPA developed LDR treatment standards in stages. In HSWA, Congress set a time
frame for the implementation of treatment standards for all wastes listed or identified as
hazardous on or before November 8, 1984. Congress set specific prohibition dates for certain
high-risk and high-volume wastes and established a three-part schedule with specific deadlines
for EPA to develop treatment standards for the remaining listed and characteristic wastes.
Wastes identified subsequent to HSWA are considered newly identified or listed. Additional
rulemakings, promulgated in "phases," addressed these new wastes. This section highlights
some especially pertinent parts of those rulemakings and identifies and explains certain complex
areas.
SOLVENT AND DIOXIN-CONTAINING WASTE
Solvent and dioxin-containing wastes were the first group of wastes for which EPA established
treatment standards. Congress set a statutory deadline for EPA to establish treatment standards for
these wastes because they are generated either in high volumes (solvent wastes) or are considered
highly toxic (dioxin-containing wastes). EPA published a final rule on November 7, 1986 (51 FR
40572), establishing effective dates and treatment standards for F001-F005 solvent wastes
(§268.30) and F020-F023 and F026-F028 dioxin-containing wastes (§268.31). The November 7,
1986, final rule also established the basic framework for the land disposal restrictions program.
CALIFORNIA LIST WASTE
A second group of hazardous wastes for which Congress set a specific LDR deadline is known
as the California list. This list was compiled from a program established by California's
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 3
Department of Health Services. The California list, which became effective July 8, 1987,
prohibited the land disposal of liquid hazardous wastes containing certain toxic constituents or
exhibiting certain properties unless subjected to prior treatment (52 FR 25760; July 8, 1987).
The targets of the list included cyanides, poly chlorinated biphenyls (PCBs), halogenated organic
compounds (HOCs), and metals. Certain HOC-containing wastes were also prohibited even
when in solid form.
Waste code-specific treatment standards addressing the constituent (or property) of concern have
superseded the California list prohibitions. For example, the treatment standard for D008 (i.e.,
the toxicity characteristic for lead) supersedes the California list prohibition on liquid hazardous
wastes containing lead. On May 12, 1997, EPA removed all references to the California list
wastes because the treatment standards for these wastes had been superseded by more specific
treatment standards (62 FR 25998).
THIRDS
HSWA §3004(g)(4) required EPA to prepare a plan by November 8, 1986, to meet the
Congressionally mandated schedule for establishing treatment standards for all hazardous wastes
identified or listed on or before November 8, 1984. When developing the plan, EPA was
required to rank the listed wastes from high to low priority, based on the wastes' intrinsic hazard
and volume generated. The Agency scheduled high-volume, high-intrinsic hazard wastes first,
while low-volume, lower-hazard wastes (including characteristic wastes) were to have treatment
standards established last. Wastes with treatment standards promulgated in the first portion of
the three-part schedule are known as First Third wastes (53 FR 31138; August 17, 1988), wastes
addressed in the second portion of the schedule are known as Second Third wastes (54 FR
26594; June 23, 1989), and wastes in the third category are known as Third Third wastes (55 FR
22520; June 1, 1990).
TREATMENT STANDARDS FOR NEWLY IDENTIFIED OR LISTED WASTES
HSWA also requires EPA to establish treatment standards for all hazardous wastes listed or
identified after November 8, 1984. EPA developed treatment standards for these wastes in
phases. EPA published the first of these rulemakings, termed Phase I,on August 18, 1992 (57
FR 37194). In addition to promulgating restrictions for certain new wastes, Phase I finalized the
alternative treatment standards for hazardous debris.
EPA finalized the Phase II Rule on September 19, 1994 (59 FR 47982). This final rule
consolidated the existing treatment standards into §268.40, created the Universal Treatment
Standards (UTS), and promulgated treatment standards for toxicity characteristic organic wastes,
coke by-products, and chlorotoluenes.
EPA finalized the Phase III Rule and subsequent partial rescission on April 8, 1996 (61 FR
15566 and 15660). These final rules modified treatment standards for reactive wastes and
decharacterized wastewaters (see Section 2.8 for a complete discussion on the status of
wastewaters), and promulgated new treatment standards for carbamate wastes and spent
aluminum potliners. Even though Phase III promulgated treatment standards for these newly-
identified carbamate wastes, in the case, Dithiocarmbamate Task Force v. EPA, the DC Circuit
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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4 - Land Disposal Restrictions
Court of Appeals vacated several carbamate hazardous waste listings, thus nullifying their
corresponding LDR treatment standards (62 FR 32974; June 17, 1997).
EPA finalized the first half of the Phase IV Rule on May 12, 1997 (62 FR 25998). This final
rule promulgated treatment standards for the wood preserving wastes and streamlined the LDR
notification requirements. EPA promulgated part two of the Phase IV Rule on May 26, 1998 (63
FR 28556). This rule finalized treatment standards for several metal wastes and certain newly-
identified mineral processing wastes, and revised the universal treatment standards for twelve
metal constituents. The rule also created a new treatability group, soil, and established soil-
specific alternative treatment standards.
2.2 LDR AND EPA'S GROUNDWATER PROTECTION STRATEGY
A large part of the hazardous waste management regulatory program, including the LDR
program, is designed to protect groundwater. Hazardous waste can pollute groundwater through
a process known as leaching, in which precipitation percolating through the ground draws
contaminants out of buried waste and carries them into groundwater. Congress understood that
hazardous waste could be made less dangerous to groundwater in two main ways: by reducing a
waste's toxicity through destruction or removal of harmful contaminants, or by reducing a
waste's teachability by immobilizing hazardous contaminants. As a result, EPA created a tiered
approach to the protection of groundwater by attempting to prevent teachability of harmful
constituents at three levels: LDR, LDUs, and groundwater monitoring. The first tier of the
approach, LDR, regulates what kind of waste can be placed on the land or in land disposal units.
This training module focuses on the LDR provisions, but more information on the other two tiers
of the groundwater protection strategy can be found in the modules entitled Land Disposal Units
and Groundwater Monitoring.
LDR requires that hazardous wastes undergo fundamental physical or chemical changes so that
they pose less of a threat to groundwater. When directing EPA to establish the LDR program in
RCRA §3004(m), Congress specified that EPA should "promulgate regulations specifying those
levels or methods of treatment, if any, which substantially diminish the toxicity of the waste or
substantially reduce the likelihood of migration of hazardous constituents from the waste." To
implement that goal, Congress gave EPA very specific directions for establishing the LDR
program. In particular, Congress required EPA to specify how hazardous wastes should be
treated to satisfy LDR's goal of groundwater protection. The rules EPA promulgated governing
how different hazardous wastes must be treated are known as treatment standards. Treatment
standards are simply instructions on how a hazardous waste should be treated.
For example, many of the chemicals capable of contaminating groundwater are organic
compounds. Incineration or burning can destroy these organic compounds, usually breaking
them down into less dangerous by-products like carbon dioxide and water. Thus, incineration of
organic-bearing hazardous wastes can protect groundwater by destroying organic contaminants
before they have a chance to enter underground water supplies. The obvious advantage of such
hazardous waste treatment is that it provides a more permanent and lasting form of groundwater
protection than hazardous waste containment. Structural barriers separating hazardous
contaminants from groundwater may eventually break down or leak. In contrast, treatment that
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 5
destroys harmful contaminants or reduces a waste's toxicity before it enters the environment is a
permanent groundwater protection solution.
Treatment, however, cannot destroy all types of contaminants found in hazardous waste. In
particular, metal elements, which are common toxic contaminants, cannot be broken down
through combustion. Treatment techniques other than incineration, however, can be used for
such wastes. For example, through a process called stabilization or immobilization, metal
contaminants can be chemically and physically bound into the wastes that contain them.
Although this treatment method does not reduce the overall concentration of toxic metals in a
hazardous waste, it does immobilize these constituents, making them less likely to leach from the
waste. Reducing the mobility or teachability of hazardous constituents in a waste is another
means of achieving LDR's groundwater protection goal.
2.3 APPLICABILITY
To be subject to the land disposal restrictions, a waste must first be a RCRA hazardous waste.
Unless a waste meets the definition of a solid and hazardous waste, its disposal will not be
subject to the LDR program.
RCRA §3004(g) requires that EPA restrict hazardous wastes from land disposal within six
months of promulgating a new listing or characteristic. Until the Agency establishes a treatment
level, newly listed or identified wastes are not subject to LDR and they may continue to be land
disposed. Generally, EPA now promulgates new listings and their treatment standards at the
same time. Once EPA promulgates final treatment requirements waste handlers must manage it
in accordance with all the requirements of Part 268 and cannot land dispose the waste until it
meets the treatment level.
EXCLUSIONS
While the LDR program generally applies to all persons who generate, transport, treat, store, or
dispose of a restricted hazardous waste, EPA excludes certain wastes from the applicability of
Part 268. The following hazardous wastes are not subject to the requirements of LDR
(§268.1(e)):
• waste generated by conditionally exempt small quantity generators as defined in §261.5
• waste pesticide and container residues disposed of by farmers on their own land pursuant
to §262.70
• newly identified or listed hazardous wastes for which EPA has yet to promulgate land
disposal restriction treatment standards
• certain low volume releases, known as de minimis losses, and laboratory wastes that are
mixed with a facility's wastewater and are discharged to the facility's wastewater
treatment or pretreatment facility.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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6 - Land Disposal Restrictions
Waste handlers may continue to land dispose wastes meeting any of these descriptions without
being subject to the LDR program. They must manage other restricted hazardous wastes in
compliance with the requirements in Part 268 unless explicitly exempted by another part of the
RCRA program.
