By Rick Dana Barlow

Questionable business decisions and poorly executed strategies lead many hospitals to flush more than money down the drain. They’re also pouring fluid medical waste into the sewers, too.

While that practice itself isn’t inherently illegal because wastewater treatment plants can effectively handle liquid medical waste as they would residential waste, the way hospitals actually do it can get them into serious trouble if they’re not careful or smart.

When it comes to treating and disposing or simply collecting and disposing of fluid medical waste, hospitals and other healthcare facilities have four primary choices.

"Believe it or not, some hospitals take shortcuts," said David Watermeier, director of marketing for                 Saf-T Pump from Cardinal     acute care at DeRoyal Industries Inc. (Knoxville, TN). He called one of them "cap and can." Basically, the healthcare worker places the cap on the filled suction canister and drops it
                                                 into the red bag as infectious medical waste. Another involves merely pouring the contents down the hopper sink and into the drain. With the average national price range of hauling red bag waste at 21 cents to 30 cents per pound, the first shortcut can be expensive.

"A full three-liter suction canister weighs nearly 7.5 pounds," noted Chris Hosler, vice president of marketing at Dornoch Medical Systems Inc. (St. Louis). "The typical operating room will generate about two tons of fluid waste each month. Disposal of a single three-liter canister can easily exceed $2.25. In California, we are seeing these costs rise as high as $8 per canister."

The second shortcut can be extremely expensive. That’s because of the healthcare worker’s dangerous exposure to splashing and aerosolized particulate matter from the infectious fluid. Even if that healthcare worker sports all of the required personal protective equipment, the Occupational Safety and Health Administration still will issue costly citations because such practice violates OSHA’s bloodborne pathogens standard.

Thankfully, the practice is "definitely trending downward," according to Watermeier, but "it still happens." Indeed, Hosler estimates that roughly 25 percent to 30 percent of hospitals continue to pour potentially infectious fluids (be it blood, other bodily fluids or irrigation fluids) down the hopper as standard practice, while others use it as a last-minute option of convenience. Stephanie Lipp, senior market manager of the Medi-Vac line at Cardinal Health Inc.’s Medical Products and Services division (McGaw Park, IL) isn’t so generous. In fact, based on their calculations, her group estimates that about 65% of hospitals do it this way on a frequent basis. "While this option may be very economical for the hospital it’s potentially hazardous for the healthcare worker doing it because he or she is exposed to the untreated waste through splashing or even aerosolization," Lipp said. Companies like Cardinal, DeRoyal and Dornoch calculate these percentages based on the number of suction canisters they sell in a given period.

"But we’ve seen these numbers go down as hospitals become more aware of the issue and regulations," Hosler said, reassuringly. "They know that it’s bad practice." How can the waste management companies know this? Trade show tales all share a common theme: When company representatives ask some hospital attendees how they handle fluid medical waste they blush, lower their heads and laugh nervously before admitting their sin in an audible tone barely above a whisper.

Searching for alternatives

Hospitals and healthcare facilities have two other choices, either of which is more economical than the other, depending on whom you ask.

One involves pouring a powdered solidifying agent into the fluid-filled canisters that turn the liquid content into a gelatinous substance after five to 10 minutes. Then those canisters can be disposed of as red bag waste. Some solidifiers include sanitizing agents, such as chlorine or glutaraldehyde, which may allow the treated medical waste to be placed in white bags, depending on state regulations. At least six companies sell solidifiers for medical applications, including Colby Manufacturing Corp., DeRoyal Industries Inc., DiSorb Systems Inc., Metrex Inc., Microtek Medical Inc., Safetec of America Inc. and ZappaTec LLC. (See chart.)                                                         Dornoch Transposal products

Because these systems are relatively new (Cardinal’s Saf-T-Pump, for example, debuted last September), market penetration is rather small – estimated to be in the low single-digit range. By and large, the majority of hospitals and other healthcare facilities either pour untreated liquid waste down the drain, dispose of full or partially filled canisters intact as red-bag waste or solidify it and dispose of the canisters as either red- or white-bag waste if their state deems it legal. More than likely, healthcare facilities use some combination of choices.

