New diet of products can help hospitals watch their 'waste' lines - News

The adage "garbage in, garbage out" is often used in reference to the ebbs and flows of information technology, but it can also have a much more literal application when it comes to waste management in healthcare facilities. Simply put, the cleaner a product is coming in, the cleaner it will be going out.

Janet Brown, medical waste manager for New York's Beth Israel Medical Center, sees effective waste management as a "front door/back door" situation. Materials managers, who bring product in through the front door, need to be cognizant of how it goes out the back door, she said.

"After years of minding the back door to make sure what goes out is handled appropriately, the focus now is on the front door," Brown said. "That means making smart purchasing decisions. Purchasers should be asking whether they really need a product or if it's just something they have to get rid of at the end of the day.

A key component to environmentally sound purchasing is changing the "lowest price-only" mentality when considering products, said Laura Brannen, co-director of Hospitals For a Healthy Environment, Lebanon, NH. Products that have the cheapest price tags don't necessarily translate into good overall value, she said.

Brannen used fluorescent light bulbs as an example. According to one vendor, she said, the bulb in highest demand is one that's cheapest and least effective. "Materials managers don't understand the role they play in waste stream management," she said. "They aren't paying attention to what happens to products once they enter the facility. Once it comes in, they feel their job is done. They're not accountable for changing those bulbs and the impact the discarded bulbs have on the environment."

Instead, materials managers need to look at the life cycle of a product, Brannen said. Since the purchasing department's responsibility extends through the life of the product, she advises that a continuous quality improvement process be implemented.

To conduct a life cycle analysis, Brown recommends that materials managers create a checklist to follow a product through its life to ascertain the costs and procedures involved with its disposal. The checklist should determine whether:

* If the product is hazardous

* Associate regulatory costs

* Whether air tests are necessary to meet OSHA standards

* If a spill kit is needed

* Whether unnecessary waste is generated.

There are numerous examples of that final point, Brown says. At Beth Israel, for instance, the facility used garbage can liners that were so thin they led to wasteful double bagging. And even though it was less expensive to order 500 business cards instead of 100, many cards were thrown out because of frequent title changes.

Brannen, who earlier worked in waste management at the Dartmouth-Hitchcock Medical Center, offers an example of how materials management at that institution has transformed into an efficient resource management team with the help of waste management.

"Because the purchase price for reusable suture sets were rising, [materials management] decided to switch to disposables," she said. "When I found out about this, I did some research and found that many of these disposable sutures were being put into sharps containers. That's an extra cost they didn't think about. Purchasers need to talk with waste managers about how to best use resources."

Mercury blues

Three top concerns in hospital waste management right now are mercury, PVC/DEHP and incineration. While experts say awareness of these issues has grown, the three still pose a triple environmental threat.

Prone to leaching into the ground and surface water, mercury is a toxin known to cause brain, lung and kidney damage. Fetuses and young children are considered to be particularly vulnerable to the effects of mercury because of their developing nervous systems.

Mercury's danger has caught the attention of legislators and if other states follow Washington state's example, a nationwide ban on mercury may be on the horizon. In April, the Washington state senate overwhelmingly passed a bill designed to reduce mercury in schools, hospitals, and homes by prohibiting the sale of mercury-based thermometers and thermostats, and requiring hospitals to develop plans for reducing the use of mercury products.

Hospitals For a Healthy Environment has been a crusader against mercury, initiating a mercury reduction program that today includes 466 hospitals, 817 clinics, 32 longterm care facilities and 134 other facilities. Also known as H2E, the group's goal is to eliminate mercury from healthcare by 2005 and cut the industry's waste output in half.

Opting to purchase mercury-free sphygmomanometers has been a source of controversy in some facilities, since critics argue that the new breed of products isn't as clinically effective. Brannen waves off that assertion. "If you educate people properly and calibrate the units correctly, they are as effective," she insists.

Besides purchasing mercury-free sphygmomanometers, environmentally conscious materials managers should switch to digital thermometers as well, Brannen said.

Mercury isn't the only toxin on the legislative hit list. DEHP, a plasticizer used in polyvinyl chloride that is linked to birth defects in babies, is also a target for elimination from hospitals. Used to soften PVC plastic medical devices, DEHP can reportedly leach into patients' bodies. In February, the California State Assembly began deliberating a bill aimed at banning the sale and distribution of medical devices containing DEHP.

In its current form, the bill would prohibit the sale and distribution of any medical device containing DEHP in California except when there is no alternative device cleared by the Food and Drug Administration. It sets a compliance date of January 1, 2005.

Charlotte Smith, president of Brookfleld, WI-based PharmEcology Associates, a consulting firm that helps hospitals develop pharmaceutical waste management practices, supports the California measure. "In sensitive populations like a developing fetus and prepubescent males, DEHP somehow mimics the endocrine hormone and can result in genital deformities," she said.

Even in the absence of a ban, some major medical device manufacturers are moving to DEHP- and PVC- free products. Still, others are resistant, Smith said.

"There is a lot of industrial might behind PVC," she said. "We've gotten a lot of pushback from the American Chemical Council. But the truth is the truth."