2.4 TREATMENT STANDARDS
LDR requires waste handlers to fundamentally change the threat posed by hazardous waste
before it is land disposed. Waste-specific restrictions are manifested as thresholds for adequate
treatment, known as treatment standards. Once EPA restricts a waste and issues a treatment
standard, the waste may be land disposed only after it meets the appropriate treatment standard.
ESTABLISHMENT OF TREATMENT STANDARDS
Section 3004(m) of the Hazardous and Solid Waste Amendments (HSWA) requires EPA to
promulgate treatment standards that reduce the toxicity or mobility of hazardous constituents to
minimize the short and long-term threats to human health and the environment. To implement
this mandate, EPA chose to base treatment standards on technical practicability instead of risk
assessment. To this end, EPA conducts research into available treatment technologies. Of all
the proven, available technologies, EPA designates the ones that best minimize the mobility
and/or toxicity of hazardous constituents as the Best Demonstrated Available Technology
(BOAT) for that waste. The Agency then establishes a waste code-specific treatment standard
based on the performance of BDAT, incorporating any existing constituent treatment levels
specified as universal treatment standards (UTS), which are discussed later in this section. EPA
expresses these treatment standards as either concentration levels or required technologies.
When EPA sets treatment standards as concentration levels, they do not limit the allowable
method of treatment to the BDAT used to establish the treatment standard; instead, the Agency
uses BDAT to determine the appropriate level of treatment for each hazardous constituent
commonly found in the waste. The regulated community may then use any method or
technology to meet the treatment standard, except for instances where application of a method or
technology would be impermissible dilution. A generator fully treating the waste before
sending it off site or a TSDF treating the waste must analyze the waste pursuant to a waste
analysis plan to determine that it meets the applicable concentration-based standards in §268.40.
When a treatment standard is a required technology, the generator or facility treating the waste
must use that technology, unless it can demonstrate that an alternative method can achieve a
level of performance equivalent to the required technology (discussed in Section 2.4). Whenever
possible, EPA prefers to use numeric treatment standards in order to stimulate innovation and
development of alternative treatment technologies.
Since the physical and chemical composition of a waste significantly impacts the effectiveness of
a given treatment technology, EPA divides the treatment standard for each waste code into two
categories: wastewaters and nonwastewaters. The Agency defines these two categories based on
the percentages of total organic carbon (TOC) and total suspended solids (TSS) present in a
waste, since these factors commonly impact the effectiveness of treatment methods.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 7
Wastewaters contain less than one percent TOC by weight and less than one percent TSS by
weight. Nonwastewaters include wastes that do not meet the definition of wastewater (§268.2).
EPA also developed alternative treatment standards for soil, debris, and lab pack wastes. The
alternative treatment standards will be discussed in the "Alternative Treatment Standards"
section of this module.
CONSOLIDATED TABLE OF TREATMENT STANDARDS
EPA originally presented the treatment standards for hazardous wastes in multiple tables, but
replaced these with a single consolidated table for wastewaters and nonwastewaters. If EPA
restricts a hazardous waste from land disposal, the treatment standard for both wastewaters and
nonwastewaters appears in §268.40. Section 268.40 expresses treatment standards in three
ways:
• constituent concentrations in mg/kg of the waste
• constituent concentrations in an extract of the waste expressed in mg/1
• treatment standards expressed as specified technologies and represented by a five-letter
code (described in §268.42).
EPA commonly expresses numeric standards in mg/kg when BDAT is a destruction or extraction
technology such as incineration. Waste handlers measure compliance with these treatment
standards by analyzing a representative sample of the waste for the total concentration of each
hazardous constituent identified in the treatment standard and comparing it to the level given for
the waste code.
EPA also expresses concentration-based treatment standards in mg/1. For wastewaters, waste
handlers demonstrate compliance by comparing the concentration of hazardous constituents
found in a composite sample of the waste with the regulatory level. For nonwastewaters, the
waste handler prepares an extract that reflects the leaching potential of hazardous constituents in
the waste. The waste meets the treatment standard if the concentration of regulated constituents
in the liquid extract falls below the regulatory levels given for the waste code. EPA requires the
use of the Toxicity Characteristic Leaching Procedure (TCLP) to obtain the waste extract. The
older and less sensitive Extraction Procedure (EP) was available for use until August 24, 1998.
EPA also expresses treatment standards in §268.40 as specified technologies for certain wastes.
Waste handlers must treat these wastes using the specified technology. Table 1 in §268.42
provides full descriptions of the technologies represented by the five-letter codes used in
§268.40. Examples include incineration (INCIN), fuel substitution (FSUBS), and mercury
retorting (RMERC). In most cases, once treated by the required technology, wastes can be land
disposed without being tested. There are, however, some exceptions. For example, all F024
wastes must be incinerated. Following incineration, the remaining residues must then also meet
the concentration levels specified in §268.40.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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i - Land Disposal Restrictions
UNIVERSAL TREATMENT STANDARDS
Use of BDAT to set treatment standards for hazardous wastes gave rise to an unintended
consequence: the numeric treatment standard applied to an individual hazardous constituent, like
benzene, could vary depending on the performance of BDAT on each listed or characteristic
wastestream that EPA evaluated. For example, nonwastewater forms of the listed wastes F005
and U019 both require treatment for benzene; however, the treatment standard originally set for
benzene in the spent solvent was 3.7 mg/kg, while the standard originally set for unused,
discarded benzene was 36 mg/kg.
To simplify the LDR program and eliminate this inconsistency between standards, the Agency
examined the range of numeric standards applied to each hazardous constituent found in
restricted hazardous wastes. Based on the range, EPA assigned a single numeric value to each
constituent for its respective wastewater and nonwastewater forms. A consolidated list of each
constituent and its treatment standards (wastewater and nonwastewater) appears in §268.48 and
is known as the UTS table. EPA used the values assigned to hazardous constituents in UTS to
adjust numeric levels found in the treatment standards table in §268.40. Applying these
universal treatment standards has not changed the hazardous constituents that waste handlers
must treat in a particular waste, as EPA only amended the numeric standards. As a result, a
common constituent found in multiple, different wastes will nonetheless carry the same numeric
treatment level. The treatment standards found in §268.40 for F005 and U019 nonwastewaters,
therefore, continue to address benzene, but EPA has adjusted the level for each to 10 mg/kg.
The creation of UTS simplifies the process of assigning treatment standards to wastes that are
newly identified or listed in the future. When a new waste contains hazardous constituents that
EPA has already addressed in UTS, the Agency will apply the existing BDAT-based numeric
standards for those particular constituents. EPA can individually evaluate constituents not
already included in UTS and add them to §268.48.
2.5 ALTERNATIVE TREATMENT STANDARDS
In addition to these waste code or site-specific exception procedures, the Agency also created a
number of broad alternative treatment standards that facilities may choose to use in lieu of
meeting the waste code-specific treatment standards. These alternative treatment standards are
only available for certain forms of restricted wastes.
TREATMENT STANDARDS FOR CONTAMINATED SOIL
Remediation of hazardous waste sites will often produce contaminated soil that the generator
must handle as hazardous waste if it contains a listed hazardous waste or if it exhibits a
characteristic of hazardous waste. These remediation wastes, due to either their large volume or
unique properties, are not always amenable to the treatment standards for hazardous wastewater
and nonwastewater. Because of this, EPA designated soil as a unique treatability group and
promulgated alternative soil-specific treatment standards in the Phase IV Final Rule (63 FR
28556; May 26, 1998). As with hazardous waste, RCRA prohibits the land disposal of
hazardous soil until the soil has been treated to meet LDR standards.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 9
A facility may treat contaminated soil to meet the waste-specific treatment standard in §268.40,
(i.e., the same standard the waste would have to meet if it was newly generated rather than found
in soil) or to meet the soil-specific standards in §268.49. The soil standards mandate reduction
of hazardous constituents by 90 percent, capped at 10 times the UTS. This means that if a 90
percent reduction of a particular constituent would bring the constituent concentration to below
10 times the UTS level, treatment need only achieve the 10 times UTS level. If the 90 percent
reduction is higher than 10 times UTS, treatment need only achieve the 90 percent reduction.
For example, a contaminated soil contains 400 mg/1 nickel. Reducing this by 90 percent would
mean treating the waste to 40 mg/1. However, the UTS for nickel is 11 mg/1, so 10 times the
UTS would be 110 mg/1. Therefore, this soil would only require treatment to 110 mg/1 to meet
the LDR soil treatment standards.
Waste handlers may also treat soils that exhibit a characteristic of hazardous waste using these
soil standards. Following treatment, however, the soil may still exhibit a characteristic of
hazardous waste, since the 10 times UTS level is sometimes above the hazardous waste
characteristic level (e.g., 10 times UTS for lead is 7.5 mg/1, while the toxicity characteristic level
is 5 mg/1). Because these soils would still be hazardous wastes, they would require disposal in a
Subtitle C facility. Soils that are no longer characteristic may be sent to a Subtitle D facility or
placed back on the land. Soils contaminated with listed wastes continue to carry the listed code
and must be managed in Subtitle C facilities even after meeting the LDR treatment standards,
unless the facility gets a site-specific ruling from their implementing agency.
