King County Medical Industry Round Table (MIRT)

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Medical Industry
Waste Prevention Round Table

REDUCING MERCURY
in Hospitals and Biomedical Facilities
A MIRT Seminar

May 23, 2001

Health Effects and Environmental Effects of Mercury
A PowerPoint presentation by Sandy Rock

Mercury is a toxic metal
Occurs in Nature
Elemental Mercury - Vapor
Inorganic and Organic - Organic form is the most dangerous
Crosses placenta and crosses blood brain barrier
Neuro toxin
Enters the body via inhalation, ingestion, and dermal absorption
Methyl Mercury, the most dangerous because it is fat soluble and easily enters the body (Enters fish, bioaccumulation, biomagnification)
Resides in muscle tissue, not fat so you can't trim away the fat and think you are avoiding the mercury

Exposure
· Vapor for elemental
· Dermal from inorganic salts, phenylHg
· Methylmercury from Fish

Health Effects
· Primarily a Neurotoxin, CNS and peripheral
· Also, Gingival, eyes, lungs, skin
· Kidneys and G-I tract
· Developmental (fetus) - multiple effects including mental retardation's, blindness, microephaly (small head), cerebral palsy, swallowing disturbances
· Biological 1/2 life is 40-70 days

Treatments
· Prevention is best
· Chelating agents
· Oral Resin (for ingestion)
· Hemodialysis (L-cysteine)
· CNS damage from MeHg permanent, no treatment, irreversible!

What can be done?
· Increase public awareness
· Conserve power
· Reduce consumption, recycle, and properly dispose of mercury-containing products
· Find Substitutes

Mercury and Dioxin Reduction: "What are Innovators Doing in the Health Care Industry?"
A PowerPoint presentation by Jamie Harvey

Health Care w/out Harm - healthcare that does not negatively impact the environment
2 tons Hg per year prevented by retailer phase-out of Hg thermometer

Question: A lot of the mercury in a hospital isn't actually in the medical equipment. Is this mercury considered in the MOU between AHA and EPA?
Answer: This is up for interpretation. The main thing is that you label Hg equipment so when it fails and needs to be replaced it is disposed of properly. The pledge program is just to pledge to reduce it is not certification that you have eliminated it

Interested in alternative disposal
Autoclave Hg will show up in autoclave exhaust and in waste water
Microwave is the same issue
Hg doesn't go away. Instead of looking at method should just phase it out

What are manufacturers doing with reclaimed Hg? You need to ask them as they are all different. It is probably not appropriate to be sending our Hg overseas. The federal government is talking about which fish have mercury and that it is a problem but they haven't actually gotten around to getting rid of it. Thermometer exchanges - do them , employees really like them. HCWH has brochures (in a range of languages) on mercury elimination that anyone can order if they'd like them. Contact Jamie at harvie@isfusa.org for ordering information.

Good success with thermometers and sphygmomanometer. Are there good alternatives to barometers? Yes

The Nasty Nine
· Chlordane
· Dieldrin
· DDT and its breakdown products
· Hexachlorobenzene
· Mercury
· Octachlorostyrene
· PCB
· 2, 3, 7, 8 TCDD (Dioxin)
· Toxaphene

Dioxins and Mercury on the Nasty Nine list come from Health Care facilities

International Joint Commission
"We conclude that persistent toxic substances are too dangerous to the biosphere and to humans to permit their release in ANY quantity."

National Mercury combustion sources
Mercury doesn't burn so DON'T SEND IT TO INCINERATORS

Ethical Considerations
· It's ironic that institutes which are working to heal those in their communities are putting out toxics
· There are warnings on fish consumption in 40 states
· 5 million people regularly eat contaminated fish from the Great Lakes
· CDC - 1 in 10 women of childbearing age have enough mercury to present a potential problem

Economic Considerations
· Clean up costs - It often costs ~$5,000 for 1 broken sphygmomanometer - you could buy 30 or 40 non-mercury ones for that cost. One local hospital recently spent $10,054 dollars to clean up a spilled sphygmomanometer.
· Regulatory Costs - 30-ppt pretreatment level in some places (fines)
· Hazardous Waste training costs
· JAHCO compliance - JAHCO is starting to ask questions

Obstacles to Mercury Elimination
· Reluctance to change
· Lack of awareness of alternative and economics
· Minimal understanding of the human and environmental impacts

Where is it in Hospitals
· Batteries
· Fluorescent
· Devices - sphyigmometers, thermometers
· Amalgam
· etc....
· Fixatives -
· B5 filtration - still leaves 25 ppm mercury, if add to 20000 gallons of water, they still exceed 30ppb mercury limit

Alternatives to Mercury Fixative
· Formalyn
· Zn Formalyn - 1-800-Anatech
· IBF - Surgipath 1=800-225-335
· St. Mary's Duluth Clinic - has slides to evaluate mercury free alternative

Historical Sources of Mercury
· Located in Wastewater piping
· Builds up in low piping

