Making Medicine Mercury Free Implementing a MercuryElimination Plan MMMF Award Process

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Making Medicine Mercury FreeImplementing a
Mercury-Elimination Plan MMMF Award Process
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Why Bother?

• AHA/EPA Goal to Eliminate Mercury in health care.
  98 Awards in 2006 awards cycle!
• Ethical responsibility/Mission Statement
• Environmental/Public Health
• Regulatory Compliance/Liability
• Safety
• Press coverage and awards
• Community Relations
• Patient/Employee satisfaction
• Potential Cost Savings

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Environmental/Health Impact

• Medical waste incinerators are major source of
  mercury
• AHA-EPA Memorandum of Understanding - 1998
• FDA and state fish consumption advisories
• New York Academy of Sciences Report
• National Resource Council (NRC) Report
• AMA, ANA, APHA resolutions

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Three goals of healing environments
Reduce stress of the buildings occupants

• Connection to nature (daylight/ views)
• Choice Control (light and ventilation)
• Social Support (program areas)
• Positive Distractions (views/ program)
• Elimination of Environmental Stressors (noise)

A better building is one that facilitates
physical, mental, and social well-being and
productive behavior in its occupants
Improve Safety

• Improved Indoor Air Quality
• Supportive Lighting Design/ Reduced Glare

Contribute to Ecological Health

• Healthier Materials
• Reduce Energy and Water Use

www.healthdesign.org
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Pervasive Impacts of Mercury

• 2004 EPA Mercury Advisory data (most recent
  released)
• 35 of lakes, 24 of rivers in US under advisory
  (some for non-mercury reasons)
• 13,183,748 lake acres and 765,399 river miles
  under mercury advisory
• 21 states have statewide advisories against fish
  consumption from all waters
• 12 states have coastal or marine fish advisories

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The Fish Connection
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Mercury toxicity

• Transmission from mother to fetus
• Bioconcentration
• Biotransformation

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Exposures

• CDC 1 in 8 US women of have blood levels that
  could put fetus at risk
• National Academy of Sciences 60,000 children
  per year exposed in utero at levels that can
  cause harm

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Public Health Warnings

• EPA/FDA/Consumer Reports
• Pregnant women, women of childbearing age, young
  children
• No shark, swordfish, king mackerel, or tilefish
• Up to 12 ounces/week of fish and shellfish lower
  in mercury - e.g. shrimp, canned light tuna,
  salmon, pollock, and catfish.
• Canned albacore (white) tuna higher mercury
  than light tuna. Limit albacore to 6 ounces per
  week.
• Fresh caught fish, follow advisory
• if no advisory, limit to one meal per week
• and no other fish meals.

Consumer Reports and others add Tuna
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Health Care Involvement

• Mercury Report to Congress 1997 Medical waste
  incinerators a major source
• (www.epa.gov/ttn/oarpg/t3/reports/volume1.pdf.)
• AHA-EPA Memorandum of Understanding - 1998
• FDA fish consumption advisories
• New York Academy of Sciences Report
• National Resource Council (NRC) Report
• AMA, ANA, APHA resolutions

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1998 American Hospital Association U.S. EPA
Memorandum of Understanding

• 1 Virtual elimination of mercury-containing waste
  from healthcare facilities waste streams
• 2 Reduce total waste volume
• 3 Identify hazardous substances for pollution
  prevention and waste reduction opportunities,
  including hazardous chemicals persistent,
  bioaccumulative, and toxic pollutants.
• H2E www.h2e-online.org

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Significant Progress

• 2005 American Hospital Association survey
• 80 of respondents had eliminated Hg thermometers
  completely
• 73 of respondents had eliminated Hg
  sphygmomanometers
• 70 had eliminated Hg gastrointestinal tubes
• 3 of 5 largest health care GPOs have eliminated
  Hg devices wherever possible

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Obstacles to Mercury Elimination

• Mercury is considered the Gold Standard
• Clinicians are trained on mercury devices
• Cost of replacements
• Old habits

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Where do we start?

• A commitment to a mercury free environment is a
  long term goal.
• Step by step, through education, mercury
  inventory, piloting alternatives, policy
  development, time-line, implementation, you will
  get there!

