Background, Trends, Issues, and Opportunities In Healthcare
Backgrounds, Trends, Issues and Opportunities in Healthcare
TR-107833-R1
Final Report, September 1999
EPRI Project Manager J. Bauch
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This report was prepared by
EPRI Healthcare Initiative
Revised from the original report by L. Friedman
Principal Investigators for the original report (April 1997) J. Emmanual T. Chester
The research for this report was sponsored by EPRI.
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Backgrounds, Trends, Issues and Opportunities in Healthcare, EPRI, Palo Alto, CA, 1999. TR-107833-R1.
iii blank page REPORT SUMMARY
The healthcare industry is undergoing more changes now than at any time during the past century. Electric utilities must be ready to address these changes by having up-to- date knowledge about the healthcare sector. This report is an attempt to provide that information so that utility representatives are prepared to market services and technologies that meet the current needs of healthcare facilities and organizations.
Background The healthcare industry is composed of a variety of public, private, and non-profit organizations. These organizations include healthcare facilities, such as hospitals, nursing homes, outpatient clinics, and doctor offices, and administrative organizations, such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations (IPAs). In addition, a few allied establishments, such as veterinarian clinics and mortuaries, share issues similar to those of healthcare facilities.
Objective This report is intended to provide members of the EPRI Healthcare Initiative with general background information on the healthcare sector, including industry trends, strategic issues, and opportunities to market electrotechnologies and electric utility services.
Approach This report is divided into seven chapters. Each chapter covers a specific area of concern for electric utility representatives. Chapters 1 and 2 of this document offer a general overview of the healthcare industry, including how the healthcare facilities market for electricity is affected by key players and forces. Chapter 3 is more focused on healthcare facilities—hospitals, nursing homes, and clinics. This section will examine their operation and structure as well as look at the organizations that own them. Chapter 4 concentrates on the regulatory agencies and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for healthcare facilities. Chapter 5 looks at overall energy use in the healthcare sector.
v Chapter 6 addresses selected technical issues for healthcare facilities and potential electrotechnology solutions. Finally, Chapter 7 offers strategies for marketing electricity services and technologies to healthcare providers.
Results The report summarizes the major trends and issues faced by the healthcare industry today and forecasts other issues that may become important in the future.
EPRI Perspective The EPRI Healthcare Initiative (HCI) is a collaborative effort with member utilities. Its purpose is to assist the healthcare industry to meet the ever-changing demands of the industry through education and the use of electrotechnology solutions that will reduce risk and liability, meet regulatory compliance demands, and ultimately provide the highest level of quality patient care.
Key Words Healthcare Reform Hospitals Nursing Homes Healthcare Funding Healthcare Facilities Healthcare Statistics Regulatory Compliance Electricity Use
vi CONTENTS
1 THE HEALTHCARE INDUSTRY SECTOR...... 1-1 Introduction ...... 1-1 Statistical Information on the Industry...... 1-2
2 THE U.S. HEALTHCARE SYSTEM ...... 2-1 The U.S. Healthcare System...... 2-1 Healthcare and the National Economy ...... 2-1 Healthcare Funding ...... 2-2 Major Players ...... 2-8 Background ...... 2-9 Payers...... 2-9 Providers ...... 2-11 The Role of Government ...... 2-12 Catalysts for Change: Healthcare Reform and the Market...... 2-13
3 HEALTHCARE FACILITIES ...... 3-1 Hospitals ...... 3-1 Classification of Hospitals...... 3-1 Type ...... 3-2 Control...... 3-2 Size and Length of Stay ...... 3-2 Private Hospitals ...... 3-4 For-Profit ...... 3-4 Catholic ...... 3-5 Secular and Other Religious Not-For-Profit...... 3-6 Public Hospitals...... 3-7 Federal Government...... 3-7
vii State and Local Government ...... 3-7 Utilization and Trends...... 3-7 Utilization...... 3-8 For-Profit Systems...... 3-9 Other Networks ...... 3-9 Other Trends ...... 3-10 Services Offered...... 3-10 Organizational Structure...... 3-12 Plant Engineering ...... 3-13 Administration...... 3-14 Safety and Environmental Services ...... 3-14 Medical Staff and Nursing Services ...... 3-15 Hospital Finances and Related Issues...... 3-15 Networks, Health Care Systems, Alliances...... 3-16 Nursing Homes ...... 3-17 Role in the Health Delivery System ...... 3-18 Structure of the Industry ...... 3-19 Utilization and Trends...... 3-22 Subacute Care ...... 3-23 Medical and Dental Offices, Freestanding Clinics, and Other Healthcare Institutions ...... 3-25 Related, Non-Healthcare Institutions...... 3-25 Role of Healthcare Payers in the Market ...... 3-26 Trade and Professional Organizations ...... 3-30 Trade Associations...... 3-31 Hospitals ...... 3-31 Nursing Homes...... 3-34 Other Healthcare Trade Associations ...... 3-35 Other Trade Associations ...... 3-36 Professional Groups...... 3-37 Hospitals ...... 3-37 Nursing Homes...... 3-40 Other Professional Groups ...... 3-40 Resources and References (for Chapters 2 and 3)...... 3-41
viii 4 REGULATIONS AND STANDARDS AFFECTING THE HEALTHCARE INDUSTRY ..... 4-1 Environmental Regulations, Licensing, and Accreditation ...... 4-1 U.S. Environmental Protection Agency...... 4-3 Medical Waste Incineration and the EPA Rule...... 4-3 CAAA Title V Applications – Pollutants from Boilers and Other Sources...... 4-5 CAAA Title VI - Recovery of Refrigerants Requirements ...... 4-5 Resource Conservation and Recovery Act ...... 4-6 Comprehensive Environmental Response, Compensation, and Liability Act...... 4-6 The Medical Waste Tracking Act ...... 4-6 Department of Transportation...... 4-8 HM-181 Regulations...... 4-8 Department of Labor...... 4-9 Occupational Safety and Health Administration ...... 4-10 Permissible Exposure Limits...... 4-10 Bloodborne Pathogen Rule...... 4-11 Proposed Indoor Air Quality Standard ...... 4-12 Guidelines on Workplace Violence in a Healthcare Setting...... 4-12 Department of Health and Human Services...... 4-13 Substance Abuse and Mental Health Services Administration ...... 4-13 Health Care Financing Administration...... 4-13 Public Health Service...... 4-14 Centers for Disease Control and Prevention...... 4-14 Guidelines for Protecting the Safety and Health of Healthcare Workers...... 4-14 Guidelines for Prevention and Control of Nosocomial Infections...... 4-14 Guidelines and Recommendations for the Prevention and Control of Bloodborne Pathogens ...... 4-15 Guidelines for Healthcare Workers Potentially Exposed to Tuberculosis ...... 4-17 Food and Drug Administration ...... 4-18 Center for Drug Evaluation and Research ...... 4-18 Center for Biologics Evaluation and Research...... 4-18 Center for Veterinary Medicine ...... 4-18 Center for Devices and Radiological Health...... 4-18 Health Resources and Services Administration ...... 4-20 HRSA’s Bureau of Health Resources Development...... 4-21 ix National Institutes of Health...... 4-21 Nuclear Regulatory Commission ...... 4-21 Low-Level Radioactive Waste Policy Act and Amendments ...... 4-22 Other Federal Agencies and Regulations ...... 4-22 Department of Veterans Affairs...... 4-22 Americans With Disabilities Act of 1990...... 4-22 Department of Energy Schools and Hospitals Program ...... 4-23 State Regulatory Agencies ...... 4-24 Medical Waste Treatment Technology Efficacy Criteria...... 4-24 Specific State Regulations on Medical Waste Treatment...... 4-25 County and Municipal Agencies ...... 4-26 Joint Commission on Accreditation of Healthcare Organizations ...... 4-27 History...... 4-27 Scope of Accreditation Programs ...... 4-28 JCAHO Board and Staff...... 4-29 The Accreditation Process in Brief...... 4-29 Types and Length of Accreditation ...... 4-30 Accreditation Standards...... 4-31 National Fire Protection Association ...... 4-32 American Society of Heating, Refrigerating, and Air-Conditioning Engineers...... 4-34 ASHRAE 62...... 4-34 ASHRAE 90.1...... 4-35 American Institute of Architects ...... 4-35 Guidelines for Design and Construction of Hospitals and Health Care Facilities...... 4-35 National Committee for Clinical Laboratory Standards...... 4-35 National Safety Council ...... 4-36
5 ENERGY USE IN THE HEALTHCARE INDUSTRY...... 5-1 Typical Energy Use and Energy Intensities for Healthcare Facilities ...... 5-1 Typical Electrical Use for Healthcare Facilities ...... 5-6 Typical Lighting Load Shape for Healthcare Facilities ...... 5-7
6 PROCESSES AND OPPORTUNITIES IN HEALTHCARE FACILITIES...... 6-1 Primary Processes in Healthcare Facilities...... 6-1 Facility Management ...... 6-2 x Occupational Safety and Environmental Services ...... 6-2 Food Services ...... 6-3 Lodging Services...... 6-3 Administrative Services ...... 6-3 Clinical Services...... 6-3 Identifying Issues and Opportunities...... 6-3 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Management...... 6-7 Profile of the Medical Waste Stream in Healthcare Facilities ...... 6-7 Municipal Solid Waste ...... 6-7 Infectious Waste...... 6-8 Hazardous Waste...... 6-10 Radioactive Waste...... 6-12 Issues and Opportunities in Occupational Safety and Environmental Services: Waste Minimization for Healthcare Facilities ...... 6-13 Recommended Waste Minimization Options ...... 6-13 Issues Regarding Waste Minimization...... 6-18 Resources and References ...... 6-18 Other Resources: ...... 6-20 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Treatment ...... 6-21 The Problem of Medical Waste...... 6-21 Alternative Treatment Technologies For Medical Waste...... 6-22 Broad Categories of Treatment Processes ...... 6-22 Low Heat Thermal Processes...... 6-23 High Heat Thermal Processes ...... 6-24 Irradiation ...... 6-25 Chemical Processes...... 6-25 Biological Processes...... 6-26 Mechanical Processes...... 6-26 Comparisons of Selected Treatment Technologies ...... 6-28 Economic Evaluation Using MATES...... 6-30 Resources and References ...... 6-31 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Device Sterilization ...... 6-33
xi Alternative Technologies for Medical Device Sterilization ...... 6-35 Hydrogen Peroxide Plasma Sterilization...... 6-35 Mixed Chemical Plasma Sterilization...... 6-36 Peracetic Acid Sterile Processing ...... 6-36 Ozonation Sterilization...... 6-36 Electron Beam Irradiation ...... 6-37 Issues and Organizations ...... 6-37 Vendor Contacts...... 6-40 Resources and References ...... 6-41 Issues and Opportunities in Facilities Engineering and Management: Efficient Lighting .... 6-43 Upgrading Fluorescent Systems...... 6-44 Fluorescent Lamps...... 6-44 Electronic Ballasts ...... 6-44 Fluorescent Reflectors...... 6-45 Lenses and Louvers ...... 6-45 Delamping or Current Limiters...... 6-46 Replacing Incandescents With Compact Sources ...... 6-46 Lighting Controls ...... 6-48 Resources and References ...... 6-50 Issues and Opportunities in Facilities Engineering and Management: Power Quality ...... 6-51 PQ and EMI...... 6-51 The Hospital Electrical Environment ...... 6-52 Power Quality Solutions for Healthcare Facilities...... 6-55 Resources and References ...... 6-59 Issues and Opportunities in Facilities Engineering and Management: Emergency Power...... 6-61 Load Transfer Devices ...... 6-61 Uninterruptible Power Supplies ...... 6-62 Resources and References ...... 6-63 Issues and Opportunities in Facilities Engineering and Management: Indoor Air Quality ...... 6-64 Indoor Air Quality Problems in Healthcare Facilities ...... 6-64 Airborne Diseases ...... 6-65 Medicated Aerosols...... 6-65 Gases and Fumes ...... 6-65 xii Other Pollutant Particles...... 6-66 Electrotechnologies for Indoor Air Quality...... 6-66 Resources and References ...... 6-69 Vendor and Other Literature ...... 6-70 Issues and Opportunities in Facilities Engineering and Management: Ozonation for Cooling Towers ...... 6-72 Problems Associated With Cooling Towers ...... 6-72 Traditional Treatment Methods...... 6-73 Ozonation as an Alternative...... 6-73 Principles of Operation ...... 6-75 Economics of Ozonation...... 6-76 Resources and References ...... 6-77 Issues and Opportunities in Facilities Engineering and Management: Space Conditioning and Distribution Systems...... 6-79 Energy-Efficient Space-Conditioning Technologies ...... 6-80 Demand-Control Ventilation...... 6-82 Room Pressure Measurement and Control...... 6-83 Dehumidification Systems ...... 6-83 Heat Pumps ...... 6-85 Resources and References ...... 6-86 Issues and Opportunities in Facilities Engineering and Management: CFCs and Refrigeration ...... 6-88 Background on CFCs ...... 6-88 Overview of the Regulations on Refrigerants...... 6-89 Phaseout Schedules...... 6-89 CFC Excise Tax ...... 6-89 Recycling Requirements...... 6-89 ASHRAE Standards ...... 6-90 UL Standards ...... 6-90 Alternative Refrigerants...... 6-90 Options for Refrigeration Owners ...... 6-91 Resources and References ...... 6-92 Institutions ...... 6-92 Government Agencies ...... 6-94 Selected Publications ...... 6-95
xiii Issues and Opportunities in Facilities Engineering and Management: Thermal Energy Storage...... 6-97 Principles of Cool Storage Operation...... 6-98 Ice Storage...... 6-98 Chilled Water Storage...... 6-100 Eutectic Salt Storage...... 6-100 Cool Storage Control...... 6-101 Cool Storage Economics...... 6-101 Thermal Energy Storage for Space Heating...... 6-101 Resources and References...... 6-102 List of Hospitals with Calmac TES...... 6-102 Printed Material, Slides, and Videos ...... 6-103 Institutions...... 6-104 Issues and Opportunities in Facilities Engineering and Management: Water Disinfection and Purification...... 6-105 Cases of Water Contamination in Healthcare Facilities...... 6-106 Chemical Treatment Methods...... 6-106 UV Disinfection...... 6-108 Ozonation...... 6-109 Resources and References...... 6-109 Issues and Opportunities in Facilities Engineering and Management: Energy Management...... 6-111 Distributed EMS for a Hospital...... 6-112 Real-Time Pricing (RTP) Controller...... 6-113 Resources and References...... 6-113 Issues and Opportunities in Food Services: Efficient Cooking and Other Kitchen Technologies...... 6-115 Electric Cooking Technologies...... 6-115 Kitchen Exhaust Ventilation...... 6-117 Heat Pump Application in Hospital Kitchens...... 6-118 Resources and References...... 6-118 Issues and Opportunities in Lodging Services: Ozone Laundry...... 6-120 Ozone-Based Laundry Operations...... 6-120 Principles of Operation...... 6-121 Closed-Loop Ozone Laundry System...... 6-122 xiv Open-Loop Ozone Laundry System ...... 6-123 Resources, References, and Vendors ...... 6-124 Issues and Opportunities in Information Systems and Telecommunications: Telemedicine...... 6-126 Modernization of Hospital Data Processing Systems...... 6-126 Growth of Telecommunications and Telemedicine ...... 6-126 Resources and References ...... 6-131 Issues and Opportunities: Resources of the EPRI Healthcare Initiative...... 6-132
7 HEALTHCARE PROVIDERS AS ELECTRIC UTILITY CUSTOMERS...... 7-1
A GLOSSARY OF COMMON TERMS ...... A-1
B SUMMARY OF SELECTED STATE REGULATORY AGENCIES AND REGULATIONS ON MEDICAL WASTE...... B-1
C ALTERNATIVE MEDICAL WASTE TREATMENT TEHCNOLOGIES: VENDOR ADDRESSES AND PHONE NUMBERS...... C-1
xv blank page LIST OF FIGURES
Figure 2-1 The Nation’s Health Dollar, Calendar Year 1997...... 2-4 Figure 3-1 Hospital Percent Change in Number of Hospital Beds: Calendar Years 1984-97...... 3-8 Figure 5-1 Energy Consumption and Intensity by Principal Building Activity, 1995...... 5-1 Figure 5-2 Breakdown of Energy Use in Trillion BTUs...... 5-3 Figure 5-3 Breakdown of Healthcare Electrical Usage, Arkansas Power & Light...... 5-6 Figure 5-4 Breakdown of Healthcare Electrical Usage, Louisiana Power & Light ...... 5-7 Figure 5-5 Typical Hourly Lighting Load Shape for a Hospital ...... 5-7 Figure 6-1 Issues and Opportunities in Facility Management ...... 6-4 Figure 6-2 Issues and Opportunities in Environmental Services and Occupational Safety ...... 6-5 Figure 6-3 Issues and Opportunities in Lodging, Clinical, Administrative and Food Services ...... 6-6 Figure 6-4 Municipal Solid Waste Composition for a Typical Hospital ...... 6-8 Figure 6-5 Sources of Reported EMI With Medical Devices ...... 6-58 Figure 6-6 HEPA Filtration Installed in Ventilation or as a Stand-Alone Unit...... 6-67 Figure 6-7 Examples of UVGI Placement...... 6-68 Figure 6-8 Ozonation System for Cooling Towers ...... 6-75 Figure 6-9 Most Commonly Reported Clinical Applications ...... 6-129 Figure 6-10 Non-Clinical Applications ...... 6-130 Figure 6-11 Funding Sources...... 6-130
xvii blank page LIST OF TABLES
Table 2-1 National Health Care Expenditures: 1960 - 1997...... 2-2 Table 2-2 National Health Expenditures, by Source of Funds and Type of Expenditure: 1997 ...... 2-5 Table 2-3 National Health Care Expenditures Average Annual Growth Rate From Prior Year Shown, Selected Calendar Years 1970-2007...... 2-6 Table 2-4 National Health Expenditures Spending by Category and Percent Distribution, 1970-2007 ...... 2-8 Table 3-1 Hospital Summary Characteristics...... 3-3 Table 3-2 Leading Multihospital Health Care Systems - 1998 ...... 3-5 Table 3-3 Largest Catholic Multihospital Health Care Systems - 1998 ...... 3-6 Table 3-4 Facilities and Services Provided by Hospitals: 1997...... 3-11 Table 3-5 Top Ten Nursing Facility Systems...... 3-20 Table 3-6 Nursing Home Expenditures by Source of Funds, 1993-2005 ...... 3-22 Table 3-7 Top Ten Subacute Care Providers ...... 3-24 Table 3-8 The Nation’s 25 Largest Individual HMO Plans ...... 3-28 Table 3-9 Top 30 PPOs by Number of States Served ...... 3-29 Table 4-1 Emission Limits for Hospital/Medical/Infectious Waste Incinerators...... 4-4 Table 4-2 Examples of OSHA Exposure Limits for Chemicals Common in Healthcare Facilities ...... 4-11 Table 4-3 State Regulations on Medical Waste...... 4-25 Table 5-1 Consumption and Gross Energy Intensity by Building Size for Sum of Major Fuels, 1995 ...... 5-2 Table 5-2 Floorspace, Consumption, Expenditures, Intensities of All Major Fuels for Healthcare Buildings...... 5-3 Table 5-3 Total Energy Consumption by Major Fuel, 1995...... 5-4 Table 5-4 Total Energy Expenditures by Major Fuel, 1995...... 5-5 Table 6-1 Ten Categories of Infectious Waste...... 6-9 Table 6-2 Hazardous Wastes Generated in Healthcare Facilities...... 6-11 Table 6-3 Radioactive Materials Used In Hospitals ...... 6-12 Table 6-4 Sources and Types of Common Recyclable Waste in a Hospital ...... 6-14 Table 6-5 Waste Minimization Options for Hazardous Wastes ...... 6-16 Table 6-6 Alternative Treatment Technologies for Medical Waste...... 6-26
xix Table 6-7 Comparison of Selected Treatment Technologies...... 6-29 Table 6-8 Advantages and Disadvantages of Various Sterilization Methods ...... 6-34 Table 6-9 PQ/EMI Rating of Common Hospital Equipment ...... 6-54 Table 6-10 Hospital Equipment Isolation Chart ...... 6-57 Table 6-11 Space-Conditioning Systems for Clinics and Hospitals...... 6-81 Table 6-12 U.S. Phaseout Schedule for CFCs and HCFCs in Refrigeration and Air- Conditioning Applications ...... 6-89 Table 6-13 Comparison for a Commercial Laundry Chain...... 6-123
xx 1 THE HEALTHCARE INDUSTRY SECTOR
Introduction
This report is intended as a resource for members of the EPRI Healthcare Initiative. The objectives of the study are: to provide general background information on the healthcare sector, to describe trends and strategic issues affecting the healthcare industry, and to identify electrotechnology and service opportunities for electric utility and healthcare personnel towards meeting the needs of the industry.
