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The medical waste stream | Designed for disposal
It is lunchtime at St. Luke's Medical Center in Milwaukee, at the junction of 27th Street and Oklahoma Avenue. A burly, balding man in a white T-shirt and matching overalls ambles over to an alcove just outside the cafeteria. He carries a small Styrofoam plate, which he places in a bin marked "Polystyrene," and a Styrofoam cup. He pauses to empty the remains of his drink. Then the cup, too, is tossed into the bin.
On the eighth floor, in the Oncology Department's medication room, a tall wastebasket with a swivel lid is filled almost to the brim with empty IV bags, plastic bottles and wraps. Down the hall, in the nurses' station, large rectangular paper recycling boxes are in plain view on the floor, and are emptied when full into larger bins nearby. Those big bins are marked to accept different kinds and grades of paper, and keeping them separate pays nicely: the higher grades fetch twice the price of the lower grades on the waste paper market, says Aralee Scardina, the center's environmental services manager.
At Scardina's office in the administrative wing, there's not a single garbage can to be found, but recycling bins for everything from paper to plastic to glass to batteries are in plain view. A person wanting to pitch a piece of gum is directed to the closest "real" trash can – in this case, it's a 10-inch paper bag stuck to the underside of each desk.
Only a few years ago, if a hospital employee had questioned the standard practice of sending thousands of single-use supplies to the garbage dump each year, he or she would have been ignored, if not ridiculed. Today, these examples of waste separation at St. Luke's mark a silent revolution taking place in Wisconsin medical institutions, and signify the end of decades of wasteful habits.
Medical businesses initially were exempted from the 1989 statewide recycling law as the legislation aimed to tame the more common wastes made in larger quantities. That all changed in 1994 with the passage of a new state rule designed to lessen the amount of trash produced by hospitals, clinics, nursing homes and medical laboratories.
The law is feeding the enthusiasm of people like Scardina, and undoubtedly irritating those less inspired. Either way, the movement has begun.
"Change is always an interesting experience," Scardina says, speaking of occasional indifference on the part of hospital staffers. But, she adds, "I'm real proud of people who have been able to work with [the new rule]. There's a real commitment on their part."
Thirty years ago, that lunchtime cup and plate would have been made of heavy ceramic, and washed when dirty. Thirty years ago, patient wash basins, bedpans and water pitchers were molded of stainless steel and used over and over again. But, just as pre-packaged, pre-filled, and pre-measured everything entered the grocery stores and kitchens of America, so went the trend in medical supplies. A wholesale switch to disposables started in the late 1960s to reduce labor costs associated with cleaning, repackaging and sterilizing supplies as well as reduce the chance of transmitting disease.
Today, when a patient's stitches are ready to be removed, nurses no longer need to gather supplies from different rooms but can simply order a sterile, plastic-wrapped suture removal kit complete with scissors, forceps, and antibacterial swabs. A liter of normal saline intravenous fluid now is packaged in a soft bag made of polyvinyl chloride resin, 20 bags to a cardboard box. And many medications come directly from the hospital pharmacy in disposable syringes, ready for injection.
Until recently in Wisconsin, and as is still the case in most parts of the country, all these products were thrown away after use. Plastic IV bags have become especially prevalent in hospital trash, as have plastic syringe cases and blue polypropylene covers for trays of surgical instruments. And when a technician sees surgical scissors embossed with the word "disposable," that's exactly what happens.
All too frequently this type of trash was put in the special red bags for infectious waste marked "Biohazard" that would go to the incinerator. That was a cheap solution so long as the medical waste incinerators were next door and owned by the hospital, but most of these incinerators have been closed due to air pollution concerns. Their infectious waste must be trucked to licensed treatment facilities that are typically near town but farther away from residential neighborhoods. Now the cost of treating infectious waste, either by incineration, microwaving, or autoclaving, has gone "sky high," according to Barb Bickford, DNR medical waste coordinator.Couple steep prices with the new law, and it's no surprise to find a marked reduction in the amount of waste being treated as if it were infectious.
