January 2006

The future of medical waste
by Jackie Farwell and Sharon Kiley Mack

The atmosphere in the operating room was focused but relaxed as Dr. Robert Cambria guided a thin tube into a varicose vein in a man’s thigh on a recent morning at Eastern Maine Medical Center in Bangor.

Two spotlights illuminated the patient’s leg in the otherwise darkened room as a hunched Cambria used radio frequency to heat and cauterize the potentially harmful vein. Queen’s “Bohemian Rhapsody” played softly in the background.

Just behind the doctor, long strips of white gauze used to mop up blood during the procedure were draped over the side of a small, stainless steel bucket on wheels. The operating room scrub, a technician who hands tools and supplies to the doctor during surgery, carefully separated the bloody gauze from the rest of the waste generated during the operation.

The overhead lights flipped on as Cambria finished the procedure, guiding the catheter back out of the man’s leg and stitching up the small incision. The scrub counted the stained strips of gauze, a routine precaution to catch any missing bandages that could be left inside a patient, and tied up the plastic bag lining the stainless steel bucket.

Operating room technicians flooded into the room to clean up as the nurses coaxed the man awake, and the scrub tossed the bag into a red, plastic bin marked with a biohazard symbol that sat just outside the door.

A hospital employee trained in handling biomedical waste later collected the red bin and sent the bloody gauze and other waste on its way for eventual collection at a loading dock one floor down. After being dumped into yet another red bin - this one larger and reusable - the trash was loaded onto a truck and shipped to a new treatment plant in Pittsfield.

The disposal of biomedical waste, like the bloody gauze generated during the morning’s surgery at EMMC, happens hundreds of times a day at hospitals throughout the state.

What is changing is where it all ends up.

First-of-its-kind plan
Maine’s hospitals are embarking on a new way to dispose of their biomedical waste through a collaborative effort that is the first of its kind in the nation.

Instead of shipping their blood-soaked surgical sponges, tubes and gowns out of state, where the waste is incinerated and sent to a landfill with regular trash, all of Maine’s hospitals have joined together to treat and dispose of the waste themselves.

Through the Maine Hospital Association, the state’s health care facilities have constructed a waste treatment plant in Pittsfield that by this time next year is expected to process all 2.4 million pounds of the state’s annual biomedical waste.

Maine Waste Facility, a wholly owned entity of the Maine Hospital Association, is geared to handle as much as 6 tons of the waste per day.

“This is a never-ending business. There will always be hospitals and there will always be waste,” Michael McIntyre, facility manager, said recently.

Borne as a response to rising out-of-state disposal costs and stricter environmental regulations, the effort now includes 33 of the state’s 39 hospitals. The remaining six hospitals are expected to join by this time next year.

The statewide collaboration is unlike any other in the nation, though it is similar to a decade-old cooperative in Virginia that has yet to include all of that state’s hospitals as owner-operators.

Still in its early stages, the Maine initiative is expected to save $300,000 annually, savings that eventually will trickle down to hospital customers, John C. May, president and chief executive officer of Sebasticook Valley Hospital in Pittsfield, said.

“This is 39 hospitals working together,” said May, who served on a task force that developed the new program. “All of them said, ‘If you build it, we will come.’”

In addition to the cost savings, the collaboration has eliminated hospitals’ vulnerability to trucking strikes by private waste disposal contractors, as well as many weather delays, Tom Kohlmeyer, a fire and safety officer who oversees waste disposal at EMMC, said recently.

“If any one of us has a problem, we all have a problem,” he said.

The biomedical waste can be infectious in its raw form, but it is rendered nonhazardous at the Pittsfield plant through a pressurized steam sterilization process. Machines heat the waste - much of it gowns and plastics - and then shred it for eventual disposal at Hampden’s Pine Tree Landfill.

The small percentage of pathological waste, which includes body parts and other anatomical waste, and materials used in chemotherapy procedures still are sent out of state for incineration.

The hospital association owns the waste disposal operation and equipment, positioning Maine’s hospitals as both owners and customers in the system. SteriLogic Waste Systems Inc. of Syracuse, N.Y., owns and operates the facility, and Hydroclave Systems Corp. of Kingston, Ontario, maintains the equipment.

While not explicitly outlawed in Maine, the burning of biomedical waste became economically unfeasible a decade ago after the federal Environmental Protection Agency tightened testing requirements, Scott Austin, an environmental specialist with the state Department of Environmental Protection’s biomedical waste program, said recently.

The process of autoclaving rose to the attention of Maine environmentalists, hospital administrators and lawmakers as part of a biomedical waste task force convened several years ago.

Hospitals found themselves at the mercy of Illinois-based Stericycle Inc., the only biomedical waste disposal company serving the state at the time, said Tammy Butts, Maine Hospital Association director of business development and administration.

“There was a monopoly,” she said. “They were seeing price increases, dramatic price increases, every year.”

Maine environmentalists have praised the new program, noting that although Maine’s biomedical waste was burned in Massachusetts, the harmful dioxins produced during incineration blew back across state lines.

“We were being impacted regionally by the burning of our waste just outside our state’s borders,” Michael Belliveau, who represented the Natural Resources Council of Maine on the biomedical waste task force, said recently.

Cooking the waste
The first thing a visitor notices while visiting the Maine Waste Facility in Pittsfield is the smell. While not overpowering nor unduly unpleasant, there is a definite, and hard to describe, odor. It’s a stew of wet dog, burned casserole and mildew, with possibly a sprinkling of dirt.

The second reaction is surprise at the small size of the two autoclaves that handle 9,000 pounds of medical waste a day. No bigger than the washers at a commercial laundry, the autoclaves tumble, superheat and then dry the waste.