Like all LDR treatment standards, the soil treatment standards are promulgated pursuant to
HSWA. Because the soil treatment standards are generally less stringent than current federal
requirements, they will not go into effect in authorized states until the states adopt and become
authorized for them, even though the soil treatment standards are promulgated pursuant to
HSWA.
If a state is authorized to implement the LDR treatment standards for any given waste or
constituent, and that waste or constituent is contained in contaminated soil that is subject to
LDR, then, generally, the more stringent treatment standard for the as-generated industrial waste
or constituent applies to contaminated soil until the state adopts and becomes authorized for the
soil treatment standards. This would not be the case if the state implements state waiver
authorities or other state laws to allow compliance with the soil treatment standards in advance
of adoption or authorization. (See EPA guidance memorandum from J. Winston Porter to EPA
Regional Administrators, "RCRA Permit Requirements for State Superfund Actions," November
16, 1987, OSWER Directive 9522.00-2.) Similarly, if a state has adopted, under state law, an
authorization for the requirement, and that waste or constituent is contained in contaminated soil
that is subject to LDR, the more stringent state requirement continues to apply until the state
adopts, under state law, the soil treatment standards. Once again, the state may implement state
waiver authorities or other state laws to allow compliance with the soil treatment standards in
advance of adoption or authorization. Therefore, facility representatives should contact their
state regulatory agency before undertaking soil remediation to see if the alternative treatment
standards are available in their state.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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10 - Land Disposal Restrictions
DEBRIS
Section 268.45 contains alternative treatment standards for manufactured items and
environmental media of a certain size that are contaminated with hazardous waste. EPA
developed these alternative standards because materials such as rocks, bricks, and industrial
equipment (known genetically as debris) contaminated with hazardous waste may not be
amenable to the waste code-specific treatment standards in §268.40.
Section 268.45 allows a waste handler to choose among several types of treatment technologies,
based on the type of debris and the waste with which it is contaminated. EPA divided the
alternative treatment standards for debris into three technological categories: extraction,
destruction, and immobilization. When using an alternate debris treatment standard, waste
handlers must ensure that the treatment process meets the design and operating requirements
established in §268.45, and that they treat for each contaminant, or hazardous constituent,
subject to treatment, as defined in §268.45(b). In order to be eligible for land disposal, the debris
must meet the specified performance standards in Table 1 in §268.45. For example, a
contaminated boulder that is sandblasted to remove surface contamination must be treated to a
"clean debris surface" and at least 0.6 centimeters of the surface layer of the boulder must be
removed.
Once the waste handler has treated hazardous debris according to the specification of one of
these technologies, it may be land disposed. If treated hazardous debris does not exhibit any
characteristic following treatment with an extraction (e.g., sandblasting) or destruction (e.g.,
incineration) technology, it is eligible for land disposal and can be disposed of as nonhazardous
or simply returned to the environment (§261.3(f)). Hazardous debris treated with an
immobilization technology (e.g., macroencapsulation) that is no longer characteristic can be
disposed of as nonhazardous only after a determination from the implementing agency
(§261.3(f)(2)).
LAB PACK WASTES
Laboratories commonly generate small volumes of many different listed and characteristic
wastes. Rather than manage all these disparate wastes individually, laboratories commonly take
advantage of regulatory provisions that allow them to overpack many small containers of
hazardous waste into a larger drum. These containers are known as lab packs. EPA has
assigned them an alternative treatment standard, incineration, that allows generators to apply one
treatment standard for the entire lab pack rather than applying the treatment standard for each
individual waste code contained within the lab pack (§268.42(c)). The primary condition for
application of this alternative, however, is that the lab pack may not contain any of the heavy
metal-bearing waste codes identified in Part 268, Appendix IV.
2.6 VARIANCES, EXTENSIONS, AND EXEMPTIONS
If a restricted waste does not meet the appropriate treatment standard, it is ineligible for land
disposal. Restricted wastes that waste handlers cannot land dispose because they do not yet meet
their treatment standards are termed "prohibited" wastes. Although most prohibited wastes
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 11
become eligible for land disposal through treatment to the appropriate standards, this may not be
possible in all cases. As a result, EPA created procedures that allow waste handlers to land
dispose otherwise prohibited wastes under special circumstances. The following exemptions,
variances, and extensions established in Part 268 allow wastes for which treatment standards
have been promulgated to be land disposed without meeting treatment standards, or to be treated
to a less stringent level or by a different technology:
• national capacity variance (§3004(h)(2))
• case-by-case extension to an effective date (§268.5)
• no-migration variance (§268.6)
• variance from a treatment standard (§268.44)
equivalent treatment method variance (§268.42(b))
surface impoundment treatment exemption (§268.4).
While wastes subject to any of these provisions continue to be restricted under LDR, they are not
prohibited from land disposal under these limited conditions.
NATIONAL CAPACITY VARIANCE
When developing a treatment standard, EPA reviews treatment, recovery, and disposal capacity
to see if capacity is adequate for current and future waste management needs. If there is
inadequate capacity for certain waste codes, EPA may grant a nationwide extension of the
prohibition deadline for up to two years (RCRA §3004(h)(2)). This extension is known as a
national capacity variance. To make capacity determinations, EPA compares the quantity of the
restricted waste generated with the nationally available treatment, recovery, or protective
disposal capacity at permitted and interim status facilities that will be in operation by the
effective date. If there is a significant shortage of capacity, EPA will establish an alternative
effective date based on the earliest date such capacity will be available. Waste handlers can land
dispose waste that benefits from a national capacity variance without meeting the treatment
standards. However, if they dispose of the waste in a landfill or surface impoundment, the
disposal unit must be in compliance with the minimum technological requirements of RCRA
§3004(o).
CASE-BY-CASE EXTENSION
Regional or local conditions may create a lack of adequate treatment capacity in a particular
area. In this situation, EPA may extend the effective date of a treatment standard on a case-by-
case basis. EPA grants case-by-case extensions for one year, when waste handlers appropriately
demonstrate need as enumerated in §268.5, and can renew these extensions for an additional
year. Individual extensions cannot exceed a total of 24 months (RCRA §3004(h)(3)).
If waste handlers dispose of hazardous wastes benefiting from a case-by-case extension to an
effective date in landfills or surface impoundments, these disposal units must meet the minimum
technological requirements for liners and leak-detection and be in compliance with groundwater
monitoring requirements (RCRA §3004(o)).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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12 - Land Disposal Restrictions
Although case-by-case extensions usually apply only to the waste generated at the individual
facility that sought an extension, EPA has, at times, granted "generic" case-by-case extensions
with broad applicability. The last of these generic case-by-case extensions to an LDR effective
date, a limited extension for the disposal of hazardous debris, expired May 8, 1994.
NO-MIGRATION VARIANCE
Waste handlers can land dispose hazardous wastes subject to LDR in a land-based unit without
meeting treatment standards, if a petitioner can demonstrate that there will be no migration of
hazardous constituents from the unit for as long as the waste remains hazardous (§268.6). EPA
interprets "no migration" to mean that constituents will not leave the unit boundary at
concentrations above Agency-approved health-based levels. EPA may grant a no-migration
variance for up to 10 years, but may not extend the variance beyond the term of the particular
disposal unit's RCRA permit.
No-migration petitions must include a site description, waste characterization, and monitoring
plans for evaluation by the Agency. The regulated community must also submit for review long-
term modeling estimates of concentrations in the ground's unsaturated zone and the air pathway.
EPA has granted the majority of no-migration petitions to underground wells that inject
hazardous waste deep beneath the surface. A notable example is the conditional no-migration
variance granted for the U.S. Department of Energy's (DOE's) Waste Isolation Pilot Plant
(WIPP) in New Mexico. This variance permits DOE to dispose of untreated mixed radioactive
and hazardous wastes in an underground salt dome for the duration of a test period.
VARIANCE FROM A TREATMENT STANDARD
Under certain circumstances, generators or TSDFs may petition the Agency for a variance from
using a required technology or from meeting a concentration-based treatment standard. EPA
established this variance from a treatment standard to account for those wastes for which
applicable treatment standards are unachievable or inappropriate (§268.44). In most cases,
petitioners must demonstrate that the waste is significantly different from the wastes evaluated
by EPA when developing the codified treatment standard or that such method or standard is
unachievable or inappropriate for the waste. A treatability variance may apply generically to all
waste meeting a certain description or it may be narrower in scope, applying only to a specific
waste generated at a particular site (55 FR 22526; June 1, 1990).
With the establishment of soil-specific standards, EPA promulgated an additional provision in
§268.44 for contaminated soil. Pursuant to §268.44(h)(3), variances from otherwise applicable
LDR treatment standards may be approved if it is determined that compliance with the treatment
standard would result in treatment beyond the point at which short- and long-term threats to
human health and the environment are minimized. This allows a site-specific, risk-based
determination to supersede the technology-based LDR treatment standards under certain
circumstances, allowing regulators to align cleanup levels and treatment levels. Alternative LDR
treatment standards established through site-specific risk-based variances should be within the
range of values the Agency generally finds acceptable for risk-based cleanup levels. Decisions
to grant or deny these variances will be made by EPA Regions or authorized states.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 13
EQUIVALENT TREATMENT METHOD VARIANCE
Generally, waste handlers must treat waste to which EPA has assigned a technology-based
treatment standard in §268.40 using that method of treatment prior to disposal. A person may,
however, submit an application to the implementing agency demonstrating that an alternative
treatment method can achieve a performance equivalent to that of the specified treatment
standard and can protect human health and the environment (§268.42(b)). If EPA approves the
petition granting an equivalent method variance, the alternative method may be used in lieu of
the specified technology.
