WASTE MANAGEMENT ISSUES FOR NEW ENGLAND HOSPITALS

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WASTE MANAGEMENT ISSUES FOR NEW ENGLAND HOSPITALS
HELATHCARE FACILITIES

• Presented by
• Larry Doucet, P.E., DEE
• To The
• ENVIRONMENTAL BUSINESS COUNCIL OF NEW ENGLAND

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WASTE MANAGEMENT ISSUES CONCERNS FACING
TODAYS HOSPITALSCONTROLS, COSTS COMPLIANCE
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WASTE MANAGEMENT, TREATMENT DISPOSAL

• KEY ISSUES CONCERNS FACING TODAYS HOSPITALS
• Higher Rising Costs
• Fewer Shrinking Options
• Increasing Compliance Difficulties

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• 1. HIGHER RISING COSTS
• Uncontrolled Limitless
• Major Bottom-line Impacts
• No Capital Dollars for a Solution

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• 2. FEWER SHRINKING OPTIONS
• a. Fewer Viable Treatment Technologies
• b. Fewer Off-site Disposal Vendors
• -- State Regional Monopolies
• -- Longer Transport Distances

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• 3. INCREASING COMPLIANCE DIFFICULTIES
• a. Expanded EPA Compliance Audits
• b. JCAHO Environment Of Care Compliance
• c. On-going Off-site Disposal Liabilities
• d. Image Relations to Public, Patients Staff

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HOW AND WHEN DID THESE ISSUES CONCERNS ARISE?
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• 2005 MARKS THE 35 ANNIVERSARY
• OF MEDICAL WASTE EMERGENCE
• AS AN
• IMPORTANT ISSUE
• FOR HOSPITALS
• HEALTHCARE FACILITIES

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• HOW DID THESE ISSUES EVOLVE?
• PRE-1970 MINIMAL REGULATIONS COSTS
• 1970 EPA ESTABLISHED CHANGES START
• 1970 - EARLY 80s
• Arab Oil Embargos (74 78)
• Infectious Waste As Hazardous (76,78
  80-rcra)
• APC Regulations (77-CAAA)
• Infectious Waste Guidelines (82 EPA Draft)

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• HOW DID THESE ISSUES EVOLVE?
• EARLY 1980s MID-90s
• AIDS BECOMES THE MAIN FOCUS OF CONCERN
  UNIVERSAL PRECAUTIONS BLOODBORNE PATHOGENS,
  MED WASTE TRACKING ACT, ETC.
• JCAHA STANDARDS DEFINE INFECTIOUS WASTE AS
  HAZARDOUS WASTE (85)
• BEACH WASHUPS DISPOSAL INCIDENCES (86-86)
• MED WASTE DISPOSAL INDUSTRY DEVELOPED
• DEVELOPMENT OF ALTERNATE TREATMENT TECHNOLOGIES

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• HOW DID THESE ISSUES EVOLVE?
• MID-1990s 2005
• CLEAN AIR ACT AMENDMENTS SHUT INCINERATORS
• MED WASTE DISPOSAL INDUSTRY CONSOLIDATES
• ALTERNATE TREATMENT TECHNOLOGIES FADE OUT

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• WHAT DOES THE FUTURE HOLD?
• OFF-SITE DISPOSAL MONOPOLIES?
• Seem to be Occurring
• If So, Cost Escalations Certain
• How High How Fast?
• VIABLE TREATMENT ALTERNATIVES?
• Hugh Decline in Numbers
• More than 190 of about 210 firms out of business
• Very few have as many as 5 years experience
• Questionable Long-Range Vendor Survivability?