“We originally began looking to site this plant in the Newport, Palmyra, Pittsfield area,” explained McIntyre, the facility’s manager. “We selected Pittsfield because it is so close to Interstate 95 and there was already a building here.

“This site is unique in the country in that the Maine Hospital Association both owns the plant and are the customers,” he pointed out.

The facility, a fairly small and nondescript warehouse, was constructed by the MHA in conjunction with SteriLogicME and Hydroclave Systems Corp. and through the town of Pittsfield’s efforts to create a Pine Tree Zone around its Industrial Park.

Even though this is a mechanical process, there is a lot of manual labor going on here. Workers lift 38-gallon tubs of waste over their shoulders to dump the contents inside the autoclaves.

The waste is a combination of gowns, linens, vials of blood, paper cups, operating room sponges and sheets. No pathological, anatomical or chemotherapy waste goes into the autoclaves. Although the facility is allowed to pick up those items, they are handled and treated separately. They are clearly marked in yellow containers and diverted from a trip to the autoclaves.

“There is no sorting here,” McIntyre said. Everything is color-coded: Red bags are biomedical waste; yellow containers are chemotherapy residual waste; and gray is other chemotherapy waste. Only the red bags head to the autoclaves - 800 pounds of waste per unit.

Steam is then pumped into the autoclaves and a 250 degrees Fahrenheit sterilization process takes 25 minutes to treat the waste. Emptying the autoclave tub is a complicated process because much of the waste has become twisted around - gowns caught by electrode wires - and must be removed by hand tools often found in a garden: hoes, rakes, small pitchforks.

“It is hard work, hot and it stinks,” commented an employee.

A conveyor belt then carries the waste up to the ceiling where it drops into a shredding machine. This turns the waste into smaller pieces. The shredder is noisy, but it is the autoclaves that generate the heat that forces the workers to keep the large garage-style doors opened all day. “We will probably keep them open in the winter,” McIntyre said.

Nearby there is a small bucket for collecting the titanium bits, nuts and bolts - used in joint replacement surgery - that occasionally show up in the waste by mistake.

Meanwhile, the plastic containers in which the waste is transported are collected, washed, sterilized and dried before being sent back to the hospitals for reuse. More than 250 38-gallon containers are processed each day.

Before MWF came along, all those containers were being thrown out after use, McIntyre said. “We are saving an enormous amount of material from the waste stream,” he added.

The facility, operating at maximum capacity, can handle more than 5 million pounds of biomedical waste per year.

“From here, everything goes directly to Hampden,” McIntyre said.

At the landfill
On a recent morning at Pine Tree Landfill in Hampden, a truck arrived from the Pittsfield treatment plant loaded with approximately eight tons of sterilized and shredded biomedical waste. After the truck was weighed, the load was dumped, its multicolored chunks steaming in the cool morning air.

The commercial landfill, situated next to Interstate 95 and Cold Brook Road, was licensed in June by the Maine DEP to accept approximately 2,000 tons, or 4 million pounds, of treated biomedical waste per year, becoming the first waste disposal site in the state to accept such waste.

The trucks from Pittsfield arrived one or two more times that week to dump their loads, which represent only a small percentage of the nearly 570,000 tons of solid waste received at Pine Tree each year.

Sterilized and rendered safe by the time it arrives, the biomedical waste is treated like most any other type of waste received at the landfill, Don Meagher, manager of planning and development for Casella Waste Systems Inc., which owns the landfill, said as the biomedical waste was dumped.

“It’s no different than a lot of the other material we take,” he said.

After the waste was spread, a landfill employee operating a compactor with spiked metal wheels drove back and forth over the garbage, packing it down as sea gulls picked through other bits of trash nearby.

According to the DEP license, the biomedical waste must be shredded into 3/4-inch strips, rendering it unrecognizable, Scott Austin of the DEP said. Much of the hospital waste dumped at the landfill recently was unrecognizable, though linens and crushed red bins could be identified before the trash was spread and mixed with other waste.

Not only does the shredding reduce the risk of a needle puncturing those who handle the waste, but it also indicates the garbage has been treated, Austin said.

The shredding of biomedical waste also removes the possibility that a hospital’s name could be read on the material in event that the waste is dumped improperly, environmentalist Michael Belliveau noted.

The biomedical waste leaving SteriLogic and arriving at Pine Tree Landfill does not yet meet the 3/4-inch standard, though operators plan to install new shredding blades that should tear the material to the required size.

“We want to work with them on it,” Austin said.

A look ahead
While still in the early stages of its cooperative waste disposal effort, the Maine Hospital Association has pondered the future of the operation that so far is unlike any other in the nation.

The Maine Waste Facility in Pittsfield is working at about half its maximum capacity, treating 2.4 million pounds of biomedical waste per year when the plant could handle more than 5 million pounds per year.

After the final six hospitals join the effort by this time next year - when their existing waste disposal contracts have run out - the association will look to add more laboratories, doctors’ offices, veterinary clinics, dentists’ offices and nursing homes to the mix, said Butts, the Maine Hospital Association official.

“We obviously want to use the facility to its capacity,” she said.

Beyond that, the association plans to start a complementary program to reuse and recycle the plastic containers that are used to dispose of needles and other sharp instruments, Butts said.

Through the waste disposal collaboration and other efforts, Maine hospitals are at the forefront of an emerging nationwide movement toward more environmentally responsible health care, Stacy Malkan, a spokeswoman for Virginia-based Health Care Without Harm, said recently. The organization works to make the health care industry more environmentally friendly.

“Hospitals around the country will be looking to Maine to see how it works out,” she said.

The hospital garbage has to go somewhere, and Maine might as well employ its own people and methods to do so, May of Sebasticook Valley Hospital said.

“This is our waste, and it’s our responsibility to find a way to dispose of it,” he said.

©2005 Bangor Daily News, used with permission.

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