SURFACE IMPOUNDMENT TREATMENT EXEMPTION
The management of liquid wastes in surface impoundments often serves as a means of treatment.
Typically, particulates suspended in liquid wastes settle to the bottom of impoundments, forming
sludges in which contaminants concentrate. This precipitation process may result in the
generation of sludges that are hazardous wastes. Since management of wastes in surface
impoundments is considered land disposal, even though the waste is not permanently disposed in
the unit, such generation and placement of hazardous sludges on the land without prior treatment
would normally be inconsistent with LDR's disposal prohibition. Section 268.4 allows this
practice, however, by providing an exemption for wastes treated in surface impoundments.
Waste handlers may treat hazardous waste in surface impoundments without first meeting
treatment standards provided that (1) the surface impoundment meets certain technological
requirements, (2) the treatment residues that do not meet applicable standards are removed from
the impoundment annually, and (3) the removed residues are not managed in another surface
impoundment.
2.7 STORAGE AND DILUTION PROHIBITION
In addition to prohibiting the land disposal of wastes that do not meet treatment standards, the
LDR program includes two other important prohibitions. One forbids the long-term storage of
wastes as a substitute for meeting the required treatment standards. The other prohibits the
dilution of wastes as a substitute for legitimate treatment. Like the prohibition on land disposal,
these prohibitions no longer apply once a waste meets its waste code-specific treatment standard.
STORAGE PROHIBITION
EPA promulgated the storage prohibition in order to prevent waste handlers from storing
hazardous waste in lieu of proper treatment (§268.50). EPA forbids the storage of waste subject
to a treatment standard unless the waste is being stored to accumulate such quantities as are
necessary to facilitate proper recycling, treatment, or disposal. During the first year of storage,
EPA bears the burden of proving that the waste handler is storing in order to avoid meeting
treatment standards rather than to facilitate legitimate recycling, treatment, or disposal. There is
no strict time limit on legitimate waste storage; however, after the first year of storage, the
burden of proof for showing that waste is indeed being legally accumulated to facilitate proper
future management shifts from EPA to the waste handler.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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14 - Land Disposal Restrictions
Generators accumulating waste on site in accordance with §262.34 and transporters storing
waste at a transfer facility for 10 days or less are exempt from the storage prohibition. The
storage prohibition also does not apply to wastes which qualify for an exemption from a
treatment standard such as a case-by-case extension in §268.5, a no-migration petition in §268.6,
a national capacity variance, or to wastes that were placed in storage prior to the effective date of
a prohibition on land disposal.
DILUTION PROHIBITION
EPA generally prohibits dilution of wastes as a substitute for appropriate treatment (§268.3). For
example, a waste handler may not, in most cases, achieve compliance with a numeric treatment
standard by simply mixing hazardous waste with another material that fails to reduce the
mobility or toxicity of the hazardous constituents in the waste. Similarly, EPA may consider
waste to be impermissibly diluted when a waste handler treats with an inappropriate technology.
For example, it is often impermissible to incinerate metal-bearing, inorganic wastes because
incineration fails to destroy or immobilize the hazardous metal constituents.
There are, however, certain cases where EPA permits dilution. Dilution is inherent in some
types of legitimate waste handling, such as the aggregation of similar wastes to facilitate
subsequent treatment. As a general rule, if aggregated wastes are all legitimately amenable to
the same treatment, the aggregation step does not constitute impermissible dilution. In addition,
waste handlers may dilute certain characteristic wastes that are managed in Clean Water Act-
regulated treatment systems (§268.3(b)). As well, certain characteristic wastes may be diluted to
render them nonhazardous before disposal in a deep injection well regulated under the Safe
Drinking Water Act (§268. l(c)(3)). Table 1 may be used to determine if a particular waste is
subject to a prohibition against dilution when handled in a particular manner.
TABLE 1: SUMMARY TABLE: WASTES SUBJECT TO DILUTION
PROHIBITION
Type of Waste
Characteristic Wastes Managed in Clean Water Act-Regulated
Treatment Systems (§268.3(b))
Characteristic Wastes Disposed of in Safe Drinking Water Act
Underground Injection Control Wells (§268.1(c)(3))
Wastes Subject to a National Capacity Variance (§3004(h)(2))
Wastes Disposed of in a Unit With a No-Migration Variance (§268.6)
Wastes Subject to a Case-by-Case Extension to an Effective Date
(§268.5)
Newly Identified or Listed Wastes for Which EPA Has Not Yet
Established a Treatment Standard (§268.1(e)(3))
Wastes that Meet All Applicable Treatment Standards and Prohibition
Levels
Metal -Bearing Hazardous Wastes That Are Incinerated (§268. 3 (c))
Yes
/
No
y
y
y
y
j
j
j
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 15
Waste Managed in a Corrective Action Management Unit (CAMU) or
Temporary Unit (TU) !
Wastes from Conditionally Exempt Small Quantity Generators
Regulated Under §261.5 2 (§268.1(e)(l))
Farmers Disposing of Waste On Their Own Land Under
§262.70 2 (§268. l(e)(2))
J
J
J
1 For more information about these provisions, see the module entitled RCRA Corrective Action.
2 For more information about these provisions, see the module entitled Generators.
2.8 TRACKING AND RECORDKEEPING REQUIREMENTS
EPA requires generators and TSDFs managing wastes that are subject to LDR (i.e., restricted
wastes) to meet certain notification, certification, waste analysis, and recordkeeping
requirements pursuant to §268.7. Much like a hazardous waste manifest, the LDR notification
and certification paperwork helps hazardous waste handlers and EPA enforcers ensure that
wastes are properly managed. A notification accompanies the initial shipment of each waste that
is subject to LDR and includes such information as the waste code(s), the hazardous constituents
present in the waste, and waste analysis data. EPA requires subsequent notification only when
the waste or the receiving facility changes. Additionally, if a waste can be land disposed without
further treatment, a certification to that effect must accompany the notification. EPA requires
waste handlers to retain such paperwork in order to track wastes that are subject to LDR and to
ensure that those wastes receive proper treatment prior to disposal. Section 268.7(a) contains the
tracking requirements for generators, §268.7(b) specifies the requirements for treatment
facilities, §268.7(c) contains the regulations applicable to disposal facilities, §268.7(d) contains
special notification and certification requirements that apply to hazardous debris, and §268.7(e)
contains special notification requirements for contaminated soil.
GENERATORS
Generators must determine if their hazardous waste is subject to LDR at the point of generation.
They may make this determination by testing or applying knowledge. If a waste is subject to
LDR and does not meet applicable treatment standards, generators must notify the treatment
facility in writing (§268.7(a)(2)). This notice accompanies the manifest and must include the
following information:
• EPA hazardous waste code(s)
• identification of the waste as a wastewater or nonwastewater
• manifest number associated with the waste shipment
• waste analysis data (if available)
• for characteristic wastes, any additional hazardous constituents present
• when hazardous debris is to be treated by an alternative technology in §268.45, a
statement to that effect and the contaminants subject to treatment
• for contaminated soil, a list of the constituents subject to treatment and a statement that
the soil does or does not meet LDR standards.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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16 - Land Disposal Restrictions
If a generator's waste already meets applicable treatment standards, the generator, in accordance
with §268.7(a)(3), must submit a signed certification stating that the waste meets the applicable
treatment standards. This certification accompanies a copy of the notification statement
described above.
If a generator's waste qualifies for an exemption from a treatment standard, such as a national
capacity variance, case-by-case extension, or no-migration exemption, the generator must submit
to the disposal facility a notification similar to that given in §268.7(a)(2), except that it must also
identify the date that the waste will become subject to LDR prohibitions (§268.7(a)(4)).
Generators may treat hazardous waste in accumulation tanks, containers, or containment
buildings provided the units are in compliance with certain standards applicable to TSDFs
(§262.34). EPA believes that generators should have the same recordkeeping and documentation
responsibilities that apply to TSDFs when treating wastes to meet LDR treatment standards.
Therefore, §268.7(a)(5) requires generators to prepare a waste analysis plan when treating wastes
to meet LDR. The waste analysis plans must justify the frequency of testing based on a detailed
analysis of a representative sample of the waste. The plan must contain all information
necessary for proper treatment of the waste in accordance with Part 268, and must be retained in
the facility's records (55 FR 22670; June 1, 1990). Generators who are conducting partial
treatment, but not treating to meet treatment standards are not required to have a waste analysis
plan.
TREATMENT FACILITIES
The tracking and recordkeeping requirements that apply to treatment facilities are found in
§268.7(b). EPA requires hazardous waste treaters to test treated waste to ensure that all
applicable treatment standards are met. The TSDF must perform these tests as specified in its
waste analysis plan (all TSDFs must have plans under §264/265.13). If a facility ships treated
waste off site for disposal, a notification similar to the generator's notice must accompany the
initial shipment of the waste to the disposal facility. The treater's notice must include relevant
waste codes, additional hazardous constituents present, manifest information, and waste analysis
data (§268.7(b)(3)). The treater must also include a certification that the shipment of waste
meets treatment standards (§268.7(b)(4)). If the waste or a residue of the waste will be sent for
further treatment or storage at another facility, the treater must comply with the notification and
certification requirements for a generator.