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• WHAT HAPPENS FROM HERE?
• Disposal Costs Increasingly Dominate
• Disposal Options Continually Decline
• Future Changes Remain Uncertain
• Continued Financial Difficulties For Many
  Hospitals

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WASTE MANAGEMENT, TREATMENT DISPOSAL

• PRIMARY COST REDUCTION OPPORTUNITIES
• WASTE MANAGEMENT PROGRAM IMPROVEMENTS
• ON-SITE MEDICAL WASTE TREATMENT
• SHARED SERVICE, CENTRALIZED OR REGIONAL TREATMENT
  FACILITY

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• COST SAVINGS OPPORTUNITIES-
• REDUCED MEDICAL WASTE GENERATION RATES
• 50 or More Reduction Achievable
• REDUCED OFF-SITE DISPOSAL COSTS
• Reduced Volumes and/or On-Site Treatment
• INCREASED RECYCLING BENEFITS
• Increased Recycled Volumes Reduced General
  Waste Volumes
• OTHER COST SAVING AREAS
• -- Reduced Hazardous Waste Disposal Costs
• -- Reduced Overall OM Costs
• -- Averted Fines Citations
• -- Reduced Insurance Premiums

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• OTHER BENEFITS-
• Reduced Hazardous Material Use/Disposal
• Liability Containment Averted Fines
• Increased Operational Efficiencies
• Demonstrated Corporate Responsibility
• Positive Public Image
• Continuous Quality Improvements

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• IMPLEMENTATION STEPS-
• 1. WASTE MANAGEMENT PROGRAM SURVEY ASSESSMENTS
• All Waste Streams, Practices Procedures
• Generation Rates Segregation Efficiencies
  Adherence to PP
• 2. IDENTIFY IMPROVEMENTS COST SAVINGS
  OPPORTUNITIES
• Identify/Evaluate Options Alternatives
• Volume/Generation Reduction Recycling/Reuse Haz
  Waste/Material Reduction Etc.
• Set Goals Establish Milestone Progress Targets
• 3. IMPLEMENT PROGRAM IMPROVEMENTS
• New/Revised Policies, Procedure Program Manuals
• Employee/Staff Training
• 4. PROGRAM ADMINISTRATION OVERSIGHT
• 5. MONITORING FOLLOW-UP

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• HOW MUCH MEDICAL WASTE IS GENERATED
• IN A TYPICAL HOSPITAL?
• SURVEY DATA
• SURVEYED FACILITIES
• 129 Hospitals Nationwide _at_ 43,000 Beds (Randomly
  Selected)
• 240 Million Lb/Yr Total Waste 46 Million Lb/Yr
  Red Bag Waste
• SURVEY RESULT SUMMARY
• Red Bag Waste Generation Range 0.10 to 92.7
• Red Bag Waste Generation Average 19.5
• 77 of Facilities Outside of 10 to 15 Range

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• WHY SUCH A LARGE DEVIATION?
• UNINTENTIONAL
• Mismanagement
• Regulatory Misinterpretations
• Unfamiliarity of Alternatives
• INTENTIONAL
• Rational Analyses
• Comparison of On-Site vs. Off-Site Options

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WASTE MANAGEMENT PROGRAM IMPROVEMENTS
OPTIMIZATION

• FACTORS AFFECTING INDIVIDUAL HOSPITAL WASTE
  GENERATION RATES-
• 1. Regulatory Definitions
• 2. Regulatory Interpretations
• 3. Waste Management Policies Protocols
• 4. Waste Management Practices Efficiencies
• 5. Hauler/Disposal Restrictions

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MEDICAL WASTE TREATMENT DISPOSAL ALTERNATIVES

• TREATMENT DISPOSAL OPTIONS
• Off-Site Contract Disposal
• On-Site Treatment
• Shared-Service, Centralized or Regional Facility
• ALTERNATIVE TREATMENT TECHNOLOGIES
• Thermal
• Chemical
• Irradiation
• Biological

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MEDICAL WASTE TREATMENT DISPOSAL ALTERNATIVES

• OFF-SITE DISPOSAL VS. ON-SITE TREATMENT
• OFF-SITE CONTRACT DISPOSAL
• Medical waste picked up treated/disposed
  off-site via vendor
• Facilities responsible for packaging
  manifesting
• Costs vary widely Locations facility sizes
  are main factors
• Liabilities risk remain with facilities
• ON-SITE TREATMENT
• Medical waste converted to general waste
• Much lower costs Typically 0.10 to 0.20/lb vs.
  0.25 to 2.00/lb
• Costs are controlled well know vendor
  independence
• Risk liability reductions short long-term