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www.h2e-online.org
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1. Education and outreach

• Develop a library of peer reviewed documents
• Risks of mercury exposure
• Effectiveness of alternatives
• Costs of compliance and spills
• Case studies of successful mercury elimination
  e.g. Mayo Clinic, Kaiser Permanente,
• Identify key champions for your effort
• Educate department heads and purchasing agents
• Reach out to upper management

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2. On the ground.Support!

• Educate internal health care committee structure
  including
• department heads
• clinical leadership
• board of directors
• senior administration
• nurse managers
• grand rounds
• Environment of care
• Supply Chain/Purchasing
• Identify internal champions to help get
  commitment to transition to a mercury free
  facility.
• Develop Committee Structure to eliminate mercury
  Subcommittee of Environment of Care and within
  Supply Chain Structure

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3. Manage what you have!

• Full inventory
• H2E Mercury Assessment Worksheet
• Education New employee orientation
• Annual JCAHO-required staff training
• Segregation, labeling
• Contract with hazardous waste and universal waste
  haulers.
• Spill Response (protocols/training/kits)
• Monitoring/environmental
• rounds
• JCAHO-required Record
• keeping

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Mercury Management Spills On the Ground

• Follow up Where is mercury contaminated
  material taken?
• Are the responders adequately trained?
• Are spill supplies replenished?
• Is JCAHO-required reporting of spills reflected
  in meeting minutes?
• How is the hazardous waste vendor contacted?
• Are spill materials properly stored for removal?
  (Not red bag waste!)

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Air Quality On the Ground

• Is mercury-containing equipment currently
  repaired on site? Where? Have you conducted air
  quality testing? Are safety protocols in place?
• Do you test air after spills to ensure adequate
  response?
• Are air results reported through the Environment
  of Care Committee?

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4. Lay the groundwork

• Develop a mercury elimination policy
• (H2E can provide you with samples! Just
  Ask!)
• Identify mercury-containing products currently
  purchased for your facility
• Track spills to find problem areas and worker
  safety data.
• Build a step by step mercury elimination plan
• Institute a mercury-free purchasing policy H2E
  can help with this too!

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5. Next start elimination

• Address clinical devices first
• Close the door through purchasing
• Prioritize by department/area
• Require vendor disclosure as first step
• Build a product evaluation team
• Clinician(s)
• Purchasing
• Environmental Services
• EHS
• Biomedical Engineering
• Laboratory
• Start Small Pilot your alternatives

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6. Clinical Sources

• Sphygmomanometers
• Thermometers
• Barometers
• Bougies, cantor tubes
• Pharmaceutical Preservatives

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Inventories On the ground

• Theres no easy way around it. Walking floor to
  floor, unit by unit and seeing is believing.
• So even if the unit/area insists they have no
  mercury.

Mind if I take a look around?
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On the ground with bougies and cantor tubes

• Often found in O.R., post surgical units,
  endoscopy.
• The often-orange bougies look like long snakes
  and are often not labeled as containing mercury.
  Watch for wear and tear.
• Cantor tubes are used to clear intestinal
  obstruction and are often injected with mercury
  at the bed side. While few may be used, the
  incidents of spill and improper disposal is high.
  Check with pharmacy to see if they purchase
  liquid mercury for use in cantor tubes.
• Alternatives available!

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7. Next Step Facilities

• Conduct a walk through to identify and record
  mercury-containing thermostats, switches and
  other mercury devices.
• Label each devices with a contains mercury
  label and track the elimination of mercury with
  the inventory, reporting progress through EOC or
  Safety Committee
• Identify for replacement, renovation and new
  construction
• Ask manufacturer/distributor
• Review catalog/sales materials
• Train employees/contractors
• Handle all Hg devices with care
• Do not dispose in solid waste
• Replace with mercury-free alternative
• Check with your region to see if
  mercury-containing equipment can be removed as
  universal waste. Not sure? Check H2Es state
  Universal Waste site at
• http//h2e-online.org/hazmat/druniversal.html

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Lamps a special case

• Fluorescent and HID lamps (bulbs) all contain
  mercury
• Energy efficient reduce mercury emissions
• ALL mercury lamps release Hg on breakage or
  disposal
• ALL mercury-containing lamps should be recycled
  (regardless of RCRA status) as Universal Wastes