LAND DISPOSAL FACILITIES
Section 268.7(c) contains the paperwork requirements that apply to the final link in the cradle-to-
grave management of hazardous waste, the land disposal facilities. Hazardous waste disposers
must ensure that incoming wastes or residues meet the applicable treatment standards by testing
the waste in accordance with their facility's waste analysis plan. Additionally, disposers must
maintain records on site of all notifications and certifications received from generators and
treatment facilities.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 17
SPECIAL REQUIREMENTS FOR TREATED DEBRIS
Generators or treaters of hazardous debris who claim that their hazardous debris is excluded
from the definition of hazardous waste in §261.3(f) are required to comply with certain
notification and certification requirements (§268.7(d)). Since these wastes are no longer
hazardous, the paperwork will not be sent to the disposal facility. Instead, relevant notices and
certifications are submitted to EPA and retained on site by the original generator or treater on a
one-time basis.
2.9 CHARACTERISTIC HAZARDOUS WASTES
Just like listed wastes, restricted characteristic wastes must also meet treatment standards before
they are eligible for land disposal. Since the land disposal restrictions attach at the point of
generation, waste handlers cannot circumvent treatment standards applicable to characteristic
wastes by simply removing the characteristic. Once a waste handler both decharacterizes and
treats the waste to meet the treatment standard that applied at the point of generation, however,
the waste may be land disposed in a nonhazardous, RCRA Subtitle D landfill.
TREATMENT STANDARDS
EPA established special requirements for wastes that exhibit a characteristic (§268.9). As a
general principle, a hazardous waste must meet all applicable treatment standards before land
disposal. For purposes of LDR, a generator with a listed hazardous waste must determine if the
waste also exhibits any hazardous waste characteristics (§262.1 l(c)). If a listed waste also
exhibits a characteristic of hazardous waste, the waste must meet the treatment standard for both
waste codes. An exception occurs, however, when the treatment standard for the listed waste
specifically includes a standard for the constituent that causes the waste to exhibit the
characteristic. In this case, compliance with the treatment standard for the listed waste will
satisfy both requirements, as the standard for the listed waste will operate in lieu of the treatment
standard for the characteristic waste code.
PAPERWORK REQUIREMENTS
While characteristic wastes are subject to the standard notification requirements in §268.7, EPA
subjects wastes from which the characteristic has been removed to special provisions. When
these wastes meet treatment standards and no longer exhibit any characteristic, LDR notification
and certification paperwork need not accompany the shipment to a Subtitle D facility. Instead,
§268.9(d) requires the waste handler to file a one-time notice and certification with the
implementing agency and maintain a copy on site. However, when the RCRA Burden Reduction
rule is finalized, this requirement may change. Subsequent shipments of similar waste do not
require additional notice except on an annual basis, or if the process or recipient facility changes.
DILUTION OF CHARACTERISTIC WASTES AND TREATMENT OF UNDERLYING
HAZARDOUS CONSTITUENTS
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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18 - Land Disposal Restrictions
When EPA first promulgated treatment standards for characteristic wastes, the Agency initially
determined that removal of the hazardous waste characteristic alone would adequately protect
human health and the environment. Thus, the treatment standards for these wastes appeared as
the specified technology, "DEACT," or deactivation. While Part 268, Appendix VI,
recommends particular methods of treatment to accomplish deactivation, simple dilution with
soil or water was an acceptable means to achieve compliance. Dilution of this kind was not
considered impermissible per §268.3, since it was performed as part of a specified technology.
However, in the case, Chemical Waste Management, Inc., et al. v. EPA, the plaintiffs won a
judgment against the Agency alleging, among other things, that deactivation via dilution failed to
meet the statutory mandates of RCRA §3004(m) because dilution does not reduce the mobility or
toxicity of the hazardous constituents present in the wastes. On September 25, 1992, the DC
Circuit Court of Appeals immediately vacated the treatment standards for ignitable (D001) and
corrosive (D002) wastes and remanded the treatment standards applicable to many other
characteristic wastes.
In response to the court decision, EPA published revised treatment standards for D001 and D002
wastes on May 24, 1993 (58 FR 29860). These revised standards require that certain ignitable
and corrosive wastes not only be deactivated to remove the hazardous characteristic, but that
they also be legitimately treated to meet numeric concentration levels for any constituents also
present in the wastes above the UTS levels. These constituents are known as "underlying
hazardous constituents" because they require treatment to meet LDR standards, but nonetheless
do not cause the waste to exhibit a characteristic.
On September 19, 1994, when EPA promulgated treatment standards for the newly identified
toxicity characteristic (TC) organic wastes (D018-D043) and revised the standards for some
previously restricted characteristic wastes (D012-D017), the Agency also required treatment for
underlying hazardous constituents beyond that necessary for removal of the characteristic.
When EPA promulgated revised treatment standards for metal wastes on May 26, 1998, the new
metal standards also required waste handlers to treat for underlying hazardous constituents (63
FR 28556). The creation of the UTS in §268.48 gave the Agency an easy source for the list of
constituents and appropriate treatment levels. Wastes requiring treatment for underlying
hazardous constituents must meet the numeric treatment levels enumerated in the UTS to be
eligible for land disposal. Wastes subject to treatment for underlying hazardous constituents are
easily identified since their treatment standards in §268.40 require that they comply with the
characteristic level "and meet §268.48 standards."
Part of the settlement agreement and consent decree with Chemical Waste Management, Inc. et
al., required EPA to ensure that waste handlers effectively treat characteristic wastewaters that
are managed in certain CWA and SDWA systems; to merely decharacterize or dilute these
wastes would not satisfy Congress's mandate to substantially diminish the toxicity of hazardous
waste. As a result, on April 8, 1996 (61 FR 15566), EPA finalized treatment standards for
characteristic wastes injected into deep SDWA wells, managed in non-hazardous surface
impoundments prior to CWA discharge, or discharged to land following CWA-equivalent
management. Specifically, these regulations would have required that such wastes undergo
RCRA-equivalent treatment not only to remove the characteristic, but also to destroy or
immobilize underlying hazardous constituents.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 19
Despite the finalization of these treatment standards for characteristic wastewaters managed in
certain CWA and SDWA-systems, these provisions were immediately altered by the Land
Disposal Program Flexibility Act of 1996. The new law removed the requirement that
characteristic wastewaters be treated to remove, destroy, or immobilize hazardous constituents.
As a result, characteristic wastewaters managed in certain CWA or SDWA-systems need only be
decharacterized before land disposal, and dilution may be used to satisfy this requirement.
Consequently, the Agency published, in the same Federal Register that contained the new
treatment standards, a notice to rescind those regulations and require only decharacterization for
characteristic wastewaters in accordance with the provisions of the new Land Disposal Program
Flexibility Act (61 FR 15661). See additional discussion of the statutorily mandated study of
decharacterized waste disposed of in surface impoundments in Section 4 of this module, entitled
"Regulatory Developments."
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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20 - Land Disposal Restrictions
3. SPECIAL ISSUES
The following three points discuss LDR issues of special note or concern.
3.1 POINT OF GENERATION
Generators are required to classify their solid wastes as soon as they are subject to regulation in
order to ensure that hazardous wastes will always be safely managed. Since LDR applies
additional limits to the ways in which waste may be managed, it is also necessary to immediately
determine if a hazardous waste is subject to LDR. Generators must, therefore, fully characterize
their wastes at the point of generation to determine if their hazardous waste is subject to LDR
(§262.11). If a waste is restricted at the point of generation, all Part 268 requirements continue
to apply to the waste, even if it is subsequently de-characterized or excluded from the definition
of hazardous or solid waste.
3.2 DIOXIN-CONTAINING WASTE
EPA bases the §268.40 treatment standards for dioxin-containing wastes on a BOAT of
incineration. While any technology short of dilution is permissible for achieving the required
contaminant levels, only incineration has been able to achieve them. Currently, no facility in the
United States is permitted to burn dioxin-containing wastes. In the interim, these listed wastes
must be exported or stored until treatment capacity becomes available.
3.3 LDR APPLICABILITY AND REMEDIATION WASTES
In order to ensure that site cleanups and remediation are conducted in a timely and cost-effective
fashion, EPA has designed special standards for the management of certain remediation wastes.
In the February 16, 1993, Federal Register (58 FR 8658), EPA promulgated regulations on the
use of corrective action management units (C AMUs) and temporary units (TUs) to manage
remediation waste generated during a site cleanup. Additionally, on November 30, 1998, EPA
finalized standards for a new type of unit, called a staging pile, into which a waste handler can
place solid, non-flowing remediation waste (63 FR 65874; §264.554).
To facilitate the cleanup process, these regulations effectively waive the requirement that wastes
managed in staging piles, CAMUs, TUs meet LDR treatment standards prior to storage or
disposal on the land. However, EPA established a new framework for the treatment of wastes
placed in CAMUs (67 FR 2962; January 22, 2002). Under this framework, principal hazardous
constituents (PHCs) identified in the waste must meet either minimum national treatment
standards adapted from the LDR alternative soil standards (see Section 2.5 Alternative
Treatment Standards) or, in special circumstances, site-specific treatment standards (See also the
module entitled RCRA Corrective Action).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Restrictions - 21
4. REGULATORY DEVELOPMENTS
With the completion of the "Thirds," EPA had addressed all hazardous wastes that were
identified or listed before November 8, 1984. Similarly, with the completion of Phase IV, EPA
addressed all hazardous wastes that were newly-identified or listed after November 8, 1984.