The healthcare industry comprises a variety of public, private, and non-profit organizations: hospitals, nursing homes, outpatient clinics, doctor offices, and administrative organizations such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations (IPAs). This report will focus on healthcare facilities, such as hospitals, clinics, and nursing homes, since they represent a large and technically complex customer group for the electric utility industry. It will also discuss allied establishments such as veterinarian clinics and mortuaries which have some issues (such as infectious waste) similar to those of healthcare facilities.
The electric utility industry is undergoing the greatest change since it was formed more than a century ago. Facing a future of greater competition, individual utilities are changing too, just as the healthcare industry. Electric utilities are reorganizing, offering more value-added services to their customers, seeking new markets, and looking at new ways to address old markets. With the changing nature of the industry, utilities may differ in how they choose to address the healthcare facilities market or may need different types of background information about the market. Reflecting these potentially varying interests, this report is organized into five major parts:
Chapter 2 provides an overview of the healthcare sector and how various players and forces in the sector affect the healthcare facilities market from the standpoint of electric utilities. It is intended to provide background information on the key elements in the healthcare sector and to serve as a guide to sources of more information.
Chapter 3 is a more detailed look at the organization and operation of healthcare facilities and the organizations which own and operate them.
1-1 The Healthcare Industry Sector
Regulation and accreditation are driving forces in the healthcare industry. Chapter 4 focuses on regulatory and accreditation agencies and their rules and standards that affect the industry. These include U.S. Environmental Protection Agency, Department of Health and Human Services, state agencies, the Joint Commission on Accreditation of Healthcare Organizations, and many more.
Chapter 5 gives a quick overview of overall energy use in the healthcare industry as well as the typical load in a healthcare facility.
Chapter 6 provides data on selected technical issues in healthcare facilities and electrotechnology solutions. Specifically, this section deals with:
• Processes that now use or could use electricity,
• Problems that could be addressed by electrotechnologies, and
• Service opportunities for electric utilities.
The bulk of Chapter 6 is comprised of summaries and descriptions of issues, and where possible, examples and case studies of electrotechnology and service opportunities. Each subsection lists available resources and references for more information.
Chapter 7 is a brief outline of some general strategies for working with healthcare providers as important customers of electric utilities.
Like the electric utility industry, the healthcare sector is making dramatic changes in its structure and operations. To keep this report timely and useful as long as possible, we have included information on trends and possible effects of changing laws and government policies. Also, we have included lists of organizations and data sources which could provide current information on the status of the sector and the medical facilities market in the future.
Statistical Information on the Industry
For statistical information on the healthcare industry, this report draws on data from the Bureau of the Census and other government agencies (e.g., Health Care Financing Administration) and trade associations (e.g., American Hospital Association).
It should be noted that numbers sometimes differ according to source primarily because establishments are defined differently by different groups doing the counting. Moreover, the period when data were gathered also causes discrepancies because the industry is changing so quickly. In the continuum of healthcare from acute care to long- term care, lines between categories are often ambiguous and growing more so as the industry evolves.
1-2 The Healthcare Industry Sector
Census data are an important source of statistical information about businesses and industries. The most current data from the 1997 Economic Census is expected to be made available throughout 1999 and 2000. The Bureau of Census now follows the North American Industry Classification System (NAICS) which replaces the U.S. Standard Industrial Classification System (SICS) for categorizing businesses and gathering statistical information about them. The NAICS system is the framework by which many other public and private sector groups gather statistics. NAICS was developed jointly by the U.S., Canada and Mexico to provide new comparability in statistics about business activity across North America.
In the NAICS schema “Health Care and Social Assistance” includes the categories 621 – Ambulatory Health Care Services, 622 – Hospitals, 623 – Nursing and Residential Care Facilities, and 624 – Social Assistance.
The following table summarizes Health Care and Social Assistance and their categories. For a more detailed description, refer to the U.S. Census Bureau (www.census.gov/epcd/naics).
1997 NIACS Healthcare and Social Assistance
621 Ambulatory Health Care Services 6211 Offices of Physicians 62111 Offices of Physicians 621111 Offices of Physicians (except Mental Health Specialists) 621112 Offices of Physicians, Mental Health Specialists 6212 Offices of Dentists 62121 Offices of Dentists 6213 Offices of Other Health Practitioners 62131 Offices of Chiropractors 62132 Offices of Optometrists 62133 Offices of Mental Health Practitioners (except Physicians) 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists 62139 Offices of All Other Health Practitioners 621391 Offices of Podiatrists 621399 Offices of All Other Miscellaneous Health Practitioners 6214 Outpatient Care Centers 62141 Family Planning Centers 62142 Outpatient Mental Health and Substance Abuse Centers 62149 Other Outpatient Care Centers 621491 HMO Medical Centers 621492 Kidney Dialysis Centers 621493 Freestanding Ambulatory Surgical and Emergency Centers 1-3 The Healthcare Industry Sector
621498 All Other Outpatient Care Centers 6215 Medical and Diagnostic Laboratories 62151 Medical Laboratories 621511 Medical Laboratories 621512 Diagnostic Imaging Centers 6216 Home Health Care Services 62161 Home Health Care Services 6219 Other Ambulatory Health Care Services 62191 Ambulance Services 62199 All Other Ambulatory Health Care Services 621991 Blood and Organ Banks 621999 All Other Miscellaneous Ambulatory Health Care Services 622 Hospitals 6221 General Medical and Surgical Hospitals 62211 General Medical and Surgical Hospitals 6222 Psychiatric and Substance Abuse Hospitals 62221 Psychiatric and Substance Abuse Hospitals 6223 Specialty (except Psychiatric and Substance Abuse) Hospitals 62231 Specialty (except Psychiatric and Substance Abuse) Hospitals 623 Nursing and Residential Care Facilities 6231 Nursing Care Facilities 62311 Nursing Care Facilities 6232 Residential Mental Retardation, Mental Health and Substance Abuse Facilities 62321 Residential Mental Retardation Facilities 62322 Residential Mental Health and Substance Abuse Facilities 6233 Community Care Facilities for the Elderly 62331 Community Care Facilities for the Elderly 623311 Continuing Care Retirement Communities 623312 Homes for the Elderly 6239 Other Residential Care Facilities 62399 Other Residential Care Facilities 624 Social Assistance 6241 Individual and Family Services 62411 Child and Youth Services 62412 Services for the Elderly and Persons with Disabilities 62419 Other Individual and Family Services 6242 Community Food and Housing, and Emergency and Other Relief Services 62421 Community Food Services 62422 Community Housing Services
1-4 The Healthcare Industry Sector
624221 Temporary Shelters 624229 Other Community Housing Services 62423 Emergency and Other Relief Services 6243 Vocational Rehabilitation Services 62431 Vocational Rehabilitation Services 6244 Child Day Care Services 62441 Child Day Care Services (Source: U.S. Census Bureau - www.census.gov)
1-5 blank page 2 THE U.S. HEALTHCARE SYSTEM
The U.S. Healthcare System
Although healthcare facilities and allied establishments are the focus of this report, these facilities are only one component of the healthcare industry, a vast and complex network of public, private, and non-profit institutions. This section introduces the healthcare sector and its constituent institutions and describes how they form and influence the healthcare facilities market.
Healthcare and the National Economy
The healthcare industry affects the lives of every citizen and is a pillar of the national economy. In 1997, 4,332,805 people were employed in the 6,097 U.S. hospitals. This was in addition to nursing homes, as well as ambulatory clinics and surgical centers, and even patients’ homes served by home healthcare services. And these figures do not include the thousands of people working in the nation’s insurance companies.
Healthcare is big business in the United States. According to the Health Care Financing Administration (HCFA), national healthcare expenditures amounted to $1.1 trillion in 1997. Health spending as a share of the nation’s gross domestic product (GDP) fell slightly to 13.5%, the smallest claim of health spending in the past five years. For 1993 to 1997, slow health spending growth combined with solid increases in GDP halted the steady upward path of health spending as a share of GDP that has been observed over the past three decades.
Table 2-1 shows historic trends in healthcare expenditures and gross domestic product from 1960 to 1997.
2-1 The U.S. Healthcare System
Table 2-1 National Health Care Expenditures: 1960 - 1997
National Health Expenditures, Percent Distribution, and Average Annual Percent Growth: 1960 - 1997
1960 1970 1980 1990 1994 1995 1996 1997
Gross Domestic $527 $1,036 $2,784 $5,744 $6,947 $7,270 $7,662 $8,111 Product (Billions)
U.S. Population 190 215 235 260 271 273 276 278 (Millions)
National Health $26.9 $73.2 $247.3 $699.4 $947.7 $993.7 $1,042.5 $1,092.4 Expend (Billions)
National Health $141 $341 $1,052 $2,690 $3,500 $3,637 $3,781 $3,925 Expend Per Capita
National Health 5.1% 7.1% 8.9% 12.2% 13.6% 13.7% 13.6% 13.5% Expend as % of GDP
(Source: Health Care Financing Administration, Office of Actuary, National Health Statistics Group)
National health spending growth is expected to accelerate from 1998 to 2001, growing at an average annual rate of 6.5%. This compares to 5.0% annual growth from 1993 to 1996 due mostly to slow spending growth in the private sector (2.9%), while public sector spending grew more quickly (7.5%). This pattern is projected to reverse with private sector health expenditures growing at faster average annual rates (7.2%) than the public sector (5.7%).
The nation’s total spending for health care is projected to increase to $2.1 trillion in 2007, averaging annual increases of 6.8%. Health spending as a share of gross domestic product is estimated to increase from 13.6% in 1996 to 16.6% in 2007. The Balanced Budget Act (BBA) of 1997 is expected to slow the growth in Medicare spending between 1998 and 2002.
Healthcare Funding
Healthcare funding comes from three primary sources: private health insurance, government programs, and out-of-pocket payments (also called “fee-for-service” in the healthcare industry).
2-2 The U.S. Healthcare System
Figure 2-1 shows the distribution of sources of funds used to pay for healthcare in 1997 (the latest year for which complete figures are available) and how those funds were spent. Private health insurance paid 31.9% of healthcare costs; federal programs (Medicare and Medicaid), 34.2%; out-of-pocket payments, 17.2%; state and local funds, 12.2%; and other private sources, 4.6%.
Of these funds, more than 41% went to the medical facilities: 34% to hospitals and 7.6% to nursing home care.
2-3 The U.S. Healthcare System
Where It Came From
“Other Private” includes industrial inplant, privately funded construction, and non-patient revenues including philanthropy. “Other Public” includes programs such as workers’ compensation, public health activity, Department of Defense, Department of Veterans Affairs, Indian health services, and State and local hospital and school health. NOTE: Numbers shown do not add to 100.0 because of rounding.
Where It Went
“Other Spending” includes dentist services, other professional services, home health care, durable medical products, over-the-counter medicines and sundries, public health, and research and construction. “Program Administration and Net Cost” is for private health insurance.
(Source: Health Care Financing Administration, Office of the Actuary: National Health Statistics Group)
Figure 2-1 The Nation’s Health Dollar, Calendar Year 1997 2-4 The U.S. Healthcare System
Table 2-2 shows how these funds were allocated among the major entities in the healthcare delivery market (e.g., hospitals, physicians, nursing homes, etc.) in 1997. For example, for hospital care, $228.4 billion came from government sources, primarily through Medicare and Medicaid programs. For nursing homes, this amount was $51.4 billion.