Phased Mercury Elimination - steps to taking it out
· Discontinue purchase of mercury
· Replace Hg equipment
· Educate employees
· Child Birth Educ
· Mercury free fixatives
· Fluorescent management
· Clean Traps
· Housekeeping supplies
· Mechanical switches

Setting up a task force
· Understand sources
· Understand fate in the environment - lifecycle look
· Employee education
· Mercury elimination policy

Dioxins
· Mostly from air sources
· Medical Waste incinerators - 3rd largest sources of dioxins

Health Effects
· Hormonal changes on the rise
· decreased fertility (sperm counts are reducing every year)
· endometriosis increasing

Dioxin Elimination Strategies
· Educate your organizations
· Start with small pilots
· end medical waste incineration and use alternative treatments technologies
· purchase PVC alternative #3 plastics

Don't use Chlorine Products - PVC and Plasticizers all release Dioxins

Harborview Success Story - Duane Mariotti
The safety committee said they had a problem with mercury. Now non-mercury is the standard in all patient rooms and they no longer repair mercury equipment, including manometers. In addition, the purchasers can no longer purchase mercury containing products. Duane got everyone to buy into it though the physicians took a fair amount of work. Went to a physicians meeting and talked to them about mercury. Accuracy became an issue. Duane mentioned all of the bad sides of Hg. Said he would do a program to test aneroid sphygmomanometers (random sample). Manufacturers say that Hg needs to be cleaned and refilled annually. Developed a standard. Took him three years to do this. About nine months ago they had a mercury spill from something left behind. "We will never get rid of 100% of the mercury from the hospitals. Some physicians insist on keeping Hg thermometers as "gold standard" Labs and classrooms can not be regulated very easily. These are usually governed over by safety officers. Mayo clinic looked at aneroid sphygmomanometers and found that a large number of them are off. Only negative literature on this. Probably because they did not specify high quality sphygmomanometer. Give the sphygmomanometer a slight negative pressure, should move into negative and then go back. If it doesn't go back, don't buy it. He thinks that 99% of his sphygmomanometer should be within standards.
Safety committee was very excited about the fact that sphygmomanometers were phased out. They still have a few mercury things and they are locked up and they know they are there and
Two alternatives to mercury thermometers are Axio temperature and infrared - do not use infrared on the ear. The axiotemp thermometers are very good and very accurate - Welch-Allyn sells them . Costs ~$122
It is very important to purchase high quality aneroid sphygmomanometers right from the beginning. They have to have their own serial number and automatic zeroing function.


Pam Schaeffer - Group Health
Removed virtually all mercury from their facilities
42 primary care clinics
Group Heath has an Environmental Policy
Purchasing contracts all have an Environmental Clause

Eliminated all wall mounted mercury items. Not completely mercury free but very close. Have a top down env policy. Came from CEO 10 years. Do a tremendous amount of waste reduction and recycling. Also have env language in their purchasing contract. They have standards on the products they have replaced Hg with at both primary care facilities and clinics. Have dedicated material management staff. When a piece of Hg equipment fails it is replaced with non-mercury by the material management staff. Now getting Spokane started. Providers/ physicians were the biggest hurdles to overcome as they like to hide away Hg thermometers in their drawers.

Question: On MSDS for materials do they request greater info than is usually included?
Answer: GH decided 5 years ago to stop having MSDS in books and now uses the 3E system in most places. You make a phone call to the company and they fax the MSDS to you immediately. Avoids the time needed to keep MSDSs current. 1-800- 451-8346 for more info on this system.

Question: It appears that both GH and Harborview that they both have a powerful central purchasing system. Many hospitals have very decentralized purchasing departments and purchasing often doesn't know what is going on. IS this observation correct?
Answer: 10 years ago GH was very like that. Any one could order anything. Since then they have justified dedicated materials management staff by looking at the amount of staff time it was taken the old way. Doing it department by department . The trust level is so high now that departments are willing give up their responsibilities

Insurance Overview -Carol Sangster of CHUBB Insurance
Carol's role is to help characterize the possible exposures at a facility. Will briefly summarize the issues and if we express with her our issues she can help get the right people together with the MIRT group in the future. Industry first got involved in env liability when asbestos abatement became an issue. Env exposures to any facility can effect your insurance in a number of ways and can effect the following kinds of policies:
· General Insurance
· Workman's Comp
· Property Damage
· Umbrella Liability (catastrophe) coverage
· Environmental Coverage - protects people who acquire properties.
· Directors and officers liability

When pricing an Env. Policy, there is more opportunity to have cost savings based on reduced exposures. The more controls you have, the greater the likelihood of a positive change in your policy. They will underwrite risks if there are enough adequate controls. A variety of environmental insurance products are now available i.e. brownfield cover to promote engineered remediation and property re-development. Do background checks using EDR database, gives historical perspective of known env releases. With regard to operations looking at rate and volume of haz materials and nature and volume of permitted releases. Try to consider through dialogue and observation if there is a potential for accidental releases. Pathways and potential receptors from your site are of critical importance in underwriting environmental risks. Also considers the controls you have in place to mitigate accidental releases. If there is interest in env insurance you should first work through your independent insurance agent/broker before contacting Carol. She is not licensed to sell insurance and can only act as a source of information to point you to those who she knows are involved in the application/transaction process. Carol Sangster's e-mail address is csangster@chubb.com.