With federal and state regulations stymieing the use of incinerators and imposing new packaging requirements that make it more expensive to dispose of fluid waste offsite, as well as consolidation in the medical waste hauling business shrinking the industry to one primary vendor and a few secondary players, hospitals and other healthcare facilities simply want an alternative to rising prices. "It’s pushing people to look at how to treat and dispose of waste onsite without exposing their employees to any hazards," Hosler said.

Evaluating choices

Manufacturers that offer closed collection and disposal systems and/or solidifiers offer a litany of tips on how to make the right fluid waste management decision for your facility. Obviously safety is paramount. "First and foremost, any new control must protect employees from exposure to fluid waste," Hosler noted. "The control should be easy to use and have proven efficacy in handling all types of suction canister waste, including whole blood and blood clots."

In addition, the control must also satisfy all applicable regulations – from OSHA, the Department of Transportation (DOT) and the   Environmental             DeRoyal Suction products                                Protection Agency (EPA) – regarding the safe handling and disposal of infectious waste, he added.

Furthermore, "compared to on-site fluid disposal systems, solidifying more than triples the weight of operating room infectious waste handled by environmental services personnel," he added.

Essentially, healthcare facilities have to invest in suction canisters and solidifiers (non-sanitizing or the more costly sanitizing versions) and then deal with red bagging weighty canisters, according to Lipp. For example, a full three-liter canister may weigh eight pounds after solidification. At 30 cents per pound you’re adding $2.40 to the cost of the canister and solidifier. "Depending on the surgical procedure a facility may use between four and eight canisters per procedure," Lipp said, "so you’re looking at a boatload of money collecting, treating and disposing of fluid waste." Meanwhile, closed systems enable facilities to dispose of empty canisters in the white-bag waste stream, she added.

Keeping minds open on closed systems

Closed systems also have their own mitigating factors to consider. While solidifiers represent an ongoing minimal expense (not including the suction canister and red-bag waste hauling costs), closed systems require a large capital expenditure upfront, which can range between $4,000 on the low end to $50,000 on the high end. But that doesn’t include the ongoing costs for related consumables, such as disposable lids, manifolds or tubes, and cleaning and disinfecting agents necessary for operation.

While solidifier users can buy suction canisters from any vendors they choose, closed system users may not enjoy such flexibility. Typically, they have to buy the canisters, also called collectors, from the manufacturers of the systems themselves. Cardinal claims that healthcare facilities can use competitors’ canisters in its system, but then that system doesn’t perform as a closed system due to fitted components, Lipp noted. "The Cardinal dip tube is fitted to the top of the canister," she said. "Other brands aren’t fitted so there’s an aerosolization problem when the unit sucks out fluid. Our components are geared to our products. Our system can work with other canisters but you will have that safety factor."

Watermeier offers a number of other variables to consider when comparing and evaluating closed systems. They include the evacuation rate (how long it takes for the canisters to empty), ease of installation and ease of use, how much space it will occupy, where the unit will be installed (particularly if it has mobile components), whether the system has an optional treatment parameter and whether the manufacturers will bundle related products into the deal, such as disposable or reusable canisters.

Eventually the plastic material in the reusable canisters may break down after repeated cleaning and disinfection so those canisters must be replaced, according to Ted McLaughlin, president of DiSorb Systems Inc. (Philadelphia).

In fact, McLaughlin provides a cost savings calculator on his company’s Web site that allows potential customers to plug in their usage data and compare the costs between his product and two prominent closed systems, as well as a sanitizing solidifier. Other companies provide such a service via CD or via a sales representative running the numbers on his or her laptop computer.

McLaughlin merely finds closed systems labor intensive. "Someone has to collect, transport and process the waste, maintain a verification log, clean and disinfect the canisters or collectors and redistribute them," he said. "Plus, the equipment has to be maintained by the biomedical engineering department so they have to be trained on how to use it so they can repair it. Clinicians have to be trained on it. Most of all, clinicians have to be trained not to throw away the canisters or collectors. With everybody wearing seven hats in today’s healthcare environment it just doesn’t make sense."

Editor’s Note: Be sure to visit the company Web sites listed in the Waste Watchers chart because several of them offer useful help in making economic decisions as well as useful explanations of regulations with links to regulatory sites.

WASTE WATCHERS