Table 2-2 National Health Expenditures, by Source of Funds and Type of Expenditure: 1997
Private1
Consumer Government1
All State Private Out of Private and Type of Expenditure Total Funds Total Pocket Insurance Other Total Federal Local
National Health Expenditures 1,092.4 585.3 535.6 187.6 348.0 49.7 507.1 367.0 140.0 Health Services and Supplies 1,057.5 571.9 535.6 187.6 348.0 36.4 485.5 351.8 133.8 Personal Health Care 969.0 536.7 501.0 187.6 313.5 35.6 432.4 337.3 95.1 Hospital Care 371.1 142.6 125.4 12.4 113.0 17.2 228.4 185.6 42.8 Physician Services 217.6 147.5 143.2 34.1 109.1 4.3 70.1 58.4 11.7 Dental Services 50.6 48.4 48.1 23.9 24.3 0.2 2.3 1.3 1.0 Other Professional Services 61.9 48.3 43.5 24.6 18.9 4.8 13.6 10.8 2.8 Home Health Care 32.3 14.7 10.7 7.0 3.7 3.9 17.7 15.4 2.3 Drugs and Other Medical 108.9 92.9 92.9 53.0 39.9 – 16.0 9.2 6.8 Nondurables Vision Products and Other 13.9 7.3 7.3 6.8 0.5 – 6.6 6.4 0.1 Medical Durables Nursing Home Care 82.8 31.3 29.8 25.7 4.0 1.6 51.4 34.5 16.9 Other Personal Health Care 29.9 3.6 – – – 3.6 26.3 15.6 10.7 Program Administration & Net 50.0 35.3 34.6 0.0 34.6 0.7 14.7 10.4 4.3 Cost of Private Health Insurance Government Public Health 38.5 – – – – – 38.5 4.1 34.4 Activities Research and Construction 34.9 13.4 – – – 13.4 21.5 15.3 6.3 Research 18.0 1.5 – – – 1.5 16.5 13.8 2.6 Construction 16.9 11.9 – – – 11.9 5.1 1.4 3.6
1 Amounts are shown in $ billion. Note: Research and development expenditures of drug companies and other manufacturers and providers of medical equipment and supplies are excluded from research expenditures, but are included in the expenditure class in which the product falls. Numbers may not add up to totals because of rounding. (Source: Health Care Financing Administration, Office of the Actuary, National Health Statistics Group.)
2-5 The U.S. Healthcare System
Table 2-3 National Health Care Expenditures, Average Annual Growth Rate From Prior Year Shown, Selected Calendar Years 1970-2007
1970- 1980- 1990- 1993- 1996- 1998- 2001- Spending Category 1980 1990 1993 1996 1998* 2001* 2007* National Health Expenditures 12.9% 11.0% 8.6% 5.0% 5.3% 6.5% 7.5% Health Services and Supplies 13.3 11.1 8.7 5.0 5.3 6.6 7.6 Personal Health Care 13.0 11.0 8.6 4.9 4.9 6.4 7.5 Hospital Care 13.9 9.6 8.0 3.5 3.4 4.9 6.6 Physician Services 12.8 12.5 7.8 3.2 4.7 7.1 7.8 Dental Services 11.1 9.0 7.4 6.7 6.2 6.3 6.7 Other Professional Services 16.3 18.5 10.1 7.8 7.3 8.0 8.1 Home Health Care 26.9 18.6 20.3 9.7 4.8 7.8 8.0 Drugs and Other Medical 9.4 10.7 8.0 6.6 7.7 8.4 8.8 Nondurables Prescription Drugs 8.2 12.1 9.9 7.6 9.3 9.6 9.8 Vision Products and Other 8.8 10.7 5.6 2.6 3.8 5.3 5.7 Medical Durables Nursing Home Care 15.4 11.2 9.2 5.8 5.4 5.5 6.4 Other Personal Health Care 12.0 10.8 17.0 15.4 8.3 10.9 12.8 Program Administration & Net Cost 15.9 13.1 9.8 4.2 10.4 8.0 8.4 Government Public Health 17.5 11.3 8.9 11.9 7.3 7.0 6.9 Activities Research and Construction 8.1 7.7 5.8 2.8 3.2 3.7 4.3 Research 10.8 8.4 5.9 5.5 4.1 4.4 4.7 Construction 6.2 7.1 5.7 0.0 2.1 2.8 3.7 (Source: Health Care Financing Administration, Office of the Actuary) * Projected
Patterns of growth will differ substantially across types of health care services. Hospital growth is projected to lag increasingly behind growth in drugs and physicians and other professional services as the trend away from the inpatient setting towards ambulatory care settings is reinforced by the movement of Medicare beneficiaries into managed care. Growth in spending for hospital services will remain well below growth in aggregate national health spending throughout the projection interval (Table 2-3). This is particularly the case for the period through 2001: the hospital spending share is expected to fall from 34.6% in 1996 to 32% in 2001 (Table 2-4) a faster rate of decline than has been observed in recent years.
2-6 The U.S. Healthcare System
For 1998-2000 Medicare spending for inpatient hospital services is expected to grow at the lowest rate in the program’s history (an average of 3% per year), compared with 8.2% per year for 1993-1996. Growth in outpatient services also is expected to decelerate from its historically rapid pace over the coming decade, extending a decelerating trend. Medicare’s scheduled switch to a Prospective Payment System (PPS) for outpatient services in 1999 will contribute to this slowdown. Expenditures for drugs are expected to grow at fairly rapid rates through 2007 as a result of rising utilization (number of prescriptions) to intensity (including changes and mix of prescriptions). Expenditure growth for nursing home care is expected to decelerate for 1998-2000, growing 5.1% on average (down from 5.8% for 1993-1996). This slowdown is accounted for by the effects of slower growth in Medicaid expenditures and a sharp cutback in the rate of growth for Medicare spending after the introduction of prospective payment. The decline in public-sector funding is expected to be partially offset by an acceleration in private- sector funding, primarily from out-of-pocket expenditures. Slower growth in nursing home spending also reflects the somewhat slower growth of the population over age eighty-five. Growth in population for this group is expected to average 2.4%, compared with 3.2% for 1980-1996.
2-7 The U.S. Healthcare System
Table 2-4 National Health Expenditures, Spending by Category and Percent Distribution, 1970-2007
Spending Category 1970 1980 1990 1993 1996 1998* 2001* 2007* Percent Distribution in National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Health Expenditures Health Services and Supplies 92.7 95.3 96.5 96.8 97.0 97.1 97.3 97.8 Personal Health Care 87.1 87.8 87.9 87.9 87.6 87.0 86.9 87.1 Hospital Care 38.2 41.5 36.7 36.1 34.6 33.4 32.0 30.4 Physician Services 18.5 18.3 20.9 20.5 19.5 19.3 19.7 20.0 Dental Services 6.4 5.4 4.5 4.4 4.6 4.7 4.7 4.5 Other Professional Services 1.9 2.6 5.0 5.2 5.6 5.8 6.1 6.3 Home Health Care 0.3 1.0 1.9 2.6 2.9 2.9 3.0 3.1 Drugs & Other Medical 12.0 8.7 8.6 8.4 8.8 9.3 9.8 10.5 Nondurables Prescription Drugs 7.5 4.9 5.4 5.6 6.0 6.5 7.1 8.0 Vision Products & Other 2.2 1.5 1.5 1.4 1.3 1.2 1.2 1.1 Medical Durables Nursing Home Care 5.8 7.1 7.3 7.4 7.6 7.6 7.4 7.0 Other Personal Health Care 1.8 1.6 1.6 2.0 2.7 2.8 3.2 4.3 Program Administration and Net 3.7 4.8 5.8 6.0 5.9 6.5 6.7 7.1 Cost Government Public Health Activities 1.8 2.7 2.8 2.8 3.4 3.6 3.6 3.5 Research and Construction 7.3 4.7 3.5 3.2 3.0 2.9 2.7 2.2 Research 2.7 2.2 1.7 1.6 1.6 1.6 1.5 1.3 Construction 4.6 2.5 1.8 1.6 1.4 1.3 1.2 1.0
(Source: Health Care Financing Administration, Office of the Actuary.)
* Projected
Major Players
The U.S. healthcare delivery system comprises two general groups: payers and providers. Providers are those organizations which deliver (provide) healthcare to patients (or residents, as they are called in long-term care facilities), while payers are those organizations which pay for it. Payers are insurance companies, employers, government agencies, and individual consumers, while providers include hospitals, nursing homes, clinics, and similar facilities, as well as individual physicians and their organizations. The distinction is becoming increasingly blurred. Managed care is replacing the traditional payer-provider calculus. For example, some payers, such as insurance companies, are moving into the area of delivery of healthcare, while some
2-8 The U.S. Healthcare System hospitals and physician groups are creating alliances and managed care arrangements with employers to provide healthcare directly.
Background
Many of the changes in the healthcare sector in the last decade have been due to fundamental changes in how healthcare payers reimburse providers for their services. Until the early 1980s, the most common method of reimbursement was fee-for-service arrangements in which doctors and hospitals billed payers (e.g., insurance companies or the Federal government) directly for each service performed. Changes in this system began in the early 1980s when the Federal government forced hospitals and doctors to accept a new restrictive reimbursement system known as the prospective payment system (PPS) for services provided to Medicare patients.
Under the PPS system, hospitals and doctors are reimbursed according to a fixed schedule of fees based upon 470 categories of illness. These categories are known as diagnostic related groups (DRGs). This resulted in smaller receipts from Medicare patients. Hospitals tried to compensate for this loss of Medicare revenue by hiking rates to private patients (a practice known in the industry as “cost shifting”). In response, private third-party payers like insurance companies and large employers have introduced “managed care” arrangements to control costs.
Managed healthcare is a system of pre-paid plans providing comprehensive coverage to voluntarily enrolled members. Managed care plans control costs in several ways such as (1) modifying physician incentives, especially in hospital use, (2) contracting with groups of doctors and hospitals to serve their members at lower prices, and (3) creating a health delivery organization (e.g., Kaiser Permanente) comprising salaried physicians and hospitals under a single management structure.
In their contracts with hospitals, managed care companies frequently use “capitated plans” which typically pay hospitals a pre-negotiated fixed amount per capita each month based on the number of members in the plan. This sharply contrasts with traditional fee-for-service plans which reimburse hospitals and physicians separately for each service they provide. Hospitals involved in capitated plans have their annual gross revenue from each plan fixed by the number of subscribers in that plan and can operate profitably only when their costs are below that ceiling. This creates a strong incentive for these providers to hold down costs.
Payers
Although payers are key players in the healthcare market, as utility customers they are generally distinct from providers. For example, insurance companies are typical commercial institutions occupying office buildings, and as such, they fall into the
2-9 The U.S. Healthcare System commercial market segment as utility customers rather than the healthcare segment. Consequently, this report addresses and describes payers from the standpoint of their role in the healthcare market rather than as direct utility customers.
Insurance companies are an important component in the payer category. They exert enormous influence on healthcare policy at every level, and by their payment decisions they affect services offered by healthcare providers. As shown in Figure 2-1 and in Table 2-2, private health insurance is the source of one-third of all healthcare financing and 60% of private financing in 1997. Hundreds of separate organizations make up this category. In a study done in the 1980s, the private health insurance market comprised approximately 1,000 commercial insurance companies, more than 100 non-profit Blue Cross and Blue Shield insurance plans, 700 prepaid health plans or health maintenance organizations (defined below in this section), and large employers carrying their own insurance or self insuring.
Employers are concerned about healthcare costs because they pay a sizable proportion in insurance premiums. They affect the healthcare market in several ways: influencing which healthcare plans their employees can join, influencing healthcare reform legislation through their trade associations, and in some cases contracting directly with healthcare providers such as hospitals and physician groups to serve their employees.
Federal government payments through Medicare and Medicaid account for more than half of hospital revenues in the country. Changes in federal policies on these payments have enormous repercussions throughout the healthcare sector. For more information, see the “Role of the Government” section.
Managed healthcare groups are hybrid organizations, combining a health delivery capability with a traditional payer function. These organizations typically provide prepaid plans of comprehensive coverage to voluntarily enrolled members. The two predominant types of managed healthcare are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
HMOs commonly use primary care physicians to screen patients to determine if hospitalization is required and to have as many patient services and procedures as possible performed outside of hospitals to reduce costs. Unnecessary inpatient services account for nearly a third of total U.S. hospital admissions. PPOs are a modified version of HMOs; enrollees are offered incentives to limit their provider selection to preferred providers.
Managed care groups have enormous influence on the healthcare facilities market because of their power in the industry. In 1995, 46 million persons were enrolled in 562 HMOs. According to the Inter study on managed care organizations, by 2002, 140 million persons will be enrolled in managed care and Medicare and Medicaid. 1998 finds nearly 650 managed care plans. Managed care covers 86% of workers and
2-10 The U.S. Healthcare System their families, up from 55% six years ago. (U.S. News and World Report, October 5, 1998.)
Providers
Patients’ needs range from intensive, highly-specialized treatment in critical care or surgical units of hospitals to basic provision of housing, meals, sanitation, and comfort in custodial care facilities. In between are healthcare in skilled nursing facilities, out- patient clinics, physician offices, and even patients’ homes. Providers are institutions which deliver this continuum of healthcare services to patients. They are particularly important in the healthcare facilities market because they are typically the institutions owning and operating major facilities.
As healthcare reform and competition increasingly affect the market, providers are often changing what healthcare services they offer patients, moving to a different position along the continuum of care. For example, hospitals, faced with the need to reduce costs are increasingly using out-patient centers to replace over-night stays by patients. Similarly, nursing home systems are moving into sub-acute care in which they house and provide nursing care for patients who were formerly cared for in hospitals.
Following is a description of the main types of providers. They will be discussed in more detail in subsequent sections.
Hospitals are the primary institution in the nation’s health delivery system and the major focus of the healthcare market segment for the utility industry because of their visibility in the community, the large amount of energy they consume, and the complexity of their operations. In the continuum of care concept, hospitals are the providers of “acute care,” the most expensive and technologically and medically complex level of healthcare. According to the American Hospital Association, the primary function of a general hospital is to “provide patient services, diagnostic and therapeutic, for a variety of medical conditions. A general hospital also shall provide:
• Diagnostic x-ray services with facilities and staff for a variety of procedures
• Clinical laboratory service with facilities and staff for a variety of procedures and with anatomical pathology services regularly and conveniently available
• Operating room service with facilities and staff.
Nursing homes, frequently called nursing facilities, long term care facilities or convalescent homes, are also a major component of the market. In 1997, there were over 17,000 nursing homes in the country, ranging from skilled nursing facilities (SNFs, pronounced “sniffs”) to long-term custodial care facilities, and their number is expected to grow as they assume some functions now carried out by hospitals. Some nursing
2-11 The U.S. Healthcare System home facilities have begun offering “sub-acute care” to patients who need extended skilled medical or rehabilitation care but not at the level or expense offered by a hospital. The trend toward managed care and strict cost control is pushing the growth of sub-acute care facilities. Another subcategory of the nursing home category is assisted living care. These are facilities offering patients a range of care levels (from semi-autonomous to traditional nursing care), depending on their health and self- reliance, in a communal setting.
Although nursing homes on average use less electricity than hospitals, they are more numerous and represent a significant proportion of the healthcare facilities market for the electric utility industry.
Clinics are also increasing in number and importance as payers seek lower-cost alternatives to hospitals. This category includes kidney dialysis centers, cancer treatment, and similar specialized facilities.
Physicians are the gatekeepers in the managed care environment, deciding how patients will be served within the healthcare system. Though numerous and important from the standpoint of healthcare delivery, their offices represent a relatively small electrical load. They are involved in other issues, such as indoor air quality and medical waste, however, which are significant within the healthcare industry.
Related, non-medical facilities include veterinary clinics, blood banks, and mortuaries. Although these facilities are not part of the healthcare sector, they have some issues in common with institutions in that sector. These include medical waste, airborne disease, and sharps disposal. As electricity customers, though, their total load is small compared to hospitals, nursing homes, and clinics.
The Role of Government
Government policies in healthcare are critical to all organizations involved in its delivery including hospitals and nursing homes. For example, in 1997, as Table 2-2 shows, government payments for healthcare totaled $507.1 billion.
Over the past thirty years, the federal government has enacted policies to provide access to healthcare for groups who otherwise would be unable to pay for it. Those policies affecting healthcare facilities the most, such as hospitals and nursing homes, include Medicare (elderly and disabled), Medicaid (poor children and adults, disabled), and Indian Health Service (Native Americans).
Current government policies on healthcare follow two principal themes: cost containment and access to healthcare. In addition there is concern for quality of care, especially related to maintenance of quality while reducing healthcare delivery costs. Although many changes are being considered at state and federal levels of government, 2-12 The U.S. Healthcare System they almost universally assume that the current system of financing and delivering healthcare is basically sound and that policies are needed to improve the current private payer system rather than replace it with a national health insurance system.