The heart of the rule requires hospitals, medical clinics and nursing homes to look closely at their waste, to determine what truly needs special treatment and what doesn't, and to separate their waste streams. Infectious waste always must be isolated. Then, the "regular" garbage is inspected further, to discover how it too, can be reduced. This may mean recycling, as in the case of polystyrene dishes and polypropylene ice pitchers; reusing, as in washable dishes, cutlery, waterproof bed pads, and surgical instruments; or reduction, as in the case of buying supplies in bulk to reduce packaging. Some doctors and nurses even are taking the initiative to collect and donate unused supplies to charities and developing countries.
Another part of the rule requires that used syringes and other medical "sharps", from diabetics injecting insulin at home, or veterinarians and farmers injecting animals, be kept separate from regular trash.
The focus on waste reduction has led to a new appreciation of just how confusing a ubiquitous term like "medical waste" can be. In Wisconsin, the term "infectious waste" is reserved for those items that can actually pass on disease, such as needles and blood-soaked items. "Medical waste" is considered to be infectious waste plus anything mixed with it. So, if the waste hasn't been sorted carefully, as was historically the case, a garbage bag could consist of a few bloody towels and sponges from the operating room, and a few pounds of recyclable plastics. Just those few contaminated items would dictate incinerating the entire bag.
At any rate, the medical managers who have embraced the new rule are finding that recovering wasted materials is reaping big rewards, in money not spent and natural resources saved.
At Ripon Medical Center in Ripon, a 40-bed hospital typically half full, about 850 pounds of "red bag" waste was hauled for treatment by Browning- Ferris Industries (BFI) last June, down from an average of 1,800 to 2,000 pounds per month before a separation program was begun. Just removing the red bags from patients' rooms helped a lot, said Phil Schaffer, director of plant operations. "We had everything going in there – anything that touched the person went into red bag waste," he says.
Leslie Boerger, a major account executive with BFI, estimates that the hospital has saved about $100 every month with the new program. Not only did Ripon reduce its infectious waste, it also sent off 345 pounds of assorted plastics in just one month last spring to a small national company: Tri-State Hospital Supply Corp., both sells hospital supplies and receives them after they are soiled, for recycling or reuse. Some parts of Ripon's contract with Tri-State cost them more, Schaffer says, but they are offset by reduced disposal expenses.
St. Luke's Medical Center, and, increasingly, the entire Aurora health care system in the greater Milwaukee area, have contracts with Tri-State for plastics supplies and recycling. Tri-State also sells recyclable plastic bags for dirty linen, and provides and resharpens metal scissors, hemostats, and similar instruments.
Bag by bag, those numbers add up. With 1,000 hospital linen bag contracts nationwide, Tri-State turned 1.3 million pounds of used polyethylene plastic bags back into new bags last year, says Dave Taylor, Tri-State's regional manager. In Wisconsin, where the firm now has several dozen contracts to recycle other plastics as well, the new rule "literally catapulted" recycling, he adds.
Another company seeking innovative ways to address the hospital waste question is Rexam Medical Packaging, of Mundelein, Ill. Rexam, a national maker of packages that are later sterilized with hospital supplies inside, has looked at the types of plastics and paper used in making those packages. Because the firm deals with many hospital supply companies of every size, it has been in an ideal position to coordinate package manufacture so that the outer wraps can be more easily recycled after the inner supplies are used.
That is not to say that all those packages are actually being recycled, however, says Lisa Stec, a Rexam research chemist. There still are plenty of challenges confronting would-be recyclers. "There's still not enough of any particular packaging type to make recycling worth it," Stec says.
The company is working to solve that problem: One of Rexam's top vice-presidents is currently a member of the Healthcare Resource Conservation Coalition, a three-year-old national association of hospitals, clinics and product suppliers working together to reduce medical waste. The group soon will have an Internet address to help people communicate about these issues.
Sharing information is essential in the recycling field. Rexam, for instance, has helped Tri-State by chemically analyzing a particular plastic, to help Tri-State find markets for some of the soiled items it accepts from hospitals.
All kinds of spent plastics are waylaid for a while at Tri-State's local warehouse in Pewaukee. At one end of the cavernous building, hippo-sized bins of smelly polystyrene food dishes share the floor with other sorted and soiled plastics, all ready to be shipped to various processing plants. Some will be ground into flakes and eventually molded into new, sterile bedpans and basins. Some is eventually added to concrete to make foundation blocks.
The blue polypropylene wrappers that cover bulky trays of surgical supplies during sterilization are sent to a recycler who is now reformulating them into McDonald's food trays, according to Taylor.