Summary of things insurers look at:
· Severity of potentially liable events
· Frequency of potentially liable events
· Amount of risk transfer
· Accidental release vs. poor business practices
· site characteristics
· locations
· Waste characterizations
· nature, volume and rate of hazardous materials
· Types that can be released by permit
· Evaluate if there is potential for unintended release
· Pathways and receptors for unintended releases.
· Balanced with controls that are in place (stuff like what she heard today)

Question: Dave W. - As an env inspector it seems there is overlap between what he and Carol does. When you look at risk management, do you see a partnership forming between agencies, insurance, and trade associations. Answer: Possibly

Premiums are more set on job titles of employees but it doesn't directly connect.

Question: We have a program called EnviroStars. Is there any kind of third party certification which could be worked into a policy at some point?
Answer: Would have to come through some kind of a group program. Haven' t heard of anything like that but . . . The things you do will ad to your insurability and thus there will be more companies interested in your institutions (so you can often get better bids)


Sandy went up front to talk about env effects of mercury and to lead Q and A session.

It's a hazard.

Also wanted to talk about sphygmomanometer. When they're taking your blood pressure they should be using the bell side of the stethoscope and not the diaphragm. The bell picks up the lower sounds which are the ones which should be measured.
There is something magical about watching a Hg sphygmomanometer going up and down. Doctors don't want to give that up. Stethoscopes are rarely used correctly anymore though they are still being used as great status symbols. Doctors always want them hanging out of their pockets.

Question: Is the mercury hazard an acute issue or long term?
Answer: The only way you will get a long term chronic problem is if you work with it every day. What are the doses that are dangerous. Has not been determined.

Question: When Hg s spilled does it get into the ventilation system?
Answer: Yes, it dissipates into the air and will spread through your hospital.

The number one anthropogenic source of mercury is coal plants. Natural offgassing from rocks is the primary release of it but we don't have control over that.

Jenny mentioned that she is interested in where hospitals are in phasing out mercury

VA - Had an optional program to eliminate sphygmomanometers and have eliminated all of the sphygmomanometers that they can get people to get rid of. 90-95% Hg free with regard to sphygmomanometers. One VA switched out all Hg sphygmomanometers and then the staff made them switch back to Hg.

Coulter counters contain a lot of Hg. Withdraws fluid accurately. Going to flow cytometry(sp?). Biotech companies have the luxury of being able to buy the more high tech tools which often have been made without mercury.
Over 26 regulatory bodies currently looking at what Immunex is doing. Immunex is 95% free of Hg thermometers. Doing a battery collection program. Takes years and years to go through the FDA process to get permission to use a different instrument or process that is more env friendly.

Question: How did you get voluntary switch-out of Hg?
Answer: VA People remember the Hg spills and are willing to work to avoid going through it again.

UW always calls in Foss Env for any spills. Just for Foss's services costs $1000-$1500

Someone at Bowling Green University changed their sink traps, piled them up and carried them across campus. Mercury was spread everywhere. Cost $570,000 to clean up.

Mercury sits in the pipes and is probably spread throughout the METRO sewer system.

Question: When Hg goes through the traps and into the pipes who is liable?
Answer: Carol - If there is a claim presented you would determine the time sequence of events and liability is against the responsible parties. Liability depends on who owns it. Probably will be split between property owner and whoever started the event. In bowling Greens example the contractor was quite likely held liable. Directors and officers liability could also be an issue. Shareholder suits often weigh into this.

Question: Dave - Has toured at least 7 hospitals. Hard to find out who is responsible for environmental stuff. Seems very divided. How does a tech assist provider figure out who to talk to figure out what is gong on?
Answer: The easiest way is to walk up to the big bosses office an tell them you are there for an inspection. They will quickly find someone.

Every insurance policy is arranged different.

Question: If FDA wasn't involved how easy would it be to get mercury out of the fixatives?
Answer: Easy. FDA is very tight. Someone got cited for moving a fridge without clearance.

Question: Are non-mercury substitutes as good as he mercury ones?
Answer: Yes, there are a few exceptions but yes

Question: How can MIRT help?
Answer: One attendee stated that the most powerful info she can bring back to her biotech company are the stats Jamie gave about mothers and their babies being effected by mercury and the fish in the great lakes. These are the things she will use when talking with people in the future.

Question: How about on the regulation and implementation side?
Answer: The more information we have the better.

Dave mentioned the Palo Alto information (ask Dave for more info) established a huge inspection program and have large guidelines.

Alan - Hasn't seen insurance company being involved because no claims have been filed. Hospitals are absorbing costs internally and not passing costs onto insurance companies. There are definite costs savings which can be realized even when insurance doesn't play into it.

Dave W. - The two spills he was most concerned about were in the neo-natal cells. If Hg thermometers are still being used this is a big liability. If parents have not been notified of a leaked thermometer in with their child that is criminal liability.
Many people agreed with Dave on this.

End of Seminar.