Catalysts for Change: Healthcare Reform and the Market
Fundamental changes in the healthcare insurance system and in government support of programs such as Medicare are causing enormous repercussions in the healthcare system in this country. These repercussions are influencing the way healthcare institutions conduct their business and even whether some remain in business. For example, some institutions, such as hospitals which cannot receive sufficient revenue, are being forced to close, while others are declining to serve those unable to pay. At the same time, insurers are making providers accept predetermined fees for specific services. As the system for delivering healthcare seems increasingly driven by profit motives, the tendency for government agencies to impose constraints on the system is growing. Healthcare reform is the term used to characterize the changing roles of payers and providers, along with a national reassessment of the role the federal government should play in paying for healthcare and in regulating the healthcare market.
The rising cost of healthcare and the size of the nation’s total healthcare expenditures are driving the demand for changes in the system. Several factors contribute to rising healthcare costs:
• Healthcare consumers are insulated from costs which are paid by insurance companies.
• Healthcare has traditionally been delivered through fee-for-service plans in which providers are compensated in direct proportion to the amount of services rendered, with little incentive to contain costs.
• Healthcare is considered a necessity beyond the law of supply and demand to regulate its cost.
• Medical practitioners often order diagnostic procedures unnecessarily to protect themselves against potential malpractice lawsuits.
• The population is aging and requiring more healthcare.
• Medicare and Medicaid have expanded.
• The availability of new diagnostic and treatment technologies has encouraged their acquisition and use.
2-13 The U.S. Healthcare System
Although healthcare legislation died in Congress in 1994, the pressure for reform remains, as well as pressure to cut Medicare as a way of reducing federal budget outlays. In fact, every current Congressional healthcare reform plan included cuts in Medicare as a way to finance new programs. Medicare is an important element in U.S. healthcare and a major source of hospital revenue. The Health Care Financing Administration (410-786-3689 Medicare Statistical Hotline) reports that as of July 1998 (the latest data available), Medicare provides benefits to 38,567,298 citizens. The Medicare benefit payments exceeded $200 billion in 1998, with payments expected to be more than $228 billion in 1999. The American Hospital Association was opposed to cuts in Medicare for this reason.
Although much public attention is focused on healthcare legislation in Congress, competition among providers and payers is driving changes in the sector. The roles of various providers is shifting along the continuum of care as the players juggle for market share. Hospitals are consolidating into more efficient entities, nursing facility systems are moving into areas, such as sub-acute care, formerly held exclusively by hospitals. Insurers are seeking new arrangements with physician groups. These changes will have enormous implications for utility programs addressing this sector, and many of these changes are happening at the state and regional level.
Resources and References (see end of Chapter 3)
2-14 3 HEALTHCARE FACILITIES
The focus of this report is healthcare facilities, the institutions that actually deliver treatment and care to patients. These institutions comprise mainly hospitals, nursing homes, clinics, and offices of physicians and dentists. This section describes each of these groups of institutions focusing on their organization, mission, and general operation. The next section looks at their operations in more detail and discusses potential roles for electric utilities.
Hospitals
Since early in this century, hospitals have been the center of healthcare delivery in the United States. In 1997 there were 6,097 AHA registered hospitals in the U.S. including 5,082 short-term hospitals. Hospital costs represent more than a third of the nation’s total healthcare expenditure of $1.1 trillion in 1997. Because of their size, complexity, budget size, and importance in healthcare delivery, hospitals are the most important component of the healthcare facilities market.
Classification of Hospitals
Hospitals are the most visible component of the healthcare delivery system in this country. In addition to providing care for bed-ridden and ambulatory patients, hospitals are training sites for physicians, nurses, allied health professionals and centers for research.
Hospitals are often categorized by key characteristics, such as type of care offered or governance. These categories are used by trade associations, government agencies, and other groups to organize statistical information about the institutions. The categories also provide insights into organizational issues and potential strategies for power suppliers.
The American Hospital Association (AHA), the primary trade association for the hospital industry, classifies hospitals according to several categories, including type, control, size, and length of patient stay.
3-1 Healthcare Facilities
Type
In classifying by type, the AHA uses two general categories: community and non- community. Community hospitals, as defined by the AHA, are “all non-federal short- term general and other special hospitals whose facilities are open to the public. (Other special hospitals include obstetrics and gynecology; eye, ear, nose and throat; rehabilitation; orthopedic; and other individually described specialty services.)” In contrast, non-community hospitals, according to the AHA, include federal hospitals, long-term hospitals, psychiatric hospitals, alcoholism and chemical dependency facilities, and hospital units of institutions. Community hospitals are the most common type, with 90% of total hospital beds.
Control
There are two principal classes of control: public and private. Control refers to the type of organization responsible for establishing policy concerning overall hospital operation. Private hospitals may be investor-owned for-profit (sometimes called proprietary) or not-for-profit (also called voluntary). The non-profit category includes hospitals owned by religious denominations, the largest group of which by far are those of the Catholic Church. Public hospitals may be characterized by the level of government jurisdiction which owns and operates them. The AHA uses two categories of public hospitals: government-federal and government-nonfederal.
Size and Length of Stay
In categorizing hospitals by size one measure is number of beds, excluding bassinets for newborns. Another is average patient census, stated in patient-days per thousand days. In classifying by length of stay, two categories are typically used: short-term (less than 30 days) and long-term (more than 30 days).
Table 3-1 presents some summary characteristics for hospitals, showing trends in key areas from 1972-1997.
3-2 Healthcare Facilities
Table 3-1 Hospital Summary Characteristics
Hospitals—Summary Characteristics: 1972-1997
1972 1980 1990 1993 1997
Number: All hospitals 7,061 6,965 6,649 6,467 6,097
• Non-Federal 6,660 6,606 6,312 6,151 5,812
– Community hospitals 5,746 5,830 5,384 5,261 5,057
Non-govt’l, non-profit 3,301 3,322 3,191 3,154 3,000
For profit 738 730 749 717 797
State and local gov’t 1,707 1,778 1,444 1,390 1,260
– Long-term gen’l & special 216 157 131 117 125
– Psychiatric 529 534 757 741 601
– Tuberculosis 72 11444
• Federal 401 359 337 316 285
Beds: All hospitals (1,000) 1,550 1,365 1,211 1,163 1,035
Expenses: All hosp (billions $) 32.7 91.9 234.9 301.5 342.3
Personnel: All hosp (1,000) 2,671 3,492 4,063 4,289 4,333
Outpatient Visits (millions) 219.2 263.0 368.2 435.6 520.6
(Source: American Hospital Association)
In addition to the AHA, the Census Bureau gathers statistics on medical facilities. As described previously, the federal government uses the North American Industry Classification System (NAICS).
Census data are useful for providing information on trends in specific geographic areas, say within a particular utility service territory. The Census Bureau will make available 1997 data throughout the years 1999 and 2000. Statistics are usually updated every five years.
From the standpoint of electric utility marketing programs, the key category of hospitals is control, i.e., public or private control. Although the AHA divides hospitals into public and private categories, these can be further subdivided to provide a better 3-3 Healthcare Facilities understanding of the market. The three major categories of private hospitals are for- profit, Catholic not-for-profit, and other not-for-profit. Public hospitals include Veterans Administration hospitals and municipal hospitals.
Almost all for-profit hospitals and many not-for-profit hospitals are part of a multi- hospital system under a single corporate owner. These are described and listed in the following paragraphs. In addition to being affiliated under a common corporate ownership, hospitals also participate in alliances which, according to a definition by the American Hospital Association, work “on behalf of individual members in provision of services and products and in the promotion of activities and ventures.” Alliances are described in “Hospital Finances and Related Issues” section. Hospital and other health sector trade associations and professional groups are described in the “Trade and Professional Organizations” section.
Private Hospitals
For-Profit
In 1997 there were 797 for-profit hospitals in the country, providing approximately 115,000 beds with 3,953,000 admissions and 40,919,000 outpatient visits. Almost all of the hospitals were organized into multi-hospital systems, of which there were 39. In 1999 the number of multi-hospital systems has grown to 288. The largest for-profit hospital management system is Columbia Healthcare, which merged with HCA in February 1994. The system has grown dramatically, from 22 hospitals in 1992 to 320 hospitals in 1998. Other large for-profit systems include Quorum Health Group/Quorum Health Services, Inc., Tenet Healthcare Corp., and Healthsouth Corp.
Table 3-2 shows the ten largest multihospital health care systems as of 1998. This list includes for-profit and not-for-profit systems.
3-4 Healthcare Facilities
Table 3-2 Leading Multihospital Health Care Systems - 1998
# of Beds # of Hospitals
Columbia/HCA Healthcare Corp. 55,617 320
Department of Veterans Affairs 53,315 144
Quorum Health Group/Quorum Health 28,095 259 Resources, Inc.
Tenet Healthcare Corp. 24,915 129
Catholic Health Initiatives 11,484 62
Daughters of Charity National Health System 10,049 34
Magellan Health Services 5,887 66
Healthsouth Corp. 5,787 73
Universal Health Services, Inc. 5,646 37
Brim 3,438 49
(Source: The AHA Guide to the Health Care Field, 1998-1999 edition.)
Catholic
Most Catholic hospitals are owned and governed by a religious congregation, providing more limited policy discretion to a governing board of trustees. A major difference between Catholic and other not-for-profit hospitals is that Catholic institutions must obtain diocesan approval for major organizational changes such as mergers and acquisitions. Ordinary corporate or policy changes are handled as in secular non-profit hospitals. As with other for-profit and not-for-profit hospitals, Catholic healthcare institutions are frequently organized into groups, or, using the common term of the healthcare industry, systems. As of 1998, there are 45 Catholic Church-related multihospital healthcare systems. The largest Catholic management systems are Daughters of Charity National Health System and the Catholic Health Initiatives. Catholic hospitals are also organized into a trade association, namely, Catholic Health Association, which addresses issues of common interest to its members.
Table 3-3 presents the largest Catholic systems.
3-5 Healthcare Facilities
Table 3-3 Largest Catholic Multihospital Health Care Systems - 1998
# of Beds # of Hospitals
Catholic Health Initiatives 11,484 62
Daughters of Charity National Health System 10,049 34
Catholic Healthcare West 7,412 35
Catholic Health East 5,980 18
Sisters of Mercy Health System - St. Louis 5,313 22
Marian Health System 4,692 15
Mercy Health Services 4,550 31
Sisters of Providence Health System 3,518 19
SSM Health Care System 3,499 20
Bon Secours Health System, Inc. 3,292 14
Holy Cross Health System Corp 2,743 11
Sisters of Charity of the Incarnate Word 2,674 11 Healthcare System
Sisters of St. Joseph Health System 2,652 11
Hospital Sisters Health System 2,596 13
Wheaton Franciscan Services, Inc. 2,484 12
Subtotal, 15 Largest Catholic Systems 72,938 328
ALL Other Respondent Catholic Systems 27,942 144
Total, All Respondent Catholic Systems 100,880 472
(Source: The AHA Guide to the Health Care Field, 1998-1999 edition.)
Secular and Other Religious Not-For-Profit
In 1997, of the 5,082 general short-term hospitals (as defined by the AHA), 3,000 are non-government, not-for-profit. Of this total, approximately one quarter are Catholic institutions. The remainder are predominately secular, though some are affiliated with religious denominations such as Seventh Day Adventist, Methodist, Jewish, or Baptist. 3-6 Healthcare Facilities
In these institutions, policy is set by a governing board of directors, either of independent institutions or, more commonly today, of a system of non-profit institutions.
Public Hospitals
Federal Government
The largest operator of public hospitals in the country is the U.S. Department of Veterans Affairs (VA). As Table 3-2 indicates, the VA operates 144 hospitals, with over 53,000 beds. In addition to its acute care hospital services, the VA is one of the nation’s largest provider of long-term care services.
State and Local Government
In this category, local government is by far the largest player. Of the 5,082 general, short-term hospitals in the 1997 AHA census (latest data available as of 1999), 1,260 were classified as local and state government. The largest local government hospital network is New York City Health and Hospital Corporation, although recent news stories indicate that the system is attempting to reorganize and partially privatize due to operating deficits and other problems.
Utilization and Trends
The hospital industry faces a period of uncertainty. The growth of managed care is reducing hospital profits in general and forcing changes in basic operations to reduce costs and increase income. The federal government is poised to make fundamental changes in funding of two programs responsible for a large proportion of hospital income: Medicare and Medicaid. Hospitals are reorganizing, and for-profit systems are increasing their share of the market.
As the demand for inpatient services has fallen, hospitals have closed staffed beds at a steady rate in an attempt to curtail overhead costs. Since 1990, 88,000 staffed community beds have closed, a ten-percent reduction in inpatient capacity. Despite these closures and because of an even faster drop in inpatient days (down 16%), occupancy rates have fallen from 64.5% in 1990 to 59.6% in 1997.
3-7 Healthcare Facilities
0
-0.5
-1
-1.5 Percent -2
-2.5
-3 1990 1991 1992 1993 1994 1995 1996 1997
Calendar Years
SOURCE: American Hospital Association: National Hospital Panel Survey, 1990-97
Figure 3-1 Annual Percent Change in Number of Hospital Beds: Calendar Years 1990-97
Utilization
Despite an upward turn in admissions in 1993, the downward trend continued through 1995, with only a 1% increase from 1993 to 1997, due to systemic changes in the healthcare system, especially the move to managed care. Total admissions in community hospitals declined 13.4% between 1982 and 1993. The decline was 40% in rural hospitals over the same period. The rise of HMOs contributed to this decline because HMOs used alternatives to hospitalization as a way to hold down costs: careful case management, greater use of outpatient care, and greater emphasis on preventative care. HMO hospitalization rates were more than one-third less than the national average. Similarly, Medicare and other third-party payers are requiring that many procedures previously performed in hospitals be conducted in outpatient clinics. Consequently, corresponding to the decline in hospitalization rates has been an increase in outpatient visits to community hospitals, rising 6.1% in 1992 and 6.8% in 1993. From 1993 to 1997, community hospital outpatient visits rose approximately 23%.
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For-Profit Systems
Although industry experts predict that the hospital industry will continue to contract as managed care gathers a greater portion of the healthcare market, for-profit hospital management systems have potential to do well. Standard and Poor’s predicts that for- profit hospital systems will benefit from acquiring non-profit hospitals unable to compete in a healthcare market driven by the need to reduce operating costs. An increasing number of hospitals are associated with national systems, a tendency that is accelerating as competition increases in the healthcare field. Joining in systems offers institutions opportunities to reduce costs though economies of scale as well as to share operational and management expertise. As the number of for-profit systems increase, more hospitals will be explicitly seeking profits to share with the system owners.
In the face of pressure to reduce costs, breadth of services and economies of scale will increase in importance, a situation that large, low-cost systems should be able to exploit more effectively than marginal, individual non-profit hospitals. The most recent Standard and Poor’s forecast predicts that large systems will acquire many marginal not-for-profit hospitals struggling in the current market, and will benefit from alliances with physician groups and other firms involved in outpatient services.
Other Networks
Non-profit hospitals are also seeking new alliances, though most frequently with other non-profit hospitals than with for-profit ventures for fear of losing their tax-exempt status. Non-profit hospitals rely primarily on public and private sector funds for capital projects and need to acquire new medical equipment to help a hospital compete in its market. Non-profit hospitals face other financial problems, including a slippage in credit ratings, which will increase the cost of capital monies.
As with private and other non-profit hospitals, Catholic healthcare systems are undergoing mergers into broader healthcare networks to strengthen religious ties, establish more powerful geographically linked networks, and offer economies of scale to effectively implement managed care plans. Linkage is difficult for some Catholic hospitals because of the physical dispersion of their facilities and the ownership by different religious institutions. More than 80% of Catholic hospitals in the country belong to a health network. Catholic hospitals have facilities in four to twelve states, but none has more than 15% of the total beds in a single state. Because Catholic hospitals are often not the major providers of care in a region, they typically are less profitable, have an older physical plant and equipment, and treat more Medicaid patients. Urban Catholic hospitals could be vulnerable in a more competitive market
3-9 Healthcare Facilities due to these shortcomings as well as to the difficulty of sharing technologies with other institutions. In some urban areas, however, Catholic hospitals are becoming major players because of their positioning in a particular market. Rural Catholic hospitals may be less vulnerable fiscally than their urban siblings since they can be an area’s sole provider of inpatient services.
