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Monday, June 24, 2024

Medical Waste: Where Does It All Go?


In 2005 there existed over 7,000 hospitals and 35,000 long-term care facilities in the United States. These numbers don’t include ambulatory facilities, dentists, home care or physicians’ offices. That adds up to a lot of medical waste. Did you ever wonder what happens to the small amount of unused drugs left in an IV bag, leftover pills, blood waste from tests, or products used during surgical or emergency care?

After medical waste washed up on several East Coast beaches, concern over the potential health hazards prompted Congress to enact the Medical Waste Tracking Act (MWTA) of 1988. MWTA defines medical waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals.” This definition includes, but is not limited to: blood-soaked bandages, culture dishes and other glassware, discarded surgical gloves, discarded surgical instruments, discarded needles used to give shots or draw blood (e.g., medical sharps), cultures, stocks, swabs used to inoculate cultures, removed body organs (e.g., tonsils, appendices, limbs) and discarded lancets.

More specifically, MWTA, which amended the Solid Waste Disposal Act, did the following: Defined medical waste and established which medical waste would be subject to program regulations; established a cradle-to-grave tracking system utilizing a generator initiated tracking form; required management standards for segregation, packaging, labeling and marking, and storage of the medical waste; and established record-keeping requirements and penalties that could be imposed for mismanagement of waste.

On June 24, 1989, regulations for this two-year program went into effect, and they expired on June 21, 1991. Regulations were in place for New York, New Jersey, Connecticut, Rhode Island and Puerto Rico. Simultaneously, the EPA gathered information and performed several studies related to medical waste management. The MWTA and EPA’s associated program served to focus attention on the medical waste issue and provided a model for states and other federal agencies to aid in the development of their own medical waste programs.

To date, scientists have identified numerous pharmaceutical compounds at discernable concentrations in our nation’s rivers, lakes, and streams (EPA-HQ-OW-2006-0771-1694). To address this issue at the source, the EPA is studying how pharmaceutical drugs are entering waterways and factors that contribute to the current situation. On this front, the EPA initiated a study on pharmaceutical disposal practices at health care facilities including hospitals, hospices, long-term care facilities, health care clinics, doctors’ offices and veterinary facilities. Unused pharmaceuticals include dispensed prescriptions or those that have expired, as well as the residuals remaining in used and partially used dispensers, containers, and devices (e.g., intravenous (IV) bags emptied into sink). For many years, a standard practice at many health care facilities was to dispose of unused pharmaceuticals by flushing them down the toilet or drain.

So what are we doing about it? The EPA has proposed the addition of hazardous pharmaceutical wastes to the Universal Waste Rule, which would provide a system for the disposal of hazardous pharmaceutical wastes, resulting in protection of public health and the environment. The rule encourages generators to dispose of non-hazardous pharmaceutical waste as universal waste, thereby removing this unregulated waste from wastewater treatment plants and municipal solid waste landfills. The revised rule would also facilitate the collection of personal medications from the public at various facilities. Currently the federal Universal Waste Rule includes batteries, pesticides, mercury-containing equipment, and lamps. At this point in time, the EPA does not have a projected date for the finalization of the rulemaking to add hazardous pharmaceutical wastes to the federal universal waste program.

Individual states have set their own criteria for handling both hazardous and non-hazardous medical waste. Some hospitals have taken it upon themselves to go beyond the standard and adopt stringent methods and guidelines, often partnering with waste disposal companies geared specifically to handle medical waste. Cayuga Medical Center in Ithaca, New York, has partnered with Stericycle, a medical waste disposal company, to lead the way in medical waste control.

“What prompted us to undertake this program was the increased attention given to medical waste compliance issues generated a few years ago by then Attorney General Andrew Cuomo,” Mike Judd, director of pharmacy for Cayuga Medical Center, said. “Minnesota, the land of a thousand lakes, takes their water and environment seriously and they were one of the first states to raise the standard. Ninety-eight percent of our drugs are non-hazardous but, with our program in place, compliance has been surprisingly complete with few errors across the board.” The program includes education and training of hospital staff, identification of drugs by category, notification of methods of disposal and tracking of the waste after removal.  A code is attached to each drug on the nurse’s notification schedule, on the drug dispenser and on the disposal bins, making compliance simple.

“The staff really understood the program quickly and each new employee gets additional training, either by someone on our team or by Stericycle, who has been a great partner in establishing this program,” Mary Brickey, director of environmental services for Cayuga Medical Center, said . “We are also being a very green hospital by reusing a special container for our ‘medical sharps’.  Stericycle has provided us with a reusable sharps container that can be emptied, avoiding any stick hazards, then completely sanitized so it can be used again, eliminating the multiple plastic containers previously used. I should mention our new wing was built to LEED Silver standard as well.” Brickey stated that the medical, housekeeping and maintenance staff all work together to make this program successful and maintain compliance.

Medical waste regulations are primarily controlled by individual states. What are the requirements in Arizona? Under Title 18. Environmental Quality, Chapter 13. Dept. Of Environmental Quality Solid Waste Management, the State lists one protocol under R18-13-1418 and allows under sub-section B:  A generator of discarded drugs may flush them down a sanitary sewer if allowed by the wastewater treatment authority. Additional handling requirements for certain wastes are listed under R18-13-1420 and require incineration, autoclaving, protective packaging for certain types of waste, then incineration, grinding of medical sharps, as well as the following of federal or state law as prescribed under specific requirements. The established requirements are strict and fairly comprehensive, but increased demand for medical treatment is on the horizon—the largest segment of the American population, the baby boomers, began turning 60 a few years ago.

To facilitate investigation efforts, the EPA developed state-of-the-art analytical methods capable of detecting low levels of various pharmaceuticals, steroids and hormones. The agency has visited many facilities and consulted with organizations in the health care industry, as well as federal, state and local government agencies, and commissioned the National Academy of Sciences to provide scientific advice on the potential risk to human health from low levels of pharmaceutical residues in drinking water.  The EPA continues to solicit recommendations from a wide range of stakeholders and plans to publish a final version of the proposed requirements document in 2011.

William Janhonen teaches green building at several colleges and universities in the Northeast.


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