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ON-SITE MEDICAL WASTE TREATMENT TECHNOLOGIES

• THERMAL TECHNOLOGIES
• TEMPERATURES 205?F TO 20,000?F
• Low-Heat Processes
• Hot Air Oil
• Infrared Radiation
• Microwaves Macrowaves
• Hot Water
• Steam Direct Indirect Low High
  Temperature Chemical
• High-Heat Processes
• Incineration
• Pyrolysis
• Plasma Plasma Pyrolysis

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ON-SITE MEDICAL WASTE TREATMENT TECHNOLOGIES

• OTHER TECHNOLOGIES
• Chemical (Disinfection) Technologies
• Shredding Required
• Must Use Chlorine Compounds
• Once-Through Recirculation Systems
• Irradiation Technologies
• Electron Beam Radiation
• Cobalt 60
• Biological Process
• Shredding With Enzymes
• Single Demonstration Process

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EVALUATING ALTERNATE TREATMENT TECHNOLOGIES

• EVALUATION/SELECTION DIFFICULTIES
• Many technologies are new under development
• Most vendors have no full-scale operational
  systems
• DATA COLLECTION DIFFICULTIES
• Potentially misleading limited data
• Few facilities with limited experience
• UNSTABLE DECLINING INDUSTRY

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EVALUATING ALTERNATE TREATMENT TECHNOLOGIES

• KEY EVALUATION CRITERIA
• 1. Demonstrated Performance
• 2. Technical Performance Criteria
• 3. Vendor Qualifications
• 4. Environmental Permitting Issues
• 5. Occupational Health Safety Issues
• 6. Facility Infrastructure Requirements
• 7. Economics

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EVALUATING ALTERNATE TREATMENT TECHNOLOGIES

• WHAT SEEMS TO BE THE BEST ALTERNATIVE?
• CONVENTIONAL STEAM AUTOCLAVE SYSTEM
• Autoclave Processing Unit
• Autoclave Bins
• Bin Dumper
• Optional Automation System
• Optional Integrated Shredder
• -- Treated Waste and/or Confidential Documents
• ADVANTAGES
• Long-proven widely recognized accepted in by
  most state agencies
• Easy to permit negligible public opposition
• Easy to operate maintain high degree of
  reliability
• Small space requirements
• Lowest capital operating costs
• -- Financing options available (ECOS) No
  capital needed

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CONVENTIONAL STEAM AUTOCLAVE
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AUTOCLAVE WITH BINS IN FRONT OF LOADING DOOR
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LOADING OF BINS INTO AUTOCLAVE TREATMENT CHAMBER
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MOVING BIN TO COMPACTOR DUMPER
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SHARED-SERVICE, CENTRALIZED REGIONAL TREATMENT
FACILITIES

• COMBINED WASTE STREAMS SHARED OPERATIONS
• SIGNIFICANT ADVANTAGES
• Highly favorable economics
• Minimum capital OM costs
• "Automatic" off-site cost reductions
• Enhanced off-site contractor negotiations
• Divorces waste treatment from hospital operations
• Accommodates affiliated small-quantity generators
• VARYING DEVELOPMENT/IMPLEMENTATION OPTIONS
• Participating hospitals only
• Independent developer/investor only
• Combination (depending on risks, control,
  profits)
• Split/program components transport treatment

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WASTE MANAGEMENT AS PART OF A COMPREHENSIVE
ENVIRONMENTAL COMPLIANCE PROGRAM

• SHOULD HEALTHCARE
• EXECUTIVES WORRY ABOUT ENVIRONMENTAL COMPLIANCE?