As the healthcare market responds to increased competition and pressures for reform, there is a trend toward consolidation, resulting in the formation of large networks both of healthcare providers and of payers. The direction of this consolidation is still uncertain but it is likely to have great influence on the market. In particular, strong payer networks, in the form of HMOs or PPOs, will be able to exert even stronger pressure on providers, e.g., hospitals, to offer steep price discounts. Strong provider networks might offer their members the opportunity to build long-term relationships with particular consumers or to move into related areas such as financing.
Other Trends
Although healthcare is in a period of extreme uncertainty, industry experts see several trends emerging:
• Traditional hospital providers will continue to consolidate, and excess bed capacity will be reduced through mergers.
• Outpatient services will continue to grow.
• Hospitals will diversify into affiliations with home health agencies and long-term facilities such as nursing homes.
• The pressure for hospitals to reduce costs will increase.
• Hospitals and physicians will increasingly form integrated healthcare systems.
• HMO growth will continue.
Healthcare is delivered locally, however, and local factors such as demographics, economic conditions, and the management of particular institutions can cause variations from national trends.
Services Offered
Hospitals are the primary facility delivering healthcare services, and as a result hospitals typically offer a variety of services. Table 3-4 lists the most common facilities and services provided by the 5,021 hospitals reporting and the proportion of hospitals
3-10 Healthcare Facilities which offer each type. The most common services offered are general medical surgical for the adult (87.3% of responding hospitals), emergency department (85%), social work services (84.7%), and outpatient surgery (83.6%).
Table 3-4 Facilities and Services Provided by Hospitals: 1997
Hospital Hospital Service With Service % of total Service With Service % of Total Adult Day Care Program 544 10.8% Nutrition Programs 2,849 56.7% Alcohol/Drug Abuse or Dependency 777 15.5% Obstetrics Inpatient Care 3,152 62.8% Inpatient Care Alcohol/Drug Abuse or Dependency 1,199 23.9% Occupational Health Services 2,831 56.4% Outpatient Services Angioplasty 1,047 20.9% Oncology Services 2,710 54% Arthritis Treatment Center 346 6.9% Open Heart Surgery 921 18.3% Assisted Living 211 4.2% Other Special Care 760 15.1% Birthing/LDR/LDRP Room 3,002 59.8% Outpatient Care Center (Freestanding) 1,169 23.3% Breast Cancer Screening 3,554 70.8% Outpatient Care Center Services 3,403 67.8% (Hospital Based) Burn Care 158 3.1% Outpatient Surgery 4,197 83.6% Cardiac Catheterization Laboratory 1,596 31.8% Patient Education Cntr 2,633 52.4% Case Management 2,867 57.1% Patient Representative Services 2,954 58.8%
Children Wellness Program 803 16.0% Physical Rehabilitation Inpatient Care 1,345 26.8% Community Outreach 2,770 55.2% Physical Rehabilitation Outpatient 3,623 72.2% Services Crisis Prevention 822 16.4% Positron Emission Tomography (PET) 190 3.8% CT Scanner 3,770 75.1% Primary Care Dept. 1,644 32.7% Dental Services 1,372 27.3% Psychiatric Child/Adolescent Svs. 1,106 22% Diagnostic Radioisotope Facility 2,793 55.6% Psychiatric Consultation/Liaison 1,717 34.2% Services Emergency Department 4,270 85% Psychiatric Education Svs. 1,368 27.2% Extracorporeal Shock Wave Lithotripter 634 12.6% Psychiatric Emergency Svs. 1,807 36% (ESWL) Fitness Center 1,136 22.6% Psychiatric Geriatric Svs. 1,676 33.4% General Medical Surgical Care: Adult 4,385 87.3% Psychiatric Inpatient Care 1,989 39.6% General Medical Surgical Care: 2,509 50% Psychiatric Outpatient Svs. 1,597 31.8% Pediatric Geriatric Services 2,046 40.7% Psychiatric Partial Hospitalization 1,324 26.4% Program Health Fair 3,290 65.5% Radiation Therapy 1,181 23.5%
Health Information Center 2,010 40% Reproductive Health 925 18.4% Health Screenings 3,342 66.6% Retirement Housing 177 3.5% HIV/AIDS Services 1,772 35.3% Single Photon Emission Computed 1,554 31% Tomography (SPECT) Home Health Services 2,616 52.1% Social Work Svs. 4,255 84.7% Hospice 1,250 24.9% Sports Medicine 1,536 30.6% Intensive Care: Cardiac 1,817 36.2% Support Groups 2,863 57% Intensive Care: Medical Surgical 3,329 66.3% Teen Outreach Svs. 590 11.8% Intensive Care: Neonatal 821 16.4% Transplant Services 447 8.9% Intensive Care: Pediatric 418 8.3% Transportation to Health Facilities 1,392 27.7% Long-Term Care: Intermediate Care 549 10.9% Trauma Center (Certified) 978 19.5% Long-Term Other Long Term Care 792 15.8% Ultrasound 3,963 78.9% Long-Term Care Skilled Nursing Care 2,096 41.7% Urgent Care Center 1,554 23% Magnetic Resonance Imaging (MRI) 2,114 42.1% Volunteer Svs. Dept 3,919 78.1% Meals on Wheels 752 15% Women’s Health Services 1,883 37.5% Neonatal Intermediate Care 645 12.8% (Source: American Hospital Association. Hospital Statistics, 1999 edition.)
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Hospitals are conducting an increasing proportion of their services on an outpatient basis as a way to reduce cost. This trend is generally attributed to the increase in managed care and the accompanying pressure to lower costs. The AHA reports that from 1993 to 1997 outpatient visits to community hospitals increased by 23%, and outpatient surgeries to community hospitals increased by 16%. The number of these outpatient surgery facilities affiliated with hospitals has grown steadily in recent years. Many of these outpatient procedures are carried out in freestanding facilities and mobile care units.
In addition to outpatient services, subacute care is another area which has grown steadily in the past decade. Subacute care facilities serve persons who no longer need inpatient hospital care but who are not well enough to go home. These facilities cost much less than hospitals to operate. This area is discussed below in the section on nursing facilities.
Organizational Structure
Hospitals in the United States are organized hierarchically in a traditional pyramid arrangement, with authority flowing down through levels of supervisors in a system of command similar to the military. Undergirding this organizational structure is a strong system of rules and regulations addressing health, environment, and safety issues, as well as patient welfare. Organizational structures vary widely among hospitals and generalizations are difficult. To give a general look at hospital organizations, the present discussion uses the common structure of an independent not-for-profit community hospital. The internal organization of for-profit and government hospitals are similar.
In not-for-profit hospitals and other healthcare organizations, the top of the organizational pyramid is the governing body which is usually the board of trustees. In a hospital operating as a single, independent unit, the board has enormous power and responsibility, because the board’s primary mission is the oversight of a single institution. In organizations comprising several hospitals (as well as other institutions or organizations, in some cases), the board is necessarily less involved with each hospital. In some not-for-profit hospitals and systems, particularly those operated by Catholic orders or other religious organizations, significant decisions such as major capital expenditures, are often made by the sponsoring organization rather than the board of directors.
The board sets overall policy and has ultimate fiscal responsibility. It carries out these functions through its own committees such as finance, operations, and so on. The board is not involved in day-to-day operations of the hospital but instead delegates those duties to a chief executive officer. Until the mid-80s the position of chief executive officer, especially in not-for-profit hospitals, was often called the Administrator. More recently, though, there has been a move toward corporate titles such as President or 3-12 Healthcare Facilities
CEO, though government hospitals still use the title Administrator. This report will use the more general term, CEO.
In for-profit hospitals and healthcare organizations, the policy setting function is carried out by corporate officials and ultimately the corporate board of directors. In government institutions like Veterans Administration hospitals, the policy function is set by legislation and regulations and overseen by national and regional administrators.
The CEO usually directs the organization through the senior level managers (vice presidents), each responsible for a single department or function. These functions include (but are not necessarily limited to) business or fiscal services, nursing services, ancillary medical services, and support services.
In addition to overseeing the CEO, the board maintains a formal relationship with the medical staff. The Board, the administration, and the medical staff are the three pillars of power in a hospital. The board sets policy and has overall responsibility for the institution. The administration carries out that policy and creates the environment in which care of patients can occur. The medical staff supervise the delivery of the medical services and along with the patients are the primary users of the hospital. Hospitals are complex organizations because of the dynamic relationship between these three groups. The doctors’ actions on patients in a hospital (and even on recommending that patients use a particular hospital) affect the operation and management of that hospital. The administration of a hospital affects the quality of care patients receive and the type of medical services available to them. Recognizing this interdependence, hospital boards often include physicians as members.
Within a hospital organization, there are several functions of importance to electric utilities: Plant Engineering, Safety and Environmental Services (including Occupational Safety and Health, Waste Management, Central Supply, and Sanitation), Administration, and Medical Staff and Nursing Services.
Plant Engineering
The Plant Engineering Department (sometimes called Facilities Engineering or Central Facilities) is responsible for providing HVAC (heating, ventilation, and air conditioning), power and light, and facility maintenance. To carry out these responsibilities, Plant Engineering (1) operates and maintains the boiler facilities that burn natural gas to generate steam and hot water, (2) operates and maintains the central plant chillers that use electricity to provide space cooling, and (3) maintains the electrical distribution system within the hospital.
In addition to these traditional physical plant functions, Plant Engineering often is responsible for maintenance of biomedical electronic equipment and for operations of telecommunications equipment. (As an example of the need for this last function, 3-13 Healthcare Facilities
Voluntary Hospitals of America, the largest alliance of hospitals in the nation, has a satellite communications system which is used for educational programs and management functions, and is available for lease by outside groups.) Often the director of plant engineering is called the hospital engineer or facilities engineer.
Plant Engineering is important to electric utilities because it is the hospital department that is directly responsible for electricity supply and usage. Moreover, Plant Engineering is concerned with issues related to electricity, such as power quality, energy conservation, etc.
Administration
The senior level manager (vice president) in charge of support services (which include plant engineering and environmental services) is an important person in a hospital’s decision-making structure from an electric utility viewpoint. The hospital CEO has approval authority for capital projects up to a specific level, commonly $1 million; amounts above that would require approval from the board or system leadership.
In some cases utility representatives might maintain regular contact with a hospital’s administration, say for large scale projects, like thermal energy storage. More commonly, however, the utility representatives work directly with the hospital engineers in developing programs and come to the administration for approval of large projects or to discuss issues such as rates or emission compliance.
In considering the decision-making structure of a healthcare institution, it is important to understand that typically as the approval authority goes up, the level of technical expertise and appreciation goes down. Consequently, the type of information that must be provided by a utility for a particular project must be carefully tailored to the audience and the decision-making process of an institution. Hospital engineers need to understand the financial models required to convince a senior manager of the value of a prospective investment.
The management environment is changing in hospitals as they respond to the evolving healthcare market. Reducing cost and improving quality are important themes among hospital administrators, as many are emphasizing management techniques such as Continuous Quality Improvement, Performance Improvement, and FOCUS/PDCA (Find a process to improve, Organize, Clarify, Understand, Select/Plan, Do, Check, Act).
Safety and Environmental Services
These functions include environmental regulatory compliance, emergency response planning, material safety data sheets, worker right-to-know programs, risk
3-14 Healthcare Facilities management plans, occupational safety and health issues, low-level radioactive waste issues, and hazardous waste minimization and recycling programs. Another major responsibility is treatment, disposal, and tracking of medical waste. The name and location of these functions varies with the organization. In some hospitals these functions fall under the Safety and Environmental Services Departments, while in others it is the Office of the Safety Coordinator, the Staff Industrial Hygienist, or Environmental Officer. Safety officers are also likely to be in quality assurance and external compliance areas. Often hospitals designate a vice president responsible for all standards, including quality and safety. Another important department under this category is Central Services (Central Supply or Sterile Supply). This department is responsible for collecting and receiving patient-care items, equipment, and packages; the central services department also stores, processes, maintains, and dispenses these items to all parts of a hospital, and is in charge of sterilization of medical instruments.
Medical Staff and Nursing Services
As the people who actually deliver healthcare, these two groups would be involved in many utility programs relating to hospitals. They have enormous influence on hospital policies and procedures and could be involved in decisions relating to utility-hospital programs. For example, the infection control nurse, chief respiratory therapist, or in- house tuberculosis specialist are key allies when dealing with the issue of airborne nosocomial (hospitalization acquired) diseases and indoor air quality. Acceptance by the medical staff and nursing services of a new medical waste treatment system could go a long way in convincing the administration to invest in a new technology. The medical and nursing staff are often the first to encounter the effects of a power quality problem.
Hospital Finances and Related Issues
Traditionally hospitals have been reimbursed by payers, such as insurance companies or the federal government, separately for each service provided to a specific patient. This method is called a fee-for-service plan. In contrast, many HMOs and other managed care providers are moving toward capitated plans in which they compensate hospitals on a pre-negotiated fixed rate per capita each month, based on the number of members in the plan. Hospitals relying on capitated business have their annual revenues fixed by the number of subscribers in their managed care customer base and can operate profitably only when their operating costs fall below the revenue ceiling. This provides a strong incentive for hospitals to hold down costs and eliminate unnecessary inpatient services. In conventional fee-for-service plans the reimbursement method rewards hospitals and physicians for providing services and procedures to patients. Furthermore, a glut of hospital beds combined with cost controls and discounts demanded by managed care payers have reduced hospital profit margins and hurt their creditworthiness.
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In 1997 nearly all hospital expenditures were funded by third parties. Medicare and Medicaid funded nearly half of all hospital expenditures, while private health insurance paid for another third. Consumers directly paid for only three percent of all hospital services. Medicare spending for hospital services grew more than twice as fast (6.4%) as overall hospital spending (2.9%) in 1997 and 60% faster than overall hospital spending throughout the 1990s. Medicaid spending for hospital services dropped in 1997 (off 2.7%) probably as a result of growing managed care enrollment, the decline in Medicaid recipients and restrictions placed on states’ disproportionate share payments to hospitals.
Networks, Health Care Systems, Alliances
In the complex arena of American healthcare delivery, hospitals are not independent, stand-alone institutions. Many are part of a larger structure under a single corporate owner. (These multi-hospital systems are described earlier in this chapter.) Others are joining with payers such as insurance companies or even large employers in managed care associations, and some are even establishing their own HMOs. (These payer- provider arrangements are discussed later in this chapter under the section “Role of Healthcare Payors in the Market.”) Hospitals also participate in local and national trade associations such as the American Hospital Association or the Catholic Health Association. In addition, their managers and specialists participate in professional groups. Both of these organizations are discussed in the “Trade and Professional Organizations” section.
The AHA Guide to the Healthcare Field provides the following descriptions:
Networks
A network is a group of hospitals, physicians, other providers, insurers, and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Networks are very fluid in their composition as goals evolve and partners change.
Health Care Systems
To reflect the diversity that exists among health care organizations, the term health care system identifies both multihospital and diversified single hospital systems.
Multihospital Systems—is two or more hospitals owned, leased, sponsored, or contract managed by a central organization.
Single Hospital Systems—single, freestanding member hospitals may be categorized as health care systems by bringing into membership three or more, and at least 25 percent, of their owned or leased non-hospital organizations. Organizations provide, or
3-16 Healthcare Facilities provide and finance, diagnostic, therapeutic, and/or consultative patient or client services that normally precede or follow acute, inpatient, hospitalization; or that serve to prevent or substitute for such hospitalization.
Alliances
An alliance is a formal organization, usually owned by shareholders/members, that works on behalf of its individual members in the provision of services and products and in the promotion of activities and ventures. The organization functions under a set of bylaws or other written rules to which each member agrees to abide.
Alliance hospitals form with each other to improve operations by sharing of information and services, group purchasing, public relations, and joint ventures. In 1999 the AHA Guide lists thirty alliances with memberships ranging from one to over 1500.
Refer to the AHA Guide for a complete listing of each category.
These networks, health care systems, and alliances are important for electric utilities to contact. The American Hospital Association maintains lists of hospital groups (along with contact information) which it publishes annually in the AHA Guide to the Healthcare Field, an indispensable source of information for any organization, including electric utilities, interested in better understanding the hospital industry.
Nursing Homes
As the population ages, an increasing percentage is made up of elderly people, many of whom are in need of nursing care, either at home or in a facility. This section looks at nursing facilities, one of the largest components of the healthcare facilities market.