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Green Tip Lamps

• Not RCRA waste, BUT
• Not always lower mercury content
• Some exactly the same Hg content as non-green-tip
• Mercury released through incineration
• Fate of this mercury in landfills not understood
• Recycling prevents release every time

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9. Laboratory Sources

• Laboratory chemicals
• Mercury active ingredient -- B5, Zenkers
• Mercury preservatives
• Thermometers/thermostats
• Refrigeration, analyzers, building
• Burners
• Pressure regulation devices
• Cleaning chemicals

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Lab Mercury Elimination

• Establish priorities
• B5, Zenkers mercuric chloride
• Thermometers, devices
• Mercury preservatives
• Pilot alternatives
• Establish disclosure requirements for all
  purchasing
• Not MSDS, or concentration - actual amount
• Require chemist signature
• Develop a step by step plan for mercury
  elimination, with timeline
• Establish mercury-free purchasing policy

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On the ground in labs

• Identify laboratory champion
• Set up a meeting with chemical distributor to
  assist in review of all chemicals and
  identification of those with mercury as a
  preservative.
• Use H2E as a resource to connect with H2E
  partners that have eliminated mercury in labs.

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10. Get Recognition Making Medicine Mercury
Free Award

• National recognition for leaders in mercury
  reduction
• Over 150 winners since 2002
• First in 2002 U. of Rochester at Strong
  Memorial and one of latest Metro Health Care in
  Grand Rapids. MI. Full list http//h2e-online.or
  g/awards/winners.cfmMMMF
• Rewards development and execution of
  comprehensive mercury reduction plan and
  generates positive regional press.

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MMMF APPLICATION STEP BY STEP
98 MMMF winners in 2006!
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1. Facility Information

• Adjusted Patient Days
• Adjusted patient days TTL patient days X (TTL
  Patient Revenue (Inpatient outpatient)/Inpatient
  Revenue
• Admitting or finance will have this data
• of licensed beds
• For long term care - of beds and of FTEs

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2. MMMF Award Check List

• Established Mercury Facility Policy Statement
• Established a Mercury Management Policy that
  includes
• Protocols for safe handling
• Mercury Spill Cleanup Procedures
• Disposal Procedures (recycling or regulated safe
  disposal to avoid disposal in the waste stream.)
• Education and Training of facility protocols
  including information about mercury and its
  effect on human health and the environment
• Process to regularly review mercury use reduction
  and elimination progress for continuous quality
  improvement.

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3. EPP Policy

• Implemented Environmentally Preferable Purchasing
  Policy that bans the purchase of
  mercury-containing products without prior
  approval.
• (Attach Policy)

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4. Thermometers

• Replaced all mercury-containing thermometers
  including those sold in pharmacy and sent home
  with patients.
• Manufacturer of nonmercury thermometer now in use.

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5. Sphygmomanometers

• Replaced all or majority (75) of
  sphygmomanometers and have a replacement plan and
  phase out timeline in place for total
  elimination. What has been replaced? If not
  100, what is the timeline?
• Attach supplemental information.

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6. Other clinical devices

• Replaced all or majority (75) of clinical
  devices including bougies, miller abbot tubes,
  dilators etc Description of which have been
  replaced and name of alternative. If not 100
  eliminated, timeline of complete elimination.
• Attach supplemental information.

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7. Other clinical devices

• Implemented program to recycle fluorescent light
  bulbs.
• Name of vendor.
• Attach supplemental information.

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8. Battery Collection

• Implemented program to recycle batteries.
• Name of vendor.
• Attach supplemental information.

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9. Inventoried Facilities

• Inventoried and labeled all mercury-containing
  facility devices (switches, thermostats etc..)
• Plan in place to substitute nonmercury devices.
  Attach description of which items have been
  replaced and describe the plan and timeline to
  totally eliminate remaining devices.

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10. Labs

• Replaced B5/Zenkers Stains with nonmercury
  substitute. What replacement are you using?

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11. Lab Inventory

• Inventoried mercury-containing lab chemicals with
  a plan for substitution.
• Describe process and plan for substitution.

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12. Inventoried Lab Thermometers

• Replaced at least 75 with a total phase out plan
  in place. Provide timeline for 100 replacement.

