Reduce. Recycle, Reuse: Managing a Healthful Environment

Hospitals generate mountains of trash and hazardous waste, but not all of that refuse heads for the landfill or roasts in the incinerator. Many hospitals have implemented reduction, recycling and reusing programs for a wide variety of items — batteries, circuit boards, mercury, medical equipment and chemicals, to name a few. And their employees say it’s second nature to be watchdogs for waste.

Word-associate with “hospital” and you’ll most likely get these responses: clean, white, sterile, green.

Yet hospitals regularly generate mountains of trash and hazardous waste, and these unintended products clog landfills in bags and spew noxious chemicals during incineration.

That dichotomy was not lost on the federal government. Thus, the Environmental Protection Agency (EPA) in June 1998 struck an agreement to clean up healthcare with the American Hospital Association (AHA of Chicago). The parties inked their intentions in a Memorandum of Understanding. That collaboration gave rise to the creation of a nonprofit organization called Hospitals for a Healthy Environment (Washington, D.C.). A year-and-a-half after getting off the ground, the organization is hitting its stride with hundreds of hospitals signed on to reduce solid waste and cut down on energy and water consumption. With the possible inclusion of the Veterans Administration hospitals soon, those ranks will double.

Those sitting in the recycling-and-waste-reduction bandwagon talk in a rather matter-of-fact way about their programs. Several say that recycling and reduction is engrained into their everyday life — like brushing one’s teeth. They started doing what they do not only because it makes sense environmentally but because it also makes cents economically. Being green saves green, especially in the long run.

Eye on the back door
Watching your backside takes on new meaning when it comes to healthcare waste reduction and recycling. Laura Brannen of Hospitals for a Healthy Environment and a partner organization called Health Care Without Harm (Washington, D.C.) says there are numerous examples where savings have been realized. Included in the information on both organizations’ Web sites are reports of waste-reduction efforts. One of those reports is from Itasca Medical Center (Grand Rapids, Minn.), a 108-bed community hospital with an attached 35-bed convalescent nursing care center.

The hospital adopted a trilevel approach to waste reduction, looking to reduce the toxicity of materials used and examining the market for existing or new products that can be reused, are repairable, refillable or more durable, and result in a longer life than the items they replace. The result was more than $11,000 in savings, not counting disposal fees the hospital avoided by recycling. Itasca also decreased its disposal: a six-cubic-yard dumpster previously emptied five times a week now was being emptied twice a week. Hauling costs alone dropped by $5,000 a year. Even changes as mundane as stocking reusable dinnerware in the cafeteria made a big difference.

The Itasca study is several years old, and the potential for savings are even greater given higher hauling fees and tipping fees at landfills. But the report underscores some simple things that can be done to achieve cost savings in the neighborhood of 85 percent to 95 percent even with investing in reusable items. One of these involved the examination of battery use by the hospital’s nursing staff, whose members used flashlights powered by conventional D-cell batteries when checking on patients at night. The hospital replaced the conventional flashlights with rechargeable ones, avoiding the need to purchase and toss more than 1,200 batteries a year.

Although batteries of this type are mostly mercury-free, they do contain trace amounts of toxic materials, and, therefore, have an adverse environmental impact. Gaylord Hospital (Wallingford, Conn.) tackled this problem by finding vendors who will accept used batteries at no cost to the hospital. Ed Estep, a facility support services supervisor, explained how the hospital placed special recycling containers for batteries at locations where they would get the most use. All conventional-cell batteries and batteries commonly used in biomedical equipment go in these bins. The result is 600 to 800 batteries taken out of the waste stream each month, stuffed into five-gallon containers.

“We’ve been doing that full steam for about a year or two,” Estep says.

Recycling such items is not mandated; Gaylord started its program out of environmental concerns. It’s taken some effort to get people to comply with it, but Estep’s department, which combines the efforts of facility maintenance and biomedical engineering, has helped convince hospital management of the program’s benefits. Environmental reasons aside, should recycling of alkaline batteries become mandatory, the hospital is in a good position to comply with a decree.

“You can deal with what’s happening today or deal with it tomorrow, and if we can stay one step above the rest, that’s good,” Estep comments. “If something happened [like mandatory battery recycling], we’re all set. We’re ahead of the game.”