According to the American Healthcare Association (AHCA), one of the primary trade groups for for-profit long-term care organizations (along with the American Association of Homes and Services for the Aging), in 1997 there were 17,176 Medicare and/or Medicaid certified nursing facilities, with 1.8 million beds and 1.5 million residents. The typical nursing facility resident is a white female Medicaid beneficiary aged 75 years or older. It is estimated that the nursing facility population aged 65 or older will grow to 5.5 million or nearly 7% of the population aged 65 and over by 2050 (Nursing Facility Sourcebook, 1998). The average nursing facility patient needs help with activities of daily living such as eating, moving from place to place, going to the toilet, dressing, and bathing. Nearly two thirds of nursing facility residents are disoriented or have memory impairment.
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Role in the Health Delivery System
Nursing homes are primarily establishments engaged in providing inpatient nursing and health-related personal care. They do not provide diagnostic, surgical, or extensive medical services as hospitals do. Their role in the healthcare delivery system is between that of hospitals and home healthcare. The system is changing, though, as are the traditional roles of the system’s institutions.
Nursing homes fall into five broad categories:
• Skilled nursing facilities (both hospital and non-hospital based)
• Intermediate care facilities
• Custodial care facilities
• Subacute care facilities
• Continuing care retirement communities
Skilled nursing facilities, according to the Standard Industrial Classification system definition, provide inpatient and rehabilitative service to patients requiring continuous healthcare, but not hospital services. Care is ordered by and under direction of physicians, and staff includes licensed nurses continuously on duty. Skilled nursing facilities are the most common type of nursing home.
Intermediate care facilities also provide continuous nursing and rehabilitative services but not on a continuous basis. Personnel are on duty continuously but licensed nurses are required only part of each day. The line between skilled and intermediate nursing facilities is sometimes blurred, and various organizations account for the categories differently.
Custodial care facilities provide nursing and health-related care to patients who do not require the degree of care and treatment of a skilled or intermediate care facility. Examples of custodial care facilities include convalescent homes with healthcare and homes for the mentally retarded, with healthcare.
Subacute care facilities, according to a definition developed by the AHCA and the Joint Commission on Accreditation of Healthcare Organizations, provide care which is generally more intensive than care from a traditional nursing facility, but less than the acute care provided by a hospital. Subacute care is comprehensive inpatient care designed for patients with an acute illness, injury, or exacerbation of a disease process. It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific, active, complex medical conditions. Generally, subacute patients need between four and seven hours of skilled nursing care 3-18 Healthcare Facilities each day, compared with eight or nine hours for hospital patients. Subacute care facilities charge less than acute care hospitals for similar care and services. As a result, some managed care organizations are moving hospital patients to subacute care facilities before discharge.
Continuing Care Retirement Communities (CCRCs) compose a rapidly growing area providing care for more than 270,000 residents who are still ambulatory, according to the U.S. Department of Commerce. CCRCs provide housing and healthcare in a campus-style setting with convenient services such as housekeeping and meals. The levels of care range from assisted living to skilled nursing. Additional healthcare services include emergency response, health clinics, wellness programs, hospice, primary and specialty physician care, dental care, pharmacy, and physical therapy. These facilities are often very expensive and not covered by Medicare.
Structure of the Industry
There are over 17,000 certified and uncertified nursing homes in the United States. The number of nursing homes may vary, the specific number depending on the definition the organization doing the counting uses for “nursing home.” Some discrepancies may be found between government data and trade associations. Both sources offer information that is useful in understanding the market.
In 1997, nursing facility ownership was approximately 65% for-profit, 29% nonprofit and approximately 6% government owned and operated. Fifty-three percent of facilities were owned and operated by a national multifacility chain and 47% were independently owned or operated. In 1997, 14% of the facilities also were owned or operated by a hospital organization. (Nursing Facility Sourcebook, 1998)
The industry primarily comprises several dozen public and private systems. The top ten, ranked by number of beds, is shown in Table 3-5. The two largest systems are Beverly Enterprises and Vencor.
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Table 3-5 Top Ten Nursing Facility Systems
Revenue Sources: % Revenue From: Total Beds Beds Other Other Living Public/ SNF/NF Private/ Company Name/ Address/ SNF/NF Therapy Revenue Assisted Nonprofit Subacute Subacute % VA and % VA Operating subacute) Pharmacy (including Home Care Home States with % Medicaid % Medicare CEO Telephone % Occ. Rate Total SNF/ NF % Private Pay Total Facilities Total
Beverly Enterprises 5111 Rogers Ave. Pub. 64,124 n/a 574 89 31 29 26 45 n/a $3.3 58 13 n/a 13 16 n/a n/a David R. Banks Suite 40-A billion Fort Smith, AZ 72919 (501) 452-6712
Vencor 400 W. Market St. Pub. 40,869 4,825 311 92 33 30 23 44 3 $2.8 80 <1 n/a 4 6 1 9 W. Bruce Lunsford 3300 Providian Ctr. billion Louisville, KY 40202 (502) 596-7300
Paragon Health 1 Ravinia Dr., Suite 1500 Network1 Atlanta, GA 30346 Keith Pitts (770) 393-0199
Living Centers of America Pub. 22,902 n/a 196 83 13 26 34 40 n/a $1.1 66 n/a n/a 17 16 n/a 1 Houston, TX billion
GranCare, Atlanta 15,195 n/a 126 87 15 42 13 26 19 $924.4 73 3 <1 0 17 3 4 Merger Total 38,097 million
Genesis Health 148 W. State St. Pub. 21,642 757 155 91 12 24 39 37 n/a $1 60 3 <1 9 26 1 1 Ventures2 Kennett Square, PA 19348 billion Michael R. Walker (610) 444-6350
The Multicare Companies 16,058 n/a 154 92 11 25 42 33 0 $628.3 60 10 n/a 17 11 n/a 2 Hackensack, NJ million Merger Total: 37,700
Sun Healthcare 101 Sun Lane NE Pub. 22,004 3,323 183 91 21 24 38 28 10 $1.5 36 24 <1 16 5 0 19 Group3 Albuquerque, NM 87109 billion Andrew L. Turner (505) 821-3355
Regency Health Services 11,148 1,108 106 90 5 32 33 35 n/a $612 44 27 0 11 4 6 8 Tustin, CA million Merger Total: 33,152
Integrated Health 10065 Red Run Blvd. Pub. 21,625 3,700 172 94 30 49 34 17 0 $1.7 19 19 0 11 0 33 18 Services4 Owings Mills, MD 21117 billion Robert H. Elkins (410) 998-8428
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Revenue Sources: % Revenue From: Total Beds Beds Other Other Living Public/ SNF/NF Private/ Company Name/ Address/ SNF/NF Therapy Revenue Assisted Nonprofit Subacute Subacute % VA and % VA Operating subacute) Pharmacy (including Home Care Home States with % Medicaid % Medicare CEO Telephone % Occ. Rate Total SNF/ NF % Private Pay Total Facilities Total
Community Care of America Pub. 4,592 0 54n/a9 2230480$131.6 n/a n/a n/a n/a n/a n/a n/a Naples, FL million Merger Total: 26,217
Life Care Centers 3570 Keith St., NW Priv. 25,319 6,368 190 87 28 29 32 39 0 $1 63 29 2 0 1 0 5 of America Cleveland, TN 37312 billion Forrest L. Preston (423) 472-9585
ManorCare Health 11555 Damestown Rd. Pub. 24,335 6,665 177 n/a 28 18 57 25 n/a $1.5 50 23 4 0 15 8 0 Services Gaithersburg, MD 20878-3200 billion Stewart Bainum, Jr. (301) 979-3000
Extendicare Health 105 W. Michigan St. Pub. 17,269 2,407 161 89 13 31 31 37 1 $857 86 n/a 2 1 7 2 2 Services5 Milwaukee, WI 53203 million Joy Calkin (414) 278-7799
Arbor Health Care Co. 3,580 1,193 30 90 5 33 35 31 1 $233.5 35 52 2 1 10 0 0 Lima, OH million Merger Total: 20,849
The Evangelical 4800 W. 57th St. NP 17,645 n/a 208 91 26 14 38 48 0 $632 89 n/a 2 0 0 1 8 Lutheran Good P.O. Box 5038 million Samaritan Society Sioux Falls, SD 57117-5038 Charles Balcer (605) 362-3100
(Source: Provider Magazine, January 1998. C. Fisher, p. 41-46.) n/a Not Available. All information provided by participating companies.
1New company formed in November with the merger of Living Centers of America, Houston, and GranCare, Atlanta.
2Genesis acquired The Multicare Companies, Hackensack, N.J., in October.
3Sun acquired Regency Health Services, Tustin, Calif., in October. It also has a merger pending with Retirement Care Associates, Atlanta. Revenues include international operations.
4IHS acquired Community Care of America, Naples, Fla., in September. It also expects to acquire before year end Horizon/CMS Healthcare’s long term care operations.
5Subsidiary of Extendicare, a public company in Markham, Ontario, Canada. The numbers reflect the company’s U.S. operations only. In November, the company acquired Arbor Health Care Co., Lima, Ohio.
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Utilization and Trends
Although hospitals are in a difficult market position, the nursing home sector is doing well. As Table 2-4 shows, according to the Health Care Financing Administration, the annual increase in nursing home expenditures has exceeded that of hospitals in recent years, a trend that is expected to continue. HCFA forecasts national expenditures for nursing home care to reach more than eight percent per year over the next decade.
A major contributor to this trend is the increase in the number of older Americans. The proportion of the population over 65 is expected to more than double in the next 25 years. This will increase the need for nursing home beds. Also, nursing homes companies are expanding into areas such as rehabilitative care and subacute care formerly carried out by hospitals. These areas generate higher revenues, often several times the amount earned on a regular nursing bed.
Funding for nursing homes is expected to change somewhat in the next decade. According to the HCFA forecasts, government share of nursing home revenues is expected to drop from 64% of the total in 1994 to 56% in 2005. This is shown in Table 3-6
Table 3-6 Nursing Home Expenditures by Source of Funds, 1993-2005
1993 1994 1995 2000 2005 Type of Expenditure Amounts in Billions of Dollars Private Expenditures 26.0 26.6 29.3 48.9 77.4 Consumer Expenditures 24.7 25.2 27.7 45.9 72.8 Out of Pocket 23.0 23.4 25.7 42.3 66.7 Private Insurance 1.7 1.8 2.0 3.6 6.1 Other Private Expenditures 1.3 1.4 1.6 2.9 4.6
Government Expenditures 43.6 47.6 50.9 72.3 102.1 Federal Funds 28.3 31.4 33.9 48.7 68.9 State and Local Funds 15.3 16.3 17.0 23.6 33.3
Total Public and Private 69.6 74.2 80.2 121.2 179.6
Medicare (Subset of Federal Funds) 6.1 7.9 9.5 14.0 18.9 Medicaid (Subset of Federal Funds, & State 36.0 38.3 39.9 55.7 79.1 & Local Funds)
(Source: Health Care Financing Administration)
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Subacute Care
Another important trend with respect to nursing homes is the recent and rapid growth in the number of subacute care facilities. Within the past five years, nursing facilities have opened subacute care units to accommodate patients who need extended skilled medical or rehabilitation care, but not at the technical or cost level of a hospital. There are more than 700 providers of subacute care with a total of approximately 27,000 patient beds, accounting for more than 8 million patient-days and $3.4 billion in revenues per year. About three-fourths of funding for subacute care comes from Medicare.
Subacute care has grown in importance since implementation of the prospective payer system in hospitals. Also contributing to the rise in these facilities is an increase in complexity of nursing home care due to changes in medical technologies and treatment for certain medical conditions. Subacute care represents care between that traditionally offered by a hospital and that by a nursing home. As a result, both nursing facility systems and hospitals are entering into the subacute care field. Table 3-7 lists the top ten largest subacute care providers.
One industry consultant forecasts in the October 1995 issue of Healthcare Strategic Management that the subacute care market will grow substantially in the next five years, with utilization increasing two-fold and revenues nearly three-fold. This trend is expected to offer a new market for skilled nursing facilities, strengthening that area of the healthcare sector. The entry of hospitals into this market could create significant competition for nursing facilities.
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Table 3-7 Top Ten Subacute Care Providers
Name/ Chief Executive Public/ Address/ Officer Private Telephone Total Subacute Beds Total Facilities With Beds Subacute States in Which Subacute Facilities Operate Occupancy % Subacute Rate Patient Subacute Annual Days Subacute Days as % of Days Inpatient Revenue Operating Total % Revenue From Subacute Services Revenue Subacute Average per Day
ManorCare Health Pub. 11555 Damestown Rd. 6665 171 28 n/a 1.2 16 $1.5 23 $288 Services Gaithersburg, MD 20878-3200 million billion Stewart Bainum, Jr. (301) 979-3000
Life Care Centers of Priv. 3570 Keith St., NW 6368 192 28 76 869,086 12 $1 29 $330 America Cleveland, TN 37312 billion Forrest L. Preston (423) 472-9585
ServiceMaster Pub. 3839 Forest Hill-Irene Road 5082 167 27 n/a n/a n/a n/a n/a n/a Diversified Health Memphis, TN 38125 Services (901) 624-1600 Steve Martin
Vencor Pub. 400 W. Market Street 4825 138 30 n/a 1.7 19 $2.8 n/a n/a W. Bruce Lunsford 3300 Providian Center million billion Louisville, KY 40202 (502) 596-7300
Integrated Health Pub. 10065 Red Run Blvd. 3700 84 26 80 n/a n/a $1.7 19 $352 Services Owings Mills, MD 21117 billion Robert N. Elkins (410) 998-8428
Sun Healthcare Group Pub. 101 Sun Lane, NE 3323481287 1.1 16 $1.5 24 $412 Andrew L. Turner Albuquerque, NM 87109 million billion (505) 821-3355
Summit Care Corp. Pub. 2600 W. Magnolia Blvd. 2415 38 n/a n/a n/a n/a $198 n/a n/a William C. Scott Burbank, CA 91505 million (818) 841-8750
Extendicare Health Pub. 105 W. Michigan St. 2407 81 13 n/a n/a n/a $857 n/a n/a Services Milwaukee, WI 53203 million Joy Calkin (414) 278-7799
Mariner Health Group Pub. 125 Eugene O’Neill Dr. 1,691 83 18 n/a 538,194 26 $659 19 $396 Arthur W. Stratton Jr. New London, CT 06320 million (860) 701-2000
Arbor Health Care Co.1 Pub. 1100 Shawnee Rd. 1,193 29 4 82 342,381 31 $233.5 52 $355 Pier C. Borra Lima, OH 45805 million (419) 227-3000
(Source: Provider Magazine, January 1998. Published by American Healthcare Association) n/a Not Available 1Acquired in November by Extendicare Health Services, Milwaukee. All information provided by participating companies. The American Health Care Association defines subacute care as comprehensive inpatient care designed for patients with an acute illness, injury, or exacerbation of a disease process. It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization. Generally, subacute patients need between four and seven hours of skilled nursing care each day—compared with eight or none hours for hospital patients.
From the standpoint of electric utilities, subacute care facilities will operate and have needs similar to that of skilled nursing facilities. The management orientation of each
3-24 Healthcare Facilities subacute care facility will reflect that of the type of organization operating it: nursing facility system or hospital system.
Medical and Dental Offices, Freestanding Clinics, and Other Healthcare Institutions
Medical and dental offices and clinics are by far the most common points of contact between the healthcare sector and the public. According to the 1992 Census, there were 200,000 offices and clinics of doctors of medicine, more than 100,000 offices and clinics of dentists, and approximately 75,000 other health care offices and clinics.
The last category includes chiropractors, optometrists, podiatrists, as well as other healthcare practitioners such as acupuncturists. Together these offices and clinics comprised 85% of all healthcare establishments in the country and account for more than a third of the gross receipts of the industry.
Free standing clinics play an increasing role in healthcare delivery in this country. Acute care clinics, for example, are carrying out functions which until recently were in the purview of hospitals. Also, rural health clinics are the main source of medical care in some parts of the country.
Other institutions and groups providing healthcare services include home health agencies, biomedical laboratories, blood banks, hospices, physician and dentist offices, and pharmacies. Although the fraction of healthcare expenditures going to them is quite small, these institutions can be important in the healthcare network in their areas. For example, as managed care organizations focus increasingly on reducing costs, more patients are treated at home instead of in hospitals and nursing homes. Consequently, home health agencies represent the fastest growing portion of this sector.