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13. Other chemicals

• Other mercury containing products. What are
  other challenges? (Pharmacy, Cleaning chemicals,
  dental amalgam and other and which products.)
• Other innovative programs? Outreach? Community
  initiatives?

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III. H2E Goals

• Facility goals and describe any activities
  including source reduction.

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MMMF Award Application

• Award Application Check List
• Mercury Elimination Policies
• Mercury Management Policy
• Environmentally Preferable Purchasing

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MMMF Award Check-List

• Partner of H2E
• MMMF Award Application
• No outstanding OSHA violations
• 3 copies of everything
• Back up/Supporting information
• Email and send in regular mail

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Tools

• H2Es 10 Step Guide to Recycling Fluorescent
  Lamps
• http//www.h2e-online.org/pubs/tensteps/fluor10st
  eps.pdf
• HCWHs Guide to Battery Collection
  http//www.noharm.org/library/docs/Going_Green_Bat
  ter_Roundups_-_Get_Charged.pdf
• NIH List of Mercury-Containing Lab Chemicals and
  Equipment and Alternatives http//www.nih.gov/od/
  ors/ds/nomercury/alternatives.htm
• Cal DHSs Mercury Manager tool
  http//www.h2e-online.org/tools/merc-man.htm
• (click on Mercury Assessment Worksheet)
• HCWHs List of Mercury-Containing Items in a
  Healthcare Setting http//www.noharm.org/library/
  docs/Going_Green_List_of_Mercury-Containing_Items_
  i.pdf

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H2E Resources/Guidance

• Awards Process
• www.h2e-online.org/programs/award/index2004.htm
• Mercury Backgrounder
• www.h2e-online.org/tools/mercury.htm
• Measuring Blood Pressure Accurately
• http//www.noharm.org/mercury/sphygmo
• List serve www.h2e-online.org/programs/list.htm
• Universal Waste Guidelines
• www.h2e-online.org/tools/univwaste.htm
• 10 steps to bulb recycling
• www.h2e-online.org/tools/univwaste.htmflu
• Mercury Elimination Plan
• www.h2e-online.org/pubs/mercurywaste.pdf
• Fish Advisories
• www.h2e-online.org/tools/merc-oth.htmfish
• H2Es Healthier Choices for Electronic Equipment
  
• From Procurement to the End-of-Life
• http//www.h2e-online.org/pubs/Pub7-01-HealthierCh
  oices.pdf

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Other Mercury Resources

• Massachusetts Academic Scientific Community
  Organization www.masco.org
• U.S. Food Drug Administration -
• www.cfsan.fda.gov
• Health Care Without Harms Fast Facts -
• http//www.noharm.org/library/docs/Going_
• Green_The_Mercury_Problem_-_Fast_Facts.pdf
• HCWH Making Medicine Mercury Free Resource Guide
  -
• http//www.noharm.org/library/docs/Going_
• Green_Making_Medicine_Mercury_Free.pdf
• American Medical Association www.ama-assn.org

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Sustainable Hospitals Project
www.sustainablehospitals.org
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Premier Inc.s Free List of Mercury Containing
Pharmaceuticals
http//www.premierinc.com/all/safety/resources/mer
cury/premier_products.jsp
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Dental Mercury

• Dental Mercury Removal Systems

http//www.sustainablehospitals.org/cgi-bin/DB_Rep
ort.cgi?pxWrptCatid25
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Dental Mercury

• Dentist the Menace

http//www.noharm.org/library/docs/Dentist_the_Men
ace.pdf
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Be Like Mercury Persistent!

• Support
• Communication
• Data
• Goal Setting
• Team Approach
• Simplicity
• Tracking/Reporting
• Cost Savings

SUCCESS!
www.h2e-online.org
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Need Help?

• Hospitals for a Healthy Environment
• www.h2e-online.org
• Partner Coordinator -Janet.brown_at_h2e-online.org
• 413/253-0254
• Environmentally Preferable Purchasing Specialist
  
• Sarah.obrien_at_h2e-online.org
• 802/479-0317
• State Program Coordinator
• Cecilia.deloach_at_h2e-online.org
• 1/800-727-4179
• Director
• Laura.brannen_at_h2e-online.org
• 603/795-9966
• Executive Assistant/Webmaster
• Liza.nanni_at_h2e-online.org
• 603/795-9966