by Arthur McCoy
While in the midst of the COVID-19 pandemic, it is an ideal time to assess the options for managing infectious waste. As we consider modern solutions, it is important to be aware of how hospitals have historically managed this waste stream. Just as recent as 25-30 years ago, most hospitals actually managed their infectious waste on-site. The technology of the time was incineration. Based on the 1990 Clean Air Act Amendments, most incinerators were ultimately shut down because they were unable to pass stack testing. Many hospitals transitioned to cleaner technologies such as autoclaves to properly treat this infectious material. However, an unintended consequence of this regulation shifted a majority of hospitals to outsource the treatment of their infectious material. Hospitals opted for this temporary solution because it required no capital investment.
Many of these hospitals invested millions of dollars to upgrade their incinerators, yet they were still unable to pass air quality testing. According to Carl Solomon Sr., Director of Environmental Services at UC San Diego Health “Some states, such as California, have completely banned the incineration of medical waste due to air emission and safety concerns, requiring expensive transport and treatment of the waste off the medical center’s campus.”
As many hospitals are reconsidering their strategy for managing infectious waste, we will examine the justification used by many hospitals and healthcare systems that are transitioning back to an on-site model. The two business models of managing infectious waste, on-site and off-site, are dramatically different. While some off-site service vendors try to build financial and operational dependance on their respective services, the on-site model delivers the exact opposite by providing the hospital operational and financial independence from any waste service provider. Following are points that many hospitals consider while making a decision on either business model:
Why did so many hospitals treat on-site 25- 30 years ago? The underlying justification was related to basic infection control practices: treat at the point of generation. Whether it is infectious patients or infectious waste, hospitals strive to minimize these infectious outputs into their respective communities. This sentiment is very much alive today as we plan and respond to deadly emerging pathogens.
Bio Safety Labs that have a rating of 4 (BSL4) are used for studying and containing such exotic pathogens as Ebola Virus, smallpox, and Lassa Virus. Such labs are required to autoclave their infectious waste prior to leaving the facility.1
The reality for hospitals is that we could continue to see an uptick in these emerging diseases. As a result, many hospitals are now looking to include on-site treatment infrastructure as a proactive health and safety measure to prevent the further spread of disease. In order to protect our healthcare heroes, PPE supplies must be fortified. Some infectious waste treatment technologies are going through the approval procedure with the FDA to reprocess certain types of PPE. The reprocessing of PPE would expand domestic inventories.
In addition to disease outbreak, hospitals need to be prepared against any natural or man-made disasters. Hospitals that lack on-site treatment infrastructure are vulnerable when the transportation infrastructure is compromised from severe storms and hurricanes. Such events could force hospitals to pile up infectious waste until waste services are able to resume.
According to Solomon,“On-site processing and treatment of biohazardous medical waste also gives a hospital surge capacity, and the ability to continue processing waste if an outside service provider is unable to access and support a hospital due to some external disaster, e.g. fire, earthquake or flood, as long as the hospital’s facilities are not damaged and their infrastructure is intact.”
In comparing the environmental impact of managing infectious waste on-site or off-site, the EPA developed a carbon footprint calculator to quantify the CO2 emissions produced by shipping the waste off-site.2 This metric is important to quantify the environmental consequence from either methodology. Bhushan Shelat - Director of Environmental Services at Stanford Health Care says, “The implementation of our on‑site biohazardous waste treatment system has proven to be a sustainable option,” suggesting this is due to the reduction of untreated waste needing to be shipped off-site for treatment.
Every infectious waste generator has a cradle-to-grave liability associated with Regulated Medical Waste. Many hospitals have elected to safely inactivate this waste on-site, before it is transported. Truck accidents are a daily occurrence, and no hospital wants the potential publicity of a waste spill that is untreated. In addition, some states are getting very aggressive in keeping untreated infectious waste out of landfills. This has resulted in severe fines and bad publicity for some hospitals. As a result, hospitals are turning to on-site technology to treat all waste from high-risk areas within the hospital.
According to Fiona Nemetz - Director, EVS, Parking, Safety and Security at Northside Hospital in Atlanta, “The improved worker safety is recognized as EVS team members no longer have to package RMW for shipment. During the packaging process, EVS team members can experience cuts or lacerations from contaminated medical devices when they are attempting to get them into the secondary packaging.”
Aggressive Cost Savings
According to Shelat,“Since implementing our on-site program, we have significantly reduced our operating costs, additionally enabling our team to closely monitor safety and compliance as we continue to identify opportunities for improvement.”
Every hospital and health system should evaluate the financial impact of waste. It’s important to consider lifecycle costs. Regarding any capital investment, it is critical to calculate the projected payback.
Since the 1980’s, the University of Washington Medical Center has been treating on-site at several of its locations. “Last year we invested in another system that delivered a 9-month payback compared to hauling,” stated Toby Purvis – Director of Environmental Services.
According to Solomon,“Some landfills have waste acceptance policies allowing hospitals and labs to treat, through sterilization, red biohazardous waste bags and red sharps collection containers, on-site and dispose of this treated waste in their trash compactor. This adds savings if a hospital or lab is using disposable sharps collection containers.”
Nemetz goes on to say, “The cost savings are recognized when on-site solutions are utilized as the cost of the equipment can be amortized over 10 years and when that it used for calculations, there are significant cost savings compared to hauling for treatment. Typically, the vendor selling the on-site solution is able to assist with the ROI calculations. Finally, when on-site technology is utilized, the systems allow the EVS worker to transport from the soiled utility room directly to the on-site technology. This eliminates the need to package for shipment and therefore provides labor reductions. The majority of on-site technologies do not require a dedicated operator today.”
The U.S. Government’s largest healthcare system, The Department of Veterans Affairs, has seen great value with on-site processing. The VA has done extensive research to support their decision to expand onsite processing, which has resulted in other VA hospitals being approved for on-site technology. “We see on-site waste processing as a solution to reduce costs and reduce the amount of infectious waste that leaves our hospitals. On-site treatment also prepares us to respond to a pandemic without putting the community at risk,” stated Aubrey Weekes - Director, Environmental Programs Service at Department of Veterans Affairs.
In the case of Solomon, he recommends having medical waste treatment systems with redundancy, so you can continue to process biohazardous waste should equipment be out of service for any reason, e.g. scheduled maintenance, down-time for required spore ampule testing, or other reasons.
According to Rudy Vingris - Healthcare Business Development Manager for Waste Management, Inc., “Autoclave treatment of biohazardous/infectious waste continues to be the most prevalent and proven technology available.” He added that, “new technologies continue to evolve and come to market.”
Shelat goes on to mention that their on-site system provides process efficiencies that enable them to better manage their biohazardous waste program, including the flexibility of simultaneously compacting landfill waste.
Regardless of which methodology your hospital selects, it is advisable to fully vet the companies and technologies you consider. No one technology or service company will be a panacea without a partnership approach to doing business.
As Vice President of San-I-Pak, Inc., Arthur has been involved in the planning and implementation of hundreds on-site programs at hospitals across the country. He also served on the Underwriter Laboratory (UL) Committee 2334 for establishing standards on all medical waste treatment technologies.
1. https://www.cdc.gov/labs/pdf/CDC-BiosafetyMicrobiologicalBiomedical Laboratories-2009-P.PDF
2. https://www.epa.gov/climateleadership/center-corporate-climate-leadershipsimplified- ghg-emissions-calculator
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