Such efforts show it pays to have people paying attention to waste-reduction issues, Brannen says. General waste can run a hospital $80 a ton at a landfill, while disposing infectious waste can cost upwards of $800 a ton and hazardous waste, about $1,000 a ton.

“Generally, people have not been watching the back door,” she says. “When you ask a hospital what they’re spending on total waste management costs, they can’t tell you. You have to understand your waste stream and how much money is being spent. If you’re not, you may be tossing resources.”

The back door is only part of the solution. People at all levels of a hospital’s organizational structure can affect change; for example, those with purchasing authority can tell vendors that they won’t buy the companies’ products if they’re packaged in certain ways or contain certain chemicals or compounds.

Hospitals for a Healthy Environment, which has some 473 hospitals, 828 clinics, 37 nursing homes and 137 other healthcare facilities pledged to reduce and reuse, is working with Catholic Healthcare West (San Francisco) to examine reprocessing of single-use items. These cover a wide range of heat-sensitive items that can’t be made sterile in an autoclave. Brennan notes that the Food and Drug Administration has indicated a number of noninvasive products can be reprocessed and reused on patients safely.

Brown-bagging it
It’s been 10 years since Dartmouth-Hitchcock Medical Center in Lebanon, N.H., started looking at ways to reduce, recycle and reuse. Leading the charge at this 400-bed academic hospital is John Leigh, who holds the full-time job of recycling and waste minimization coordinator. Leigh began in 1993 on a part-time basis; within a couple of years it was evident that the job not only could be full time, but also that the entire salary could be covered by savings linked to waste-reduction efforts. In that time, the hospital’s recycling rate has more than tripled — from 10 percent to 38 percent.

“We’re still achieving growth every year, and my intention is to keep growing as long as we can,” he says. “There’s always a new idea, a new method, a new market to explore on the recycling end and, certainly, better education of staff.”

Leigh works to tackle compliance problems before they begin. All new staff, including doctors, spend an hour during their orientation period with him.

“Most people are definitely surprised when you take them down to the trash room,” he says with a chuckle. “It’s not what they expected, but it’s effective.”

Dartmouth-Hitchcock disabled its incinerator in 1995 and chose to landfill its waste. It was able to cut down on toxic emissions and add more trash to the general waste stream by purchasing large autoclave units. These units sterilize infectious waste so it can be taken out with the rest of the trash, dramatically cutting down on disposal costs. The items that can follow this path go into brown bags placed throughout the hospital instead of red ones.

Like Estep, Leigh has worked diligently to find ways to recycle items and contract with vendors when it makes sense to do so. There are new costs associated with these efforts, and payback isn’t necessarily immediate. That comes in the long term, with hospitals being able to stay ahead of the tougher environmental regulations curve.

“It doesn’t come free, but it’s part of doing business,” he says.

Pete Lynch, a biomedical technician at Dartmouth-Hitchcock, acknowledges that he needs to stop and think about what his institution is doing regarding waste reduction because it’s such a part of its regular practice. Among its activities are finding companies that accept old circuit boards and international relief agencies that accept donations of medical equipment

“It’s a pervasive part of our practice,” he asserts.

There are real occupational health issues at stake, as well. Lynch and others about 18 months ago worked to eliminate the ethylene oxide used in gas sterilization of heat-sensitive items. Aside from the fact that ethylene oxide is both flammable and highly reactive, exposure to it can cause respiratory problems, headaches, nausea, vomiting and diarrhea. Cancer, reproductive problems and mutagenic changes have been linked to ethylene oxide exposure over the long term.

“Even at fairly low levels it’s a carcinogen, and even with short-term exposure it’s a nasty thing,” Lynch points out.

The hospital replaced its old gas sterilizer units with those that employ hydrogen peroxide plasma. Advantages include shorter sterilization cycles, low temperature and humidity, no aeration requirement, no toxic chemical residues and a lesser environmental impact, he informs.

Mercury-filled thermometer

Minding your mercury
Most hospitals already have tackled the most obvious occupational culprit, that being the heavy metal mercury. The material is extremely toxic, and, once released, it represents a major long-term health risk. Like many heavy metals, it is a bio-accumulating toxin, meaning that the body cannot purge itself of mercury and so stores it in fatty tissues. Also, when mercury is metabolized in living beings it is converted into a more toxic form of mercury called methyl mercury. Even in its original form, the miniscule amount of mercury found in the average home thermometer is enough to taint an entire pond. This is why thermometer exchanges have become so popular, with electronic or zinc-based thermometers being the best substitutes.