And the IV bags are going...well, as of summer 1997, they weren't going anywhere, despite some initially promising ideas. The lack of a good market is one the most frequent obstacles faced by would-be recycling innovators. Or perhaps there's a market, but the difficulty is it's too costly to collect a full truckload of one harder-to-recycle plastic type from dozens of small hospitals and clinics.
Some would say the bags should be made from a plastic that can be more easily recycled, placing the onus on the manufacturer instead. That may be true. Some would say, as does Taylor, that the state should require the recycling of all grades of uncontaminated plastic, not just numbers 1 and 2, to encourage creativity and to increase the supply.
So far, however, the marketing and technological barriers to recycling those plastics, as well as the high costs, have kept people like Taylor dreaming. Sorting plastics remains just one of the problems, says Kate Cooper, chief of DNR Waste Management Planning and Evaluation. "At a sorting facility, people have to move quickly," she says. "They don't pick up a bottle and gaze at it."
For now, however, a sign on a door at Tri-State proudly proclaims, "We Never Say No," describing Taylor's philosophy.
The sign was printed after an employee said "can't do" to a hospital staffer inquiring if a particular item could be recycled. That's no way for a recycler to stay in business, Taylor believes. "Many hospitals ask us to do things. We find a way to do it," he says.
Scardina estimates recycling has saved St. Luke's $120,000 in landfill costs. The numbers speak for themselves: In 1991, when her program was started, virtually no cardboard or plastic had ever been recycled at the hospital. By 1996, paper recycling had quadrupled, to 423,000 pounds, cardboard recycling stood at about 340,000 pounds, followed by 75,000 pounds of varied plastics.
Meanwhile, the amount of trash St. Luke's sent to the landfill dropped precipitously, from 4.7 million pounds in 1991 to a little over 2 million pounds in 1996. If Wisconsin's law were extended to the nation's hospitals, which are estimated to generate 12 million pounds of trash every day, just imagine the difference it would make.
"We are such a minor player, it's so incredible," says Taylor. "I'm not a green thumb person, but after we started recycling linen bags, I got a sense of what would've gone to a landfill.
The amount of plastic Tri-State recycle in a year, about equals the amount that one supplier sells to all the Los Angeles hospitals in a month, he continues. "The sky's the limit."
Many Wisconsin diabetics on insulin may already cap their used needles and toss them into an empty detergent bottle instead of throwing them into the nearest trash can. But some of us, including this author, had to be embarrassed into changing our ways after being chastised by a garbage collector, who once found a capped, but loose, syringe mixed in with my general trash.
That syringe undoubtedly was frightening to behold: insulin needles are sharper than any used for sewing, fully capable of piercing tough leather gloves; there is also a risk, however small, of disease transmission. Workers have been stuck while collecting and sorting garbage and recyclables, and occasionally, whole bottles have broken open on conveyors and in compactors. In short, mismanaged syringes create trouble for everyone.
Statewide regulations now require home users of "sharps" – a term that includes syringes from the injection of animals and humans, as well as scalpels and lancets – to store them in a sturdy bottle, labeled with the words "Sharps – do not recycle." When the bottle is full, it should be capped and taken to a pharmacy, hospital, or government agency set up to accept them.
The cost is either free or minimal for home users, and no records need be kept. And, for institutions producing less than 50 pounds per month of infectious waste – which may also include blood, body fluids, human tissue, and the containers that hold them – the requirements still are slight. The waste must be kept separate and recorded, and disposed of at a licensed treatment facility.
Lowering infectious waste production to less than 50 pounds each month has actually become a goal for some medical institutions, because new conditions kick in once that limit is exceeded. Those include submitting yearly reports to the DNR, ensuring that infectious wastes are separated, and carrying out a plan to reduce the rest of the waste stream. Timelines for those waste-reduction plans vary according to the size of the clinic, hospital, or nursing home.
As of last summer, more than 400 institutions large enough to meet the reporting criteria had done so, and there are more out there, according to Barbara Bickford, DNR medical waste coordinator.
For more information, call your DNR regional office and ask for the waste management specialist. And for a list of the over 300 registered sharps collection stations statewide, contact the DNR or call the American Diabetes Association's toll free number 1-800-342-2383.
Katherine Esposito writes about natural resource and environmental issues for Wisconsin Natural Resources.