Since EPA has fulfilled its requirements to establish treatment standards for all hazardous wastes
through the Thirds and the Phases (as required by the Statute), in the future, the Agency will
propose LDR treatment standards when hazardous wastes are proposed for listing. On
November 20, 1995, EPA began this process by proposing LDR treatment standards for
petroleum refining process wastes in the same rule that proposed to list such wastes as hazardous
(60 FR 57747). The petroleum listings and their LDR treatment standards were finalized August
6, 1998 (63 FR 42110). On November 25, 2003, EPA proposed to list as hazardous waste
certain waststreams from the dyes and pigments industry. This listing, as well as LDR treatment
standards for constituents in the new listing, were finalized on February 24, 2005 (70 FR 9138)
(See Section 4.2, below). Consistent with this approach, all future waste treatment standards will
be promulgated in conjunction with the waste listing.
Currently, EPA is considering amending several aspects of the solid waste regulatory scheme.
4.1 BURDEN REDUCTION INITIATIVE
On January 17, 2002, EPA proposed to reduce the recordkeeping and reporting burden imposed
by RCRA on the states, the public, and the regulated community to meet the federal government-
wide goal established by the Paperwork Reduction Act (PRA) (67 FR 2518). When finalized,
the Burden Reduction Initiative will reduce the reporting requirements for generators and TSDFs
by eliminating or modifying non-essential paperwork. A few changes to the LDR recordkeeping
provisions are likely to be finalized.
4.2 DYES AND PIGMENTS
On February 24, 2005, EPA finalized the Waste from the Production of Dyes and Pigments
Listed as Hazardous rule, which listed as hazardous nonwastewaters generated from the
production of certain dyes, pigments, and FD&C colorants. This action is mandated by the 1984
Hazardous and Solid Waste Amendments and a consent decree (EDF v. Browner, Civil Action
No. 89-0598, D.D.C.). This listing sets annual mass loadings for constituents of concern, such
that wastes would not be hazardous if the constituents are below the regulatory thresholds. If the
wastes meet or exceed the regulatory levels for any constituents of concern, the wastes must be
managed as listed hazardous wastes, unless the wastes are either disposed in a landfill unit that
meets certain liner design criteria, or treated in a combustion unit as specified in the listing
description. This rule also adds five toxic constituents to the list of hazardous constituents that
serves as the basis for classifying wastes as hazardous. In addition, this rule establishes Land
Disposal Restrictions treatment standards for the wastes, and designates these wastes as
hazardous substances subject to CERCLA. The effective date of this rulemaking is August 23,
2005 (70 FR 9138; February 24, 2005).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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22 - Land Disposal Restrictions
4.3 MICROENCAPSULATION OF RADIOACTIVE LEAD SOLIDS
EPA anticipates taking action to grant a national determination of equivalent treatment petition
at the request of the Department of Energy. Currently, the use of containers is prohibited for the
storage of radioactive lead solids before disposal pursuant to §268.42, thus necessitating the
segregation and separation of radioactive lead solids from other debris. Containers can be
constructed of high density polyethylene (HDPE) to provide a resistant barrier to degradation by
the wastes and materials into which it may come into contact after disposal. The use of such
containers require revision to current regulation will be required to allow the use of such HDPE
containers. EPA intends approval of the equivalent treatment variance to promote faster cleanup
of contaminated sites by removing a regulatory distinction between radioactive lead solids and
other forms of hazardous debris, reduce worker exposures, and promote further advancement in
new technologies for disposal. The use of containers are expected to be less costly than
extrusion coatings and, therefore, this action would be cost neutral to cost beneficial to the
Department of Energy and other generators of radioactive lead solids (70 FR 27510, 27640; May
16, 2005).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Solid Waste and Emergency Response
(5305W)
EPA530-K-05-014
Introduction to
Land Disposal Units
(40 CFR Parts 264/265,
Subparts K, L, M, N)
United States
Environmental Protection
Agency
September 2005
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LAND DISPOSAL UNITS
CONTENTS
1. Introduction 1
2. Regulatory Summary 2
2.1 Surface Impoundments 2
2.2 Waste Piles 5
2.3 Landfills 7
2.4 Land Treatment Units 9
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Land Disposal Units -1
1. INTRODUCTION
Subtitle C of the Resource Conservation Recovery Act (RCRA) creates a cradle-to-grave
management system for hazardous waste to ensure proper treatment, storage, and disposal in a
manner protective of human health and the environment. Under RCRA §3004(a), Congress
authorized EPA to promulgate regulations establishing design and operating requirements for
land disposal units (LDUs). The requirements are intended to minimize pollution resulting from
the disposal of hazardous waste in or on the land. RCRA §3004(k) defines land disposal as
placement of hazardous waste in any of the following nine types of units:
• landfill • salt dome formation
• surface impoundment • salt bed formation
• waste pile • underground mine
• injection well • underground cave
• land treatment facility.
EPA has promulgated unit-specific technical standards for four of these LDUs within the
treatment, storage, and disposal facility (TSDF) requirements in 40 CFR Part 264/265. This
module provides an overview of the requirements for these four LDUs: landfills, surface
impoundments, waste piles, and land treatment units. LDUs that do not qualify as one of these
units are considered miscellaneous units (see the module entitled Miscellaneous and Other Units
for more details).
When you have completed this module, you will be able to summarize the land disposal unit
standards and list the relevant statutory and regulatory citations. Specifically, you will be able
to:
cite the statutory and regulatory minimum technological requirements
summarize the differences between interim status (Part 265) and permitted (Part 264)
standards for land disposal units
• find the definition of "surface impoundment" and distinguish surface impoundments from
tanks
describe surface impoundment retrofitting and retrofitting variance procedures
explain the connection between land disposal unit standards, post-closure, and
groundwater monitoring requirements.
Use this list of objectives to check your knowledge of this topic after you complete the training
session.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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2 - Land Disposal Units
2. REGULATORY SUMMARY
Regulations governing surface impoundments, waste piles, land treatment units, and landfills are
codified in Part 264/265, Subparts K through N. The standards for permitted and interim status
units address design and operating requirements, including liners and leachate collection and
removal systems (LCRS); closure and post-closure requirements; and special standards for
ignitable, reactive, and dioxin-containing wastes. In addition to these unit-specific requirements,
LDUs managing hazardous waste are subject to the general facility standards found in Subparts
A through E in Part 264/265, as well as the appropriate groundwater monitoring, closure and
post-closure, and financial assurance requirements.
For each unit discussed, this module addresses five topic areas: design and operation,
inspections, response actions, closure and post-closure, and special issues. This format will
enable you to compare and contrast the regulations for each unit.
2.1 SURFACE IMPOUNDMENTS
Subpart K in Part 264/265 contains the design and operating standards for surface impoundments
used to treat, store, or dispose of hazardous waste. Surface impoundments are very similar to
landfills in that both units are either a natural topographic depression, manmade excavation, or
diked area formed primarily of earthen materials, such as soil (although the unit may be lined
with manmade materials). The units are, however, very different in their use. Surface
impoundments are generally used for temporary storage or treatment, whereas a landfill is an
area designated for final waste disposal. Therefore, while the design and operating standards are
very similar, the closure and post-closure standards differ.
Most of the design, operating, and inspection requirements are very similar for surface
impoundments, waste piles, and landfills. The requirements are discussed in detail in this
section, with successive sections referring to this section for specifics.
DESIGN AND OPERATION
In developing design and operation requirements for surface impoundments (as well as landfills
and waste piles), EPA adopted a regulatory goal of minimizing the formation and migration of
leachate to the adjacent subsurface soil, groundwater, and surface water.
These comprehensive technical requirements for surface impoundments are the minimum
technological requirements (MTRs) mandated by RCRA §3004(o)(l)(A) and (o)(4). These
sections require a double liner, a LCRS, and a leak detection system (§§264.221(c) and
265.221 (a)). These MTRs apply to all new units, lateral expansions, and replacement units for
which construction (or reuse) commences after July 29, 1992. New, lateral expansion, and
replacement units for which construction (or reuse) began between July 15, 1985, and July 29,
1992, were required to have only the double liner and LCRS. Surface impoundments not subject
to these MTRs are subject only to single liner requirements (§264.221 (a)).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Units - 3
The double liner system consists of a top liner to prevent migration of hazardous constituents
into the liner and a composite bottom liner consisting of a synthetic geomembrane and three feet
of compacted soil material. The unit must also be equipped with an LCRS, which also serves as
the leak detection system. The LCRS, along with the leak detection system drainage layers,
must be designed with a bottom slope of at least one percent, be made of materials chemically
resistant to the wastes placed in the unit, and be able to remove the liquids at a specified
minimum rate. The LCRS itself must be designed to collect liquids in a sump and subsequently
pump out those liquids. In addition to the performance and design requirements, the LCRS must
be located between the liners immediately above the bottom composite liner, enabling the LCRS
to collect the largest amount of leachate, while also representing the most efficient place to
identify leaks. These MTRs are depicted in Figure 1 using a cross-section of a surface
impoundment.
Figure 1
CROSS-SECTION OF A SURFACE IMPOUNDMENT AND
ITS MINIMUM TECHNOLOGICAL REQUIREMENTS
Ground Water
Monitoring Well
Double Liner
Leachate Collection
and Removal System
Dike or Berm
A surface impoundment must also be designed to prevent the flow of liquids over the top of an
impoundment (or overtopping) and ensure the structural integrity of any dikes. Also, §264.222
requires that the owner or operator establish a site-specific leachate flow rate, called the action
leakage rate (ALR), to indicate when each regulated unit's system is not functioning properly.