Up in smoke: Snuffing out incineration

Perhaps the most contentious issue in waste management is incineration. Environmental advocacy groups like H2E and Health Care Without Harm, are pushing hard for the abolition of all waste burning. Although their number has dwindled in recent years due to Environmental Protection Agency regulations, incinerators are still in use today and opponents won't be satisfied until all are shut down.

Lake Forest, IL-based Stericycle is the largest waste disposal company in the medical industry and operates several incinerators across the country. While the corporation has cut the number of incinerators nationally, Health Care Without Harm is pressuring Stericycle to shutter the remaining ones as well. Besides publishing a report that outlines the health dangers of waste burning, the group planned to personally deliver its anti-incineration message to Stericycle executives at a May 6 shareholders' meeting.

One of the report authors contends that public protest is the only method that motivates industry to shut down incinerators. "In our experience, they don't voluntarily shut down incinerators," said Monica Rohde Buckhoru, coordinator of the Alliance for Safe Alternatives, Falls Church, VA. "So far, what has moved them is community opposition and outcry. If they [waste management companies] are committed to reducing incineration, they should want to do it because it's the right thing to do."

From Stericycle's perspective, the company is doing just that. CEO Mark Miller maintains that Stericycle shares the same goal of a safer environment, but that it has to operate according to the law.

"We operate in a regulatory environment and some states require that hazardous chemicals like chemotherapy waste must be incinerated," he said. "Until the laws in those states change, we will continue incinerating. Because our customers are liable, we won't do anything that would put them at risk."

Even if the laws change, PharmEcology's Smith isn't sure incineration can he completely eliminated. "Where I differ from the environmental community is on the disposal of hazardous drug waste, like chemotherapy drugs," she said. "Incineration is the best method for getting rid of them. If you put them down the drain or in a landfill, there is a risk they will leach into the water table."

Emerging technologies may eventually render the incineration debate moot, however. According to Jorge Emmanuel, PhD, a Rodeo, CA-based medical waste consultant, new methods like alkaline hydrolysis are becoming available and are designed to replace conventional burning practices.

"The process was originally designed for pathological waste, but it also digests chemotherapy waste and other chemicals like glutaraldehyde," Emmanuel said. "The process heats alkaline to temperatures higher than boiling, but it's not as extreme as incineration."

Another concept called arc plasma also uses high temperatures to destroy chemical waste. Emmanuel has been monitoring its development for a decade, but says it still needs modification before it becomes a viable method.

"I have evaluated a dozen models and most of them have engineering and emissions problems," he said. "They use quite a bit of energy and produce too much ash residue."

Industry-wide initiatives

Controlling waste is everyone's responsibility in the healthcare supply chain, sources contend. Manufacturers need to look at the materials they use to produce and package products, hospitals need to know how products are used and discarded, and group purchasing organizations need to recognize the value of environmentally friendly products, they say.

To their credit, GPOs are becoming more attuned to the environmental aspect of purchasing, Beth Israel's Brown said. "They {GPOs] are getting into it -- it's happening," she said. "Premier, Consorta, Novation and Broadlane are all dedicated to it."

Typical of the new GPO attitude is San Diego-based Premier Inc.'s position statement on Environmentally Preferable Purchasing, which states that "special consideration will be given to business partners that support environmentally friendly products and packaging."

Across the industry, Smith says responsible waste management practices are advancing, but that the effort is just beginning.

"We're off to a good start -- it's important that awareness is building," Smith said. "But it's just the tip of the iceberg -- there is a tremendous amount of work to be done, especially within the hospital. It must be a multi-disciplinary effort."

RELATED ARTICLE: Hospitals honored for waste programs

Two hospitals are being hailed as shining examples of innovation in waste management by Hospitals for a Healthy Environment. Bronson Methodist Hospital in Kalamazoo, Ml, and Dartmouth Hitchcock Medical Center in Lebanon, NH, each received the 2003 Environmental Leadership Award on April 28 from H2E, a joint effort of the American Hospital Association, American Nurses Association, Health Care Without Harm and the Environmental Protection Agency.

Both institutions are Premier owners or members and Premier itself added to the green news when the alliance received the Champions for Change award from the Hospitals for a Healthy Environment. At the same time, Catholic Healthcare West, a 42-hospital system with ties to Premier, was also named a Change Award recipient.

Bronson earned recognition for closing its medical waste incinerator, recycling lab chemicals, implementing comprehensive waste minimization and starting energy conservation programs that are directly tied to employee job performance standards. Bronson, which has been mercury-free since the early 1 990s, reduced its regulated medical waste from 9 percent to 6 percent of its total waste stream despite significant growth in both inpatient and outpatient services.

Dartmouth-Hitchcock recycles 38 percent of its waste stream and runs a successful "Redo Center" and "Trading Post," providing opportunities for staff to transfer materials to another department instead of throwing them away. Dartmouth-Hitchcock has been mercury-free since 1997 and has also eliminated the use of ethylene oxide in its facility. The organization saved approximately $363,000 in disposal costs in 2002.

"We commend these hospitals for finding new and innovative ways to provide quality patient care while improving the health of our environment," said Mac Robinson, vice president at the AHA. "Bronson and Dartmouth-Hitchcock are shining examples of what hospitals can achieve with a commitment to environmental programs."

COPYRIGHT 2003 Nelson Publishing
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