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THE RISKS OF POOR ENVIRONMENTAL COMPLIANCE

• VERY SIGNIFICANT FINES
• BAD PUBLICITY LEADING TO -
• -- Poor affect on hospitals reputation for
  quality care
• -- Loss of patients financial revenues
• -- Poor image projections on staff, patients
  general public
• -- Increased community opposition to expansion
  
• new projects

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MAJOR ENVIRONMENTAL REGULATIONS AFFECTING
HOSPITALS

• Clean Air Act (CAA)
• Clean Water Act (CWA)
• Comprehensive Environmental Response,
  Compensation
• Liability Act (CERCLA)
• Emergency planning Community Right-to-Know
  (EPCRA)
• Federal Insecticide, Fungicide Rodenticide Act
  (FIFRA)
• Resource Conservation Recovery Act (RCRA)
• Safe Drinking Water Act (SDWA)
• Toxic Substances Control Act (TSCA)
• MORE THAN 40 PARTS WITH OVER 4,600 SECTIONS IN
  THE CFR

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HOSPITAL ENVIRONMENTAL COMPLIANCE CHALLENGES

• Environmental activities rarely controlled by one
  department
• Lack awareness of spectrum of applicable
  environmental requirements
• Recordkeeping documentation scattered not
  easily retrievable
• JCAHO Standards only address limited
  environmental issues

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EPAS AUDIT POLICY

• Incentives for Self-Policing Discovery,
  Disclosure, Correction Prevention Of
  Violations
• Effective May 2000

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EPAS INITIATIVES ACTIONS

• REGIONS 1 2 (New England States, NY, NJ, CT
  PR)
• LAUNCHED COMPLIANCE INITIATIVES TARGETING
  HOSPITALS, HEALTHCARE FACILITIES,
• COLLEGES UNIVERSITIES
• Alerts
• Self-Audit pacts
• Random, unannounced inspections
• Region 2- 44 facilities inspected
• 22 enforcement actions 911,000 penalties

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EPA REGION 1 INITIATIVE STATUS AS OF JULY 2005

• Total of 480 Facilities
• 44 Inspected 24 Enforcement Actions
• 10 Formal Enforcement Actions Totaling 1.3 Mil
• 8 Settlements Totaling 560 Thousand
• 37 Audit Agreements
• 128 Voluntary Disclosures Totaling 1.1 Mil
• 1,000 Violations Corrected

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SUMMARY OF EPA REGION 1 VIOLATIONS

• IN JULY 2005
• 697 VIOLATIONS FROM 128 FACILITIES
• RCRA Violations 60
• CWA Violations 17
• EPCRA Violations 12
• CAA Violations 7
• TSCA Violations 4
• SDWA Violations 1

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SUMMARY OF EPA REGION 1 VIOLATIONS

• TOP 9 VIOLATIONS FROM 59 RESOLVED VOLUNTARY
  DISCLOSURES
• VIOLATIONS ACTS FREQUENCY
• ID of HW RCRA 92
• Universal Waste RCRA 66
• Chemical Inventory EPCRA 48
• SIP Requirements CAA 48
• SPCC CWA 44
• Labeling RCRA 35
• CFC Leak Detection CAA 32
• MSDA Records EPCRA 30
• Manifests RCRA 30

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SUMMARY OF EPA REGION 1 HEALTHCARE RCRA
VIOLATIONS

• 409 REPORTED RCRA VIOLATIONS
• ID of HW 23
• Generator Requirements 18
• Container Management 16
• Universal Waste 16
• General Facility Standards 16
• Manifests 7
• Accumulation Time 2
• UST 1

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TYPICAL RCRA VIOLATIONS IN THE HEALTHCARE
INDUSTRY

• Improper labeling of HW containers
• Inadequate, incomplete, or no HW manifests
• Improper management of mercury wastes
• -- Fluorescent lamps
• -- Thermometers
• Improper management of expired/discarded
  chemicals
• Lack of or inadequate employee training on HW
• No weekly inspections in HW accumulation areas

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SUMMARY,QUESTION DISCUSSIONS