Preliminary data from the 1997 Economic Census, U.S. Census Bureau, which is first being reported in the latter part of 1999, shows that the number of ambulatory health care services establishments totals 454,853. (See page 1-3 for a list of ambulatory health care services.)
Related, Non-Healthcare Institutions
Two other types of establishments are addressed in this report: mortuaries and veterinary clinics. They are covered in this study primarily because they have several issues or problems in common with the healthcare sector, the most important of which is disposal or treatment of biohazardous and chemical wastes. Also the issues of device sterilization and infection control are a connection to the healthcare industry.
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As utility customers, both groups of establishments represent a small electrical load. According to the 1992 Census of Service Industries, there were 15,547 funeral service and mortuary establishments in the country, employing about 88,000 persons. The American Veterinary Medical Association estimates in 1995 there were approximately 40,000 veterinarians in the country and 19,272 veterinary practices.
Role of Healthcare Payers in the Market
Most of the previous discussion in this report has focused on healthcare providers, those organizations that deliver healthcare services—and use healthcare facilities. This section addresses the other side of the healthcare equation, the payer, in particular the private sector payers: insurance companies, employers, and managed care organizations. This is a rapidly changing market as managed care becomes increasingly common. The focus will be on the nature of the payer group and how they influence the healthcare facilities market.
In response to rising healthcare costs, payers are increasingly turning to managed care plans. Managed care plans coordinate healthcare delivery through general primary care physicians who act as “gate-keepers” in deciding what care a patient receives and where. Managed care plans also control costs by contracting with healthcare delivery organizations such as physician networks or hospitals to provide care for a fixed sum or set fee schedule. Managed care plans are in contrast with the traditional “fee-for- service” system in which patients see any doctor and visit any hospital they choose; upon receiving care, the patients pay a deductible and perhaps a co-payment, and the insurer pays the remainder. The goal of managed care plans is to provide a high standard of healthcare while closely controlling costs.
There are several types of managed care plans:
• Health maintenance organizations (HMOs) are prepaid healthcare delivery enterprises that cover preventative services as well as illnesses.
• Independent practice associations (IPAs) are HMOs which contract with networks of independent physicians who are paid a fixed annual fee or a per-visit fee for each member of the IPA. IPA members are covered only when using HMO doctors and designated hospitals.
• Preferred provider organizations (PPOs) are a hybrid HMO in which members can either choose from a roster of physicians who provide care according to a set fee schedule, or choose out of plan doctors for a higher co-payment.
• Staff or group HMOs are traditional HMOs with salaried staff physicians who serve only plan members. Members, in turn, are covered only when they use the HMO physicians or hospitals.
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It should be noted that the shift towards managed care is not without some controversy. While many managed care plans are bringing medical costs down and creating innovative approaches to preventive medicine, some plans have been criticized for excluding expensive but vital medical treatments or denying healthcare in general to persons with complex or expensive-to-treat conditions in order to cut costs. (See, for example, Time Magazine, January 22, 1996.) Others relate this issue to potential problems in development and future financing of leading-edge research and advanced technology which entail high initial costs. Another issue is the large differences in the quality of services provided by managed care plans. Recently, the National Committee for Quality Assurance (P.O. Box 533, Annapolis Junction, MD 20701-0533; 800-839-6487) conducted the first comprehensive analysis of more than 200 managed care plans and assessed them using standardized performance measures. (For a list of HMOs by state along with rating scores, see U.S. News and World Report, October 5, 1998.)
Table 3-8 lists the 25 largest HMO companies, and Table 3-9, the 30 largest PPO plans by number of states served.
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Table 3-8 The Nation’s 25 Largest Individual HMO Plans
1996 Age Model Date Fed. Tax Plan Enrollment (Years) Type Qualified Statum Kaiser Foundation Health Plan1 / Oakland, CA 2,528,603 52 Group 10/77 NFP Kaiser Foundation Health Plan2 / Pasadena, CA 2,447,843 52 Group 10/77 NFP PacifiCare of California / Cypress, CA 1,417,239 19 Network 12/78 FP Health Net / Woodland Hills, CA 1,260,657 18 Group 2/79 FP Keystone Blue3 / Pittsburgh, PA 1,148,926 11 IPA 8/87 FP Oxford Health Plans-New York / New York, NY 1,142,800 11 IPA NFQ FP Harvard Community Health Plan / Dedham, MA 1,078,000 28 Staff 9/77 NFP California Care4 / Woodland Hills, CA 939,655 11 Group NFQ FP PacifiCare/FHP Health Plan-Calif. / Cerritos, CA 927,600 36 IPA 7/77 FP HMO Blue – Boston / Boston, MA 876,845 15 Network NFQ NFP HIP of Greater New York / New York, NY 817,828 50 Group NFQ NFP U.S. Healthcare-Southeastern PA / Blue Bell, PA 788,038 21 IPA 6/77 FP Medica Choice / Minneapolis, MN 754,765 22 IPA NFQ NFP Foundation Health-CA / Rancho Cordova, CA 740,434 20 Group 12/77 FP HealthPartners / Minneapolis, MN 702,034 5 Group 3/84 NFP Group Health Coop. of Puget Sound / Seattle, WA 681,406 50 Staff NFQ NFP U.S. Healthcare-New Jersey / Fairfield, NJ 680,397 12 IPA 3/83 FP Keystone Health Plan East / Philadelphia, PA 657,798 10 IPA 8/88 FP U.S. Healthcare-New York / Uniondale, NY 657,192 11 IPA 3/86 FP Tufts Associated Health Plans / Waltham, MA 625,877 16 IPA 12/82 NFP Health Options / Jacksonville, FL 599,108 12 IPA 1/85 FP NYLCare Health Plan-Mid-Atlantic / Greenbelt, MD 587,140 19 IPA 9/84 FP Humana Medical Plan-Florida / Miramar, FL 564,874 24 IPA 1/80 FP Kaiser Foundation Health Plan6 / Rockville, MD 559,143 25 Group 5/76 NFP HMO Illinois / Chicago, IL 552,000 20 Group NFQ NFP
Total 23,736,202 (Source: Hoechst Marion Roussel. Managed Care Digest Series, 1997) 1 Kaiser Foundation Health Plan/Northern California Region 2 Kaiser Foundation Health Plan/ Southern California Region 3 Keystone Blue changed its name from Keystone Health Plan/West 4 CaliforniaCare was previously listed as California Care/Blue Cross 5 PacifiCare/FHP Health Plan-California is the result of a merger between PacifiCare Health Systems and FHP International 6 Kaiser Foundation Health Plan/Mid-Atlantic Region
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Table 3-9 Top 30 PPOs by Number of States Served
# of States Total # of Total # of Served* Owned Rented Company Name/Headquarters Networks Networks The Araz Group / Bloomington, MN 51 5 16 National Preferred Provider Network / Middletown, NY 51 3 32 Vision Service Plan / Sacramento, CA** 51 3 0 Acorn Behavioral Healthcare Mgmt. / Narberth, PA** 51 1 0 CNA Managed Care PPO / Chicago, IL 51 1 0 ConserviCare / San Diego, CA 51 1 13 Davis Vision / Plainview, NY** 51 1 0 Eye Care Plan of America / Phoenix, AZ** 51 1 0 Spectrum Vision Systems / Overland Park, KS** 51 1 0 Managed Care Consultants / Las Vegas, NV 50 4 3 CorpHealth (MH, Alc., Drug) / Fort Worth, TX** 50 1 0 IntegraHome / Cincinnati, OH** 50 1 0 Select Providers / Lake Success, NY 50 1 10 Great-West Care / Englewood, CO 49 113 30 New England Care / Englewood, CO 49 61 82 Provider Networks of America / Fort Worth, TX 49 49 12 Beech Street Corporation / Irvine, CA 49 20 32 Houston Area Select PPO / Houston, TX 49 2 2 Preferred Care / Trevose, PA 49 2 26 PPO Alliance / Woodland Hills, CA 49 1 3 American Chiropractic Network / Minnetonka, MN** 48 4 0 HealthNetwork / Oakbrook, IL 47 13 34 The Affordable Medical Networks / Downers Grove, IL 47 1 0 Medco Value Plus / Orlando, FL 46 1 17 HRM CarePASS USA / Minneapolis, MN 45 16 24 ETHIX Northwest / Seattle, WA 45 1 1 MedicalControl / Dallas, TX 45 1 11 National Rehabilitation System / Southfield, MI** 45 1 5 ETHIX Great Lakes / Troy, MI 44 8 36 Lifecare Management Systems / Hope, NJ** 44 1 1 Total 319 384 (Source: Hoechst Marion Roussel. Managed Care Digest Series, 1997.) * “Number of states served” may include the District of Columbia or Puerto Rico. ** This PPO is a specialty-only PPO.
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Hospitals are responding to this surge in managed care in several ways. First, many hospitals are joining networks comprising other hospitals, physicians, insurers, and other healthcare delivery organizations. Many hospitals are forming networks themselves through collaboration with other hospitals, payers, physicians, and other healthcare organizations. Some hospitals are involved in creating managed care organizations, for example joining with physicians to create physician-hospital organizations (PHOs), IPAs, and hospital-owned or jointly-owned group practices. Some hospitals are even creating their own HMOs or PPOs.
Trade and Professional Organizations
As in any industry or business segment, institutions in the healthcare sector and their employees join together in various trade and professional organizations. For electric utilities, these organizations are sources of information about the market: statistical data, professional articles and presentations relating to the industry, anecdotal information, contacts, etc. They also offer channels to reach the market through their newsletters or professional and trade journals, or through conventions and professional meetings.
Traditionally there are two general types of organizations in the healthcare sectors: trade associations of institutions, and professional groups of individuals. Each area usually has its own collection of organizations, i.e., hospitals and their professional specialists participate in hospital organizations while nursing homes and their professional specialists participate in organizations related to nursing homes. Boundaries among these organizations are not always so clear, however. The entire healthcare industry is changing and institutions are evolving in ways that do not always fit into clear categories such as hospital or nursing home. For example, large multi-provider groups, such as Sutter Health in California, have come into existence and include hospitals, physician groups, and other services. Moreover, insurers have begun joining with providers, providers have ventured into the insurance field, and insurers are entering into the area of managed care.
With this effervescence in the healthcare field, there are new demands for data, lobbying, and organizational assistance. As a result, although traditional trade associations and professional groups remain, they have broadened their mission and membership to fit the new industry environment. Also, new associations have sprung up to address the changing character of the industry. The names of the associations and their members, however, often do not capture their variegated nature. For example, in addition to its traditional hospital membership, the Hospital Council of Southern California’s membership includes scores of subacute facilities and behavioral facilities.
Following is a list of trade associations and professional groups related to the major healthcare areas such as hospitals, nursing homes, HMOs, etc.
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Trade Associations
Hospitals
The American Hospital Association (AHA) is the umbrella trade association for the hospital industry. The purpose of the AHA is to promote the welfare of the public through leadership and assistance to its members in the provision of better health services for all people. The AHA carries out research and education projects in such areas as healthcare administration and hospital economics. The association represents hospitals in national legislation. It also offers programs for institutional effectiveness review, does technology assessments, and provides administrative services. The AHA conducts educational programs for hospital managers and staffs, and it collects and analyzes data about the industry. The AHA publishes Hospitals and Health Networks bi- weekly magazine, one of the most important publications in the industry. The AHA has several trade associations for special groups of hospitals. These include (1) the Section for Metropolitan Hospitals for institutions located within a metropolitan statistical area or provide a significant proportion of Medicare, Medicaid, and uncompensated care, (2) the General Constituency Section for Small or Rural Hospitals for institutions with fewer than 100 acute care beds and located outside a statistical metropolitan area; and (3) the Membership Section for Healthcare Systems, for hospitals belonging to healthcare systems.
Contact information:
1 N. Franklin, Suite 27 Chicago, IL 60606 (312) 422-3000 (312) 422-4700 (Fax) www.aha.org
In addition to the AHA, there are several trade associations serving special constituencies.
The Catholic Health Association of the United States is a key trade group for Catholic hospitals. Its membership also includes other Catholic healthcare organizations and facilities. Its trade magazine directed to healthcare administrators is Health Progress, published ten times per year.
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Contact information:
4455 Woodson Road St. Louis, MO 63124 (314) 427-2500 (314) 427-0029 (Fax) www.chausa.org
InterHealth is an association of non-profit, faith-based healthcare organizations. Members of the Lutheran Hospital Association of America (which disbanded in 1991), the American Protestant Health Association (which is no longer active), and other organizations formed InterHealth.
Contact information:
Suite 233 North 2550 University Avenue West St. Paul, MN 55114 (612) 646-5574
The Baptist Hospital Association is a loosely structured group of hospital administrators serving Baptist-owned hospitals and medical centers. The group meets biennially.
Contact information: c/o Valley Baptist Medical Center P.O. Box 2588 Harlington, TX 78550-2588 (956) 389-1100 www.vbmc.org
The American Osteopathic Healthcare Association has membership of more than 100 osteopathic hospitals. The association publishes a directory of osteopathic hospitals and a monthly AOHA Progress.
Contact information:
5550 Friendship Blvd., Suite 300 Chevy Chase, MD 20815 (301) 968-AOHA (301) 968-4195 (Fax) www.aoha.org
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The Federation of American Health Systems addresses the private or investor-owned hospital industry with about 1,400 hospitals and healthcare systems. The federation publishes an annual directory and report.
Contact information:
1405 N. Pierce, Suite 311 Little Rock, AR 72207-5357 (501) 661-9555 (501) 663-4903 (Fax) www.fahs.com
The National Association of Children’s Hospitals and Related Institutions (NACHRI) is a trade association of over 100 clinical medical institutions, including hospitals, that primarily serve children. The organization gathers information and conducts surveys, compiles statistics, and participates in educational programs related to children’s healthcare. The association publishes a quarterly newsletter and various reports.
Contact information:
401 Wythe Street Alexandria, VA 22314 (703) 684-1355 (703) 684-1589 (Fax) www.nachri.org
The National Association of Public Hospitals (NAPH) represents about 100 hospitals and hospital systems. The association has semi-annual meetings and publishes a quarterly newsletter Safety Net.
Contact information:
1212 New York Avenue, NW, Suite 800 Washington, DC 20005 (202) 408-0223 (202) 408-0235 (Fax) www.naph.org
Local hospital associations are most commonly organized on a state, regional, or metropolitan level. They typically provide to their members legislative and regulatory advocacy on state and national matters, business services, insurance, group purchasing, and engineering services. Each state has an association, and, in addition, there are regional state and metropolitan groups. For example, California has a state-wide organization, the California Association of Hospitals and Health Systems, as well as
3-33 Healthcare Facilities three regional associations: the Hospital Council of Northern and Central California, the Hospital Council of Southern California, and the Hospital Council of San Diego and Imperial Counties. Similar regional and metropolitan groups exist in Florida, Illinois, Iowa, Louisiana, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Washington, and Wisconsin.
These local groups are important sources of information on the healthcare industry in their region, e.g., major issues, key contacts, local trends, new regulations, pending legislation, etc.
Nursing Homes
The American Healthcare Association (AHCA) is the primary trade association of the for-profit nursing home industry. The AHCA is a federation of state healthcare organizations working on behalf of long term care providers. Its membership comprises more than 11,000 facilities providing nursing care, subacute care, and assisted living/residential care, or a combination of these. State affiliates provide a similar function on a local level and could offer useful contacts for utilities addressing the long term care market.
Contact information:
1201 L Street, NW Washington, DC 20005 (202) 842-4444 (202) 842-3860 (Fax) www.ahca.org
The American Association of Homes and Services for the Aging is a trade association with a focus on the not-for-profit nursing homes.
Contact information:
901 E Street, NW, Suite 500 Washington, DC 20004-2011 (202) 783-2242 (202) 783-2255 (Fax) www.aahsa.org
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Other Healthcare Trade Associations
The American Dental Association is the primary trade association of the dental field. The association has several publications, though nothing on dental offices or clinics as facilities.
Contact information:
211 E. Chicago Avenue Chicago, IL 60611 (312) 440-2500 (312) 440-2800 (Fax) www.ada.org
The American Association of Preferred Provider Organizations provides educational and legislative support to organizations and individuals involved in and promoting preferred provider organizations. It also functions as a clearinghouse of information on PPOs, including statistics and surveys on the industry.