Mercury is in many places, as Gregg Perry, hazardous materials manager for Merrimack Valley Hospital in Haverhill, Mass., found out. He learned of a grant program from the EPA to help hospitals rid themselves of mercury. Merrimack Valley used it to hire Stericycle Inc. (Lake Forest, Ill.).

The program took three years, including a switch over to nonmercury “rat tails,” which patients swallow for throat scans. With the mercury-encased models, the patient could suffer a double hit from ingesting the liquid and breathing the mercury vapor if the mercury were to leak out. Other lesser-known mercury sources included switches in thermostats, vacuum pumps, gauges on medical air valves and fluorescent light bulbs. For the latter, the hospital secured another grant to help with relamping the entire hospital with more efficient models of fluorescent bulbs, which also use less mercury. It also found a company to take away the old bulbs, assuring that they were being disposed of in the most environmentally friendly manner possible.

It’s not easy going green
Just as it can be difficult to get physicians to relinquish the feel of latex gloves for nitral or other nonallergenic gloves, getting them to give up on sphygmomanometers for blood pressure, also known as mercury columns, can be a chore. Here the decision is rooted in what is clinically the best instrument for the patient, and a strong argument remains that nothing beats the accuracy of a mercury column, Perry remarks. Still, Merrimack Valley got rid of 20 sphygmomanometers and replaced them with aneroid sphygmomanometers.

“People say mercury is better, but I’ve been using them [aneroid sphygmomanometers] for two years, and they’re fine,” he insists. “It’s not rocket science; you can tweak them to make them work from where you are.”

Mercury versus nonmercury sphygmomanometers was the subject of a recent article in ECRI’s (Plymouth Meeting, Pa.) Health Devices journal. The author, Chris Lavanchy, engineering director for ECRI’s Health Devices group, notes first that, yes, mercury is a highly stable liquid with limited expansion and contraction properties, and for these reasons, mercury sphygmomanometers are extremely accurate. Physicians also tend to have less confidence in digital blood pressure devices because they use computer algorithms that make some estimation to provide a reading, he summarizes.

“Patients with certain conditions may not measure appropriately,” Lavanchy says. “There’s some truth to that, but the number of patients affected are quite few.”

Lavanchy also found that digital units, because of the way they process results, offer more information for doctors interested in charting blood pressure results over time. These also can be connected to physiologic monitors that provide even more information about how the patient may be responding to a particular treatment.

Aneroid blood pressure devices can be used with confidence if they are properly maintained, he adds. Concerns about needles that won’t reset to zero shouldn’t be so great that these types of devices aren’t used in place of sphygmomanometers using toxic mercury.

“Our primary recommendation is to get rid of mercury columns and, recognizing that they will cost a bit more [to purchase non-mercury blood pressure devices], they are something that can be relied on,” he states. “It may require a little more vigilance on the part of the biomed, and having a 10 percent surplus of gauges wouldn’t be a bad idea.”

Clinicians also need to understand the dangers posed from mercury columns should they break. These contain about 100 grams of mercury, more than 100 times the amount of mercury in a thermometer. Even if the cool-looking balls of mercury rolling across the floor can be contained, the invisible mercury vapor that they release is extremely unhealthful and further compromises an already sick patient’s health.

“It’s all about building them into PM schedules and ensuring they aren’t allowed to go out of calibration,” Lavanchy offers. “Biomeds might see this as a mixed blessing, having to add to their routine work, but it’s a definite occupation safety issue for them and the hospital.”

Merrimack Valley’s Perry notes that once a clinical engineering department gets into the spirit of eliminating waste and hazardous materials, it’s easy for that spirit to infect hospital staff and foster even more aggressive plans for recycling. Sure, hospitals can use silver recovery for radiology, Perry notes, but there are many other nasty chemicals that go down the drain. Once the switch is made to digital or dry processing, environmental protection is ensured, he suggests.

“It’s a whole different concept of clinical engineering and how you purchase equipment and how it is used,” he says. “Once you start thinking about mercury and things like that, you start thinking about everything else.”