None of these technologies will be effective if the impoundment is installed improperly or
constructed of inferior materials. To ensure that a surface impoundment meets all technical
criteria, EPA requires a construction quality assurance (CQA) program. The CQA program
requires a CQA plan that identifies how construction materials and their installation will be
monitored and tested and how the results will be documented (§264.19). The CQA program is
developed and implemented under the direction of a registered professional engineer, who must
also certify that the CQA plan has been successfully carried out and that the unit meets all
specifications before any waste is received.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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4 - Land Disposal Units
INSPECTION AND RESPONSE ACTIONS
In addition to the general inspection requirements found in §264/265.15, there are two types of
specific inspections required at LDUs. The first inspection requirement addresses the design and
structural integrity of the unit (§264/265.226). The owner and operator must inspect liners and
covers for any problems after construction or installation and continue inspections weekly and
after storms to monitor for evidence of deterioration, malfunctions, improper operation of
overtopping systems, sudden drops in the level of the impoundment contents, and severe
erosions of dikes and other containment devices.
Per the second inspection requirement, owners and operators must monitor leak detection sumps
at least weekly to measure the amount of liquid in the sump and determine whether the ALR has
been exceeded. This verifies both liner integrity and leachate pump efficiency. If a leak exceeds
the ALR, the owner and operator must notify the Agency and respond in accordance with the
response action plan (§264/265.223).
Surface impoundments must also comply with two types of response actions for the design and
performance of the unit. The response action for the performance of the unit is determined by
the terms of the response action plan, triggered when the ALR has been exceeded
(§264/265.223). If the action leakage rate has been exceeded, the owner and operator must
notify the Regional Administrator or authorized state; determine what short-term actions must be
taken (e.g., shut down of the facility for repairs); determine the location, size, and cause of any
leak; and send the assessments to the Region or authorized state.
There are also emergency repair provisions for unit design failure at permitted facilities
(§264.227). If there is an indication of a failure of the containment system (e.g., a sudden drop
in the level of the contents not attributable to changes in the flow in or out of the impoundment),
the surface impoundment must be removed from service. When this occurs, the owner and
operator must follow the procedures in the contingency plan, including any necessary emergency
repairs.
CLOSURE
Owners and operators can use one of two options to close a hazardous waste surface
impoundment. The first option, called clean closure, requires the owner and operator to remove
or decontaminate all wastes and unit components at closure (§264/265.228(a)(l)). If the unit
cannot be clean-closed, then the owner and operator must employ the second alternative. Under
this approach, wastes are left in place and stabilized, free liquids are removed, and a cap or cover
is placed on top of the waste. Since surface impoundments are generally used for storage, the
second option is equivalent to closing as a landfill and requires the owner or operator to take
certain precautions for a set time period after closure, known as post-closure care
(§264/265.228(a)(2) and (b)).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Units - 5
SPECIAL REQUIREMENTS FOR CERTAIN WASTES
RCRA places special requirements on surface impoundments that handle ignitable or reactive
wastes because these wastes require continuous protection from conditions that could cause them
to ignite or react (§264/265.229).
Additionally, §264/265.230 prohibits the placement of incompatible waste or materials, as
described in Appendix V in Part 264/265, in the same surface impoundment unless certain
precautions are taken.
Furthermore, if an owner or operator of a surface impoundment plans to manage dioxin-
containing waste (i.e., F020, F021, F022, F023, F026, and F027), he or she must employ a
special management plan approved by the Regional Administrator or authorized state
(§264.231). These wastes can only be disposed of in a permitted surface impoundment.
SURFACE IMPOUNDMENT RETROFITTING
Owners and operators of existing surface impoundments that become subject to RCRA as the
result of a new hazardous waste listing or characteristic must retrofit or cease receipt of
hazardous waste and begin the closure process within four years of the promulgation of the
listing or characteristic. For example, owners and operators of surface impoundments that
became subject to RCRA as the result of the promulgation of the Toxicity Characteristic on
March 29, 1990, were required to retrofit those units to meet the minimum technological
requirements or cease receipt of hazardous waste and begin the closure process by March 29,
1994 (55 FR 11798, 11835; March 29, 1990). However, surface impoundments that do not meet
minimum technological requirements may continue to receive restricted wastes if the Regional
Administrator or authorized state grants the unit a waiver under §3005(j) of RCRA.
SURFACE IMPOUNDMENT VS. TANK
The definitions of surface impoundment and tank are very similar and tend to create confusion.
The major difference in the two definitions is what provides the structural support to the unit.
Surface impoundments are supported by earthen materials, while tanks are supported by non-
earthen materials (e.g., wood, concrete, steel, plastic). In determining whether a unit is
supported by earthen or non-earthen material, it should be evaluated as if it were free-standing
and filled to its design capacity. If the unit can maintain its structural integrity, it is considered a
tank. If the unit cannot retain its structural integrity, it is considered a surface impoundment.
2.2 WASTE PILES
Regulations governing the management of hazardous waste in waste piles are found in Part
264/265, Subpart L. Waste piles, which are essentially noncontainerized piles of solid,
nonflowing hazardous waste, are temporary units used for storage or treatment only (§260.10).
Because waste piles are temporary units are not intended for final disposal of wastes, Subpart L
does not contain post-closure care regulations for waste piles that are closed with waste in place;
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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6 - Land Disposal Units
such units however, are considered permanent or disposal units and are subject to post-closure
care since they are closing as landfills (see Section 2.4).
Owners and operators of permitted waste piles that meet special requirements are subject to
reduced regulation. Specifically, the waste pile must be located inside or under a structure and
not receive free liquid, protected from surface water run-on, designed and operated to control
dispersal of waste, and managed to prevent the generation of leachate. If these standards are
met, the owner and operator of the permitted waste pile are exempt from groundwater
monitoring requirements, as well as the design and operation requirements for waste piles
(§264.250(c)).
DESIGN AND OPERATION
Waste piles are subject to nearly the same MTRs as surface impoundments. Specifically, new
units, lateral expansions, and replacement units require a double liner and LCRS (§§264.251(c)
and 265.254). In addition, waste piles, with certain exceptions, require a second leachate
collection and removal system above the top liner. Figure 2 depicts these requirements. If the
permitted waste pile is not subject to MTR (i.e., a unit, lateral expansion, or replacement for
which construction commenced before July 29, 1992), then the unit is subject to a single liner
and basic LCRS requirements. Interim status waste piles that are not subject to MTR are subject
only to liner, run-on, and runoff controls if leachate or runoff is found to be a hazardous waste.
Figure 2
CROSS-SECTION OF A SURFACE IMPOUNDMENT AND ITS MINIMUM
TECHNOLOGICAL REQUIREMENTS
Dauale-Lmr
DouHe Leachale
Collection and
Removal Syslerr
D-Serm
provision only requires the owner and operator of a waste pile meeting MTR to record the
amount of liquids removed from the leak detection system sump at least once a week (§265.260).
Note that waste piles are not subject to the emergency repair provisions for surface
impoundments.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Units - 7
CLOSURE
Since waste piles are storage units, as opposed to disposal units, all waste residues and
contaminated subsoils and equipment must be removed or decontaminated at closure
(§264/265.258(a)). This requirement is identical to the clean closure requirements for a surface
impoundment. If the owner or operator removes or decontaminates all waste residues and makes
all reasonable efforts to remove or decontaminate all structures and soils and finds that some
contamination remains, the waste pile will then be subject to the closure requirements for
landfills, including post-closure care (§264/265.258(b)).
SPECIAL REQUIREMENTS FOR CERTAIN WASTES
Waste piles are subject to the same specialized standards for ignitable, reactive, incompatible,
and dioxin-containing waste as surface impoundments. These requirements are discussed in
Section 2.1.
WASTE PILE VS. CONTAINMENT BUILDING
Containment buildings, sometimes characterized as "indoor waste piles," are units used to hold
noncontainerized piles of hazardous waste. The difference between waste piles and containment
buildings, from a regulatory standpoint, is that containment buildings are not land disposal units.
For this reason, containment buildings are designed with a containment system rather than a liner
and leak detection system (Part 264/265, Subpart DD). The module entitled Containment
Buildings provides more information about the standards that apply to containment buildings.
2.3 LANDFILLS
Since landfills are used as final disposal sites for a large portion of the nation's hazardous waste,
it is critical that they are monitored during their entire active life, including closure, and the post-
closure period. The regulations concerning hazardous waste landfills are codified in Part
264/265, Subpart N.
DESIGN AND OPERATION
Landfills are subject to virtually the same MTRs as surface impoundments and waste piles.
They must have a double-liner, LCRSs, and leak detection (§264/265.301), and an ALR
(§264/265.302). Like waste piles, landfills require a second LCRS that is above the top liner.
Figure 3 illustrates the MTRs of landfills. In addition, landfills must have stormwater run-on
and runoff controls to prevent migration of hazardous constituents for at least a 25-year storm
and a cover to prevent wind dispersal.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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8 - Land Disposal Units
Figure 3
CROSS-SECTION OF A LANDFILL AND ITS MINIMUM TECHNOLOGICAL
REQUIREMENTS
Top Liner
Drainage Material
(j Drainage Material
; Leachate
ana Collection
Removal System
Native Soil Foundation
jttom Composite Liner
INSPECTION AND RESPONSE ACTIONS
Once again, the inspection and response action plans are almost identical to the requirements for
surface impoundments, including a response action plan if the ALR is exceeded (§§264.304 and
265.303) and a CQA program (§264/265.19). In addition, the owner and operator of a hazardous
waste landfill must perform monitoring and inspections (§§264.303 and 265.304). As with
surface impoundments and waste piles, these requirements ensure that the unit is maintained in
good working condition and that any problems are promptly detected.