Contact information:
1 Bridge Plaza, Suite 325 Fort Lee, NJ 07024 (800) 642-2515 or (201) 947-5545 (201) 947-3808 (Fax) www.aappo.org
The American Association of Health Plans (AAHP), formerly the Group Health Association of America (GHAA), is the primary trade association for the health maintenance organization industry. The association conducts research programs and workshops and publishes an annual directory as well as a magazine and bi-weekly newsletter.
Contact information:
1129 20th Street, NW, Suite 600 Washington, DC 20036 (202) 778-3200 (202) 331-7487 (Fax) www.aahp.org
The National Association for Home Care serves providers of home care, hospice, and home health aide services. It develops and promotes standards of patient care, seeks to affect legislative and regulatory processes, and gathers data and conducts market
3-35 Healthcare Facilities research related to the industry. The group also sponsors educational programs for organizations and individuals.
Contact information:
228 Seventh St. Washington, DC 20003 (202) 547-7424 (202) 547-3540 (Fax) www.nach.org
The American Medical Rehabilitation Providers Association represents the medical portion of rehabilitation. It serves rehabilitation hospitals and units, skilled nursing facilities and other post-acute rehabilitation providers.
Contact information:
1606 20th St., NW 3rd Floor Washington, DC 20009 (888) 346-4624 or (202) 265-4404 (202) 833-9168 (Fax)
Other Trade Associations
The American Veterinary Medical Association is the primary trade organization for veterinarians and is analogous to the American Medical Association for physicians. It serves as both professional and trade organization and addresses issues related to veterinary clinic operation.
Contact information:
1931 N. Meacham Road, Suite 100 Schaumburg, IL 60173 (847) 925-8070 (847) 925-1329 (Fax) www.avma.org
The Clinical Laboratory Management Association is a trade organization for clinical laboratory executives and suppliers. It was formerly the American Association of Clinical Laboratory Supervisors and Administrators. The association publishes Clinical Laboratory Management Review.
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Contact information:
989 Old Eagle Rd., Suite 815 Wayne, PA 19087 (610) 995-9580 (610) 995-9568 (Fax) www.clma.org
The National Funeral Directors Association is the trade organization for funeral directors and has a membership of about 15,000 funeral homes.
Contact information:
13625 Bishop’s Dr. Brookfield, WI 53005 (800) 228-6332 or (414) 789-1880 (414) 789-6977 (Fax) www.nfda.org
Professional Groups
Managers and professional specialists in the healthcare sector can join professional associations related to their work. Many have local chapters. These groups offer opportunities for utilities to interact more closely with the professionals in this market.
Hospitals
As part of its mission to serve the hospital industry, the American Hospital Association sponsors several organizations for hospital professionals.
The American Society for Healthcare Engineering (ASHE), a national organization for professionals involved in the operation of healthcare facilities, including facilities managers, plant engineers, hospital architects, and construction managers. ASHE has local chapters in every state and publishes a journal, Health Facilities Management as well as technical papers or issues of interest to its membership. The association recently developed an online communications system called ASHEnet.
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Contact information:
1 N. Franklin, Suite 2700 Chicago, IL 60606 (312) 422-3800 (312) 442-4571 (Fax) www.ashe.org
The American Society for Healthcare Environmental Services (ASHES) is a professional group for environmental specialists in the healthcare field. This category includes managers and directors of hospital environmental services and environmental engineers. The organization now has 16 regional groups.
Contact information:
1 N. Franklin Chicago, IL 60606 (312) 422-3750 (312) 422-4572 (Fax) www.ashes.org
The American College of Healthcare Executives (ACHE) is the primary professional society for hospital and health service executives. With a membership of 28,000, the group has local affiliate organizations which meet regularly. Its publications include Frontiers of Health Sciences Management, a bimonthly journal; Health Services Research, a bimonthly journal; Healthcare Executive, a bimonthly magazine; and Hospital and Health Services Administration, a quarterly journal.
Contact information:
1 N. Franklin, Suite 1700 Chicago, IL 60606 (312) 424-2800 (312) 424-0023 (Fax) www.ache.org
The American Society for Healthcare Central Service Personnel (ASHCSP) addresses important operational issues in central service or central supply departments of hospitals, such as sterilization. The organization has several regional groups and publishes Healthcare Central Service, a bimonthly newsletter as well as technical materials and training manuals.
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Contact information:
1 N. Franklin, 31st Floor Chicago, IL 60606 (312) 422-3750 (312) 422-4572 (Fax) www.ashcsp.org
The American Society for Hospital Food Service Administrators deals with food service in hospitals. The organization has a bimonthly newsletter as well as annual meetings.
Contact information:
1 N. Franklin, 31 North Chicago, IL 60606 (312) 422-3870 (312) 422-4581 (Fax) www.ashfsa.org
In addition there are other professional organizations for healthcare professionals that are not affiliated with the American Hospital Association.
The American Academy of Medical Administrators (AAMA) was founded in 1957. Its members include hospital administrators as well as department heads of nursing, food service management, housekeeping, and purchasing. The AAMA has several chapter organizations: American College of Cardiovascular Administrators, American College of Healthcare Information Administrators, and the American College of Oncology Administrators. The AAMA issues monthly and bi-monthly publications.
Contact information:
30555 Southfield, Suite 150 Southfield, MI 48076 (248) 540-4310 (248) 645-0590 (Fax) www.aameda.org
The American Association of Psychiatric Administrators focuses on administrators and executives of psychiatric hospitals. The group is affiliated with the American Psychiatric Association. It published the Journal of American Association of Psychiatric Administrators.
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Contact information:
Division of MHMR 2 Peachtree St., NW, Suite 4-130 Atlanta, GA 30303 (404) 657-7857 or (404) 657-5681
The College of Osteopathic Healthcare Executives (COHE) has membership of executives of osteopathic hospitals. It is affiliated with the American Osteopathic Healthcare Association.
Contact information:
5550 Friendship Blvd., Suite 300 Chevy Chase, MD 20815-7201 (301) 968-2642 (301) 968-4195 (Fax)
Nursing Homes
The American College of Health Care Administrators is a professional organization for persons actively engaged in the administration of long-term care facilities and assisted- living facilities. The organization also has 11 regional groups and 48 state groups. It publishes quarterly the Journal of Long-Term Care Administration as well as a bi-monthly newsletter, Long-Term Care Administrator.
Contact information:
325 S. Patrick Street Alexandria, VA 22314-3571 (703) 739-7900 (703) 739-7901 (Fax) www.achca.org
Other Professional Groups
The Healthcare Information and Management System Society, a division of the American Hospital Association, is a professional organization for persons involved in the field of healthcare information and management systems. The society has annual conferences as well as symposia and education workshops on specific topics, such as long-term care information systems. Publications include conference proceedings, the quarterly Health Information Management, and a monthly newsletter HIMSS News.
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Contact information:
230 East Ohio Street, Suite 600 Chicago, IL 60611-3269 (312) 664-4467 (312) 664-6143 (Fax) www.himss.org
ECRI is a non-profit health services research institution supporting safety and cost- effective patient care. ECRI sponsors a Center for Healthcare Environmental Management (CHEM) which offers certification courses in healthcare environmental management including JCAHO, OSHA, EPA, and NRC regulations related to healthcare facilities, industrial hygiene, physical plant services, waste disposal, etc.
Contact information:
5200 Butler Pike Plymouth Meeting, PA 19462-1298 (610) 825-6000 (610) 834-1275 (Fax) www.ecri.org
Resources and References (for Chapters 2 and 3)
1. 1994 HMO Industry Profile. Group Health Association of America, Washington, D.C. 1994.
2. 1995 Patterns in HMO Enrollment. Group Health Association of America, Washington, D.C. 1995.
3. 1995 Sourcebook on HMO Utilization Data. Group Health Association of America, Washington, D.C. 1995.
4. 1997 National Directory of Health Plans. American Association of Health Plans.
5. 1998 HMO/PPO Directory. Medical Economics, Montale, NJ 1998.
6. 1999 Buyers’ Guide for the Health Care Market. American Hospital Association, Chicago, IL 1999.
7. AHA Guide to the Healthcare Field 1998-1999 Edition. American Hospital Association, Chicago, IL 1998.
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8. AHA Hospital Statistics 1999 Edition. American Hospital Association, Chicago, IL 1999.
9. Bradley R. Braden, et al. “National Health Expenditures 1997.” Health Care Financing Review, 20 (1): 83-125, Fall 1998.
10. M. Brown. “The Economic Era: Now to the Real Change.” Health Care Manage. Rev., 19 (4): 64-72, 1994.
11. A. Camarow. “Plans That Opted Out.” U.S. News & World Report, 125 (13): 77-78, October 5, 1998.
12. C. Campbell. “Hospital Plant and Equipment Replacement Decisions: A Survey of Hospital Financial Managers.” Hospital & Health Services Administration, Journal of the Foundation of the American College of Healthcare Executives, 39 (4): Winter 1994.
13. Directory of Operational PPOs. American Association of Preferred Provider Organizations, St. Anthony Publishing, Inc., Washington, D.C. 1998.
14. C. Fisher. “Top 1997 Nursing Facility Chains.” Provider, 24 (1): 41-6, January 1998.
15. E. Friedman. “What’s the Future of Health Care Associations?” Hospitals & Health Networks, 68 (18): 24-8, September 20, 1994.
16. “Beyond the Crisis: Preserving the Capacity for Excellence in Health Care and Medical Science,” Edited by H.M. Greenberg and S.U. Raymond, Annals of the New York Academy of Sciences, 729: 1-199, New York, 1994.
17. M.M. Hagland. “Managing Managed Care.” U.S. News & World Report, July 24, 1995.
18. M.M. Hagland. “Merger Mania?” Hospitals and Health Networks, 68 (10): 46-8, May 20, 1994.
19. M.M. Hagland. “The Top 10 Developments in U.S. Healthcare 1990.” Hospitals, 64 (24): 38-40, December 20, 1990.
20. “Health Care Hospitals, Drugs, and Cosmetics: Current Analysis.” Standard & Poor’s Industry Surveys, New York, NY April 1994.
21. Highlights of the National Health Expenditure Projections 1997-2007. Health Care Financing Administration. (www.hcfa.gov/stats/nhe-proj/defaults.htm)
22. Highlights: National Health Expenditures 1997. Health Care Financing Administration. (www.hcfa.gov/stats/nhe-oact/hilites.htm)
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23. J. Johnson. “Are the Nation’s Hospitals Facing a Capital Crisis?” Hospitals, 64 (14): 24-29, July 20, 1990.
24. R.L. Johnson. “The Economic Era of Health Care.” Health Care Manage. Rev., 19 (4): 82-84, 1994.
25. Peter Kongstvedt. The Managed Health Care Handbook. Aspen Publishers, Rockville, MD 1996.
26. K. Levitt, et al. “National Health Expenditures in 1997: More Slow Growth.” Health Affairs, 17 (6): 99-110, November-December 1998.
27. K.R. Levit, et al. “National Health Spending Trends in 1996.” Health Affairs, 17 (1): 35--51, 1998.
28. Managed Care Desk Reference. American Association of Preferred Provider Organizations, Washington, D.C. 1996-97.
29. “Modern Healthcare.” Reprinted in Standard & Poor’s Industry Surveys, New York, NY October 6, 1994.
30. “The Next Ten Years of Health Spending: What Does the Future Hold?” Health Affairs, 17 (5): 128-40, September/October, 1998)
31. The Nursing Facility Sourcebook, American Health Care Association, Research and Data, 1998, (www.ahca.org/research/nftoc.htm).
32. Roy Parkins, John Smith. “The Impact of Current Trends on Future Patterns of Medical Practice.” The New Healthcare Market. Edited by Peter Boland, Dow-Jones- Irwin, Homewood, IL 1985.
33. “Redefining the Hospital.” Trustee Journal, August 1994.
34. National Trade and Professional Associations of the United States. Edited by J.J. Russell, et al., 28th Edition, Columbia Books, Inc., Washington, D.C. 1993.
35. U.S. Department of Commerce. U.S. Census Bureau. Economics and Statistics Administration. Service Annual Surveys: 1990. BS/90-01. Government Printing Office, Washington, D.C. 1991.
36. J.P Shapiro. “America’s Top HMOs.” U.S. News & World Report, 125 (13): 64-72, October 5, 1998.
37. Laura Souhrada. “Design and Construction.” Hospitals, 65 (4): 36,38,40, February 20, 1991.
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38. Jay Sterns. “Emerging Trends in Health Care Finance.” J. Health Care Financ., 21 (2): 1-10, 1994.
39. Office of the Federal Register. National Archives and Records Administration. The United States Government Manual. Government Printing Office, Washington, D.C. published annually.
40. U.S. Department of Commerce. U.S. Industry and Trade Outlook 1998 - Health and Medical Services, Government Printing Office, Washington, D.C.
3-44 4 REGULATIONS AND STANDARDS AFFECTING THE HEALTHCARE INDUSTRY
Environmental Regulations, Licensing, and Accreditation
Many aspects of work in healthcare facilities are regulated by a host of federal, state, and local agencies, as well as private accreditation organizations. Some hospital administrators, facility managers, environmental officers, and staff feel beleaguered by numerous and complex, often confusing, rules and regulations dealing with medical waste disposal, air emissions, OSHA standards, management of refrigerants, transport of biohazardous material, accreditation standards, life safety codes, etc. This section provides an overview of the key agencies and institutions that significantly affect the healthcare industry; it is not intended as a comprehensive presentation on all agencies and regulations dealing with healthcare. Also discussed in this section are current and upcoming regulations that are of concern to healthcare facilities.
Key agencies and institutions and selected regulations are listed below and described in subsequent sections:
U.S. Environmental Protection Agency Clean Air Act Amendments of 1990 Medical Waste Incinerator Regulations Under Title V: Pollutants From Boilers and Other Sources Under Title VI: Recovery of Refrigerants Resource Conservation and Recovery Act of 1976 and subsequent amendments Comprehensive Environmental Response, Compensation, and Liability Act of 1980 Medical Waste Tracking Act of 1988
Department of Transportation Research and Special Programs Administration HM-181: Transport of infectious substances
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Department of Labor Occupational Safety and Health Administration Permissible Exposure Limits Occupational Exposure to Bloodborne Pathogen Standard Proposed Indoor Air Quality Standard Guidelines on Workplace Violence in a Healthcare Setting
Department of Health and Human Services Centers for Disease Control and Prevention Guidelines for Protecting the Safety and Health of Healthcare Workers Guidelines for Protection and Control of Nosocomial Infections Guidelines under the AIDS Amendments of 1988 Guidelines for Healthcare Workers Potentially Exposed to Tuberculosis Food and Drug Administration Medical Device Amendments and Safe Medical Devices Act of 1990
Nuclear Regulatory Commission Low-Level Radioactive Waste Policy Act and Amendments
Other Federal Agencies
State Regulatory Agencies Medical waste treatment technology efficacy criteria Specific state regulations on medical waste treatment
County and Municipal Health Agencies
Joint Commission on Accreditation of Healthcare Organizations
National Fire Protection Association NFPA 99 and other codes
American Society of Heating, Refrigeration and Air-Conditioning Engineers ASHRAE Standard 62 ASHRAE Standard 90.1
American Institute of Architects Guidelines for Design and Construction of Hospitals and Health Care Facilities
National Committee for Clinical Laboratory Standards Guidelines for Laboratory Safety and other guidelines
National Safety Council
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U.S. Environmental Protection Agency
Medical Waste Incineration and the EPA Rule
On September 15, 1997, the U.S. EPA promulgated its final rule on “Standards of Performance for New Stationary Sources and Emission Guidelines for Existing Sources: Hospital/Medical/Infectious Waste Incinerators.” The regulation was based on Section 129 of the 1990 Clean Air Act Amendments which directed the EPA to reduce pollutants from incinerators, specifically including hospital/medical/infectious waste incinerators (the term “medical waste incinerators” will be used in this report). When the rule was finalized, EPA estimated that 846,000 tons (767,00 Mg) of hospital and medical/infectious waste were being burned annually. Of particular concern are emissions of dioxins, furans, particulate matter, lead, cadmium, mercury, and acid gases.
Under the rule, all medical waste incinerators are subject to emission limits depending on the incinerator’s waste burning capacity (see Table 4-1). To meet the EPA limits, most incinerators will have to install scrubbers; older incinerators may also have to retrofit their secondary chambers to achieve proper temperatures and residence time for good combustion. In addition, incinerator operators have to conduct periodic stack tests to show compliance with the rule