CLOSURE
Since landfills typically serve as permanent disposal sites, the closure and post-closure
requirements for landfills are somewhat different from those for other land-based units. One
example is the requirement for a final cover over the landfill that can provide long-term
minimization of liquid migration through the closed landfill, promote drainage, accommodate
settling, and function with a minimum amount of maintenance (§264/265.310(a)). After closure,
the owner or operator must comply with the post-closure requirements in §§264/265.117 through
264/265.120 covering such actions as monitoring and maintenance (see the module entitled
Closure and Post-Closure). In addition, the owner and operator must maintain the final cover,
leak detection system, and groundwater monitoring system, as well as prevent run-on and runoff
from damaging the final cover and protect the surveyed benchmarks (i.e., location and
characteristics) of the landfill.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Units - 9
SPECIAL REQUIREMENTS FOR CERTAIN WASTES
Like surface impoundments and waste piles, landfills are subject to certain restrictions for the
management of ignitable, reactive, incompatible, and dioxin-containing wastes. Unlike other
units, though, the placement of bulk or noncontainerized liquid hazardous waste or hazardous
waste containing free liquids in any landfill is prohibited (§264/265.314(b)). The placement of
nonhazardous liquids in a landfill is also essentially prohibited (§§264.314(e) and 265.314(f)).
There are only certain situations when containers holding free liquids can be placed in a landfill
(e.g., small containers such as ampules, containers that are products such as batteries, or lab
packs) (§§264.314(d) and 265.314(c)). If sorbents are used to treat hazardous wastes so that the
waste no longer contains free liquids, the owner and operator must use nonbiodegradable
sorbents.
SPECIAL REQUIREMENTS FOR CERTAIN CONTAINERS
To prevent significant voids that could cause collapse of final covers when containers erode, and
to maintain and extend available capacity in hazardous waste landfills, containers placed in a
landfill must be either at least 90 percent full or crushed, shredded, or in some other way reduced
in volume, unless the containers are very small, such as ampules (§264/265.315).
Finally, there are special standards for lab packs or overpacked drums being placed in a landfill
(§264/265.316). Lab packs generally contain small containers of a wide variety of hazardous
wastes in relatively small volumes that are packed in sorbent material to prevent leaking. This
sorbent material must be nonbiodegradable.
2.4 LAND TREATMENT UNITS
While surface impoundments, waste piles, and landfills share many regulatory standards, land
treatment units (LTUs) are significantly different both in purpose and in management. Land
treatment involves the application of waste on the soil surface or the incorporation of waste into
the upper layers of the soil in order to degrade, transform, or immobilize hazardous constituents
present in hazardous waste. Essentially, the waste is treated within the matrix of the surface soil,
whereas the major goal of the other units is to prevent migration to the surface soil. Specifically,
the waste must be placed only in the unsaturated zone, the portion of the surface soil above the
water table (or the highest point of the groundwater flow). Based on the proximity to the
groundwater, the success of land treatment is highly dependent on the operational management
of the unit.
Because the goal of land treatment is to let the soil microbes and sunlight degrade the hazardous
waste, the design and operating standards are significantly different from those imposed on the
three types of units previously discussed. Land treatment units generally do not use
impermeable liners to contain wastes. Instead, units rely on the physical, chemical, and
biological processes occurring in the topsoil layers. In a sense, these units can be viewed as an
open system.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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10 - Land Disposal Units
Maintenance of proper soil pH, careful management of waste application rate, and control of
surface water runoff are all key to the operation of a land treatment unit. The regulations for
hazardous waste land treatment units are in Part 264/265, Subpart M.
Because placement of hazardous waste in a land treatment unit is considered land disposal, land
disposal restrictions (LDR) standards must be considered. If the hazardous waste does not meet
the applicable treatment standard prior to placement in the land treatment unit, the unit owner or
operator must obtain a no-migration variance before applying any hazardous waste to the unit,
per §268.6. (See the Land Disposal Restrictions module for more details concerning the LDR
standards and no-migration variances.)
DESIGN AND OPERATION
Owners and operators of land treatment units must devise a program and demonstrate its
effectiveness given the design of the unit and characteristics of the area. In addition, the
regulations require specific operating requirements to be met in the treatment program. The
following discussion details these requirements.
Treatment Program and Demonstration
The requirements outlined for the treatment program, including design and operating criteria and
unsaturated zone monitoring, stem from a treatment demonstration. The purpose of the
treatment demonstration is to show that hazardous constituents in the waste can be completely
degraded or immobilized in the treatment unit. A treatment demonstration may involve field
testing on a sample soil plot or laboratory testing. The Regional Administrator or authorized
state uses information provided by the treatment demonstration to set permit standards. Interim
status units are not required to establish a treatment program because the interim status
regulations are self-implementing. Owners and operators can only place hazardous waste in the
LTU, however, if the waste will be rendered nonhazardous or less hazardous (§265.272(a)).
During the treatment demonstration, the owner and operator must establish the following
parameters:
Specify the wastes that may be handled at the unit. In general, land treatment is confined
to wastes that are primarily organic and that can be greatly reduced in volume by
physical, chemical, and biological decomposition in surface soils. The owner and
operator must be able to account for smaller fractions of heavy metals and persistent
organic compounds by immobilizing those constituents (§264.271(a)(l)).
• Formulate a set of operating measures. The LTU must be operated in a manner that will
maximize degradation, transformation, and immobilization of hazardous waste
constituents. The specifics of the operation are discussed in the following section of this
module (§264.27l(a)(2)).
• Establish unsaturated zone monitoring. The purpose of this program is to make sure that
treatment is occurring within the treatment zone and that all hazardous constituents are
being adequately treated. The information provided from the monitoring can help the
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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Land Disposal Units -11
owner and operator "fine tune" the treatment process to maximize the success of the
treatment. Unsaturated zone monitoring involves soil monitoring (e.g., obtaining soil
samples) immediately below the treatment zone (§264.271(a)(3)).
• Define the treatment zone. This zone comprises the horizontal and vertical dimensions of
the unsaturated zone in which the owner and operator intend to perform the actual
treatment. The zone can be no deeper than 1.5 meters (5 feet) and the bottom of the zone
must be at least one meter (3.2 feet) above the seasonal high water table (§264.271(c)).
Operation
Basic design and operating requirements are outlined in §§264.273 and 265.272. These sections
require the Regional Administrator or authorized state to specify certain parameters in the
facility permit:
• rate and method of waste application
• measures to control soil pH
• measures to enhance microbial and chemical reactions
• measures to control the moisture content of the treatment zone.
In addition, land treatment units are subject to requirements for stormwater run-on and runoff
controls. Management to control wind dispersal and weekly inspections are also required.
Food Chain Crops
In some cases, the owner and operator may grow food-chain crops on a land treatment unit
(§264/265.276). The Agency believes that this can be done safely if certain conditions are met
that require the owner or operator to demonstrate that hazardous constituents are not present in
the crop in abnormally high concentrations. Additionally, if cadmium is present in the unit, the
owner and operator must comply with additional management standards specified in §264.276(b)
and (c).
INSPECTIONS AND RESPONSE ACTIONS
Although there are no requirements to inspect the unit, the owner and operator must maintain
unsaturated zone monitoring to assure that the unit is meeting its performance standards
(§264/265.278).
As discussed earlier, the purpose of unsaturated zone monitoring is to provide feedback on the
success of treatment in the treatment zone and to determine if hazardous constituents are
migrating out of the treatment zone (i.e., the monitoring program must be designed to determine
the presence of hazardous constituents below the treatment zone). Generally, this means that the
owner and operator would monitor for the most stable hazardous constituents found in the wastes
placed in or on the treatment zone. However, unsaturated zone monitoring is not a substitute for
groundwater monitoring. Both are required for land treatment units.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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12 - Land Disposal Units
To perform unsaturated zone monitoring, the owner and operator must first establish which
constituents must be monitored and the background levels of those constituents in the soil. The
frequency of the monitoring is based on the elements of the operation of the LTU, such as the
frequency, timing, and rate of application of the waste. Once the samples have been taken, the
owner and operator must determine whether there is a statistically significant change over the
background values (i.e., the natural constituent levels in the soil) for any hazardous constituent.
If there is a statistically significant increase in the hazardous constituents of concern, the owner
and operator must notify the Regional Administrator or authorized state within seven days, and
submit a permit modification within 90 days to change the operating practices at the facility to
sufficiently treat hazardous constituents within the treatment zone.
CLOSURE
When a land treatment unit is being closed, the owner and operator must maintain all operating
parameters to continue the treatment processes, as well as maintain run-on and runoff controls
and unsaturated zone monitoring. The major element of the closure procedure is placing a
vegetative cover over the closing unit that is capable of maintaining growth without extensive
maintenance. At the completion of closure, the owner or operator may submit the closure
certification by an independent qualified soil scientist in lieu of an independent registered
professional engineer. Closure and post-closure requirements are waived when the hazardous
constituents in the treatment zone no longer exceed background levels.
SPECIAL REQUIREMENTS FOR CERTAIN WASTES
Like other LDUs, land treatment units are subject to limitations regarding ignitable, reactive,
incompatible, and dioxin-containing wastes (§§264/265.281, 264/265.282 and 264.283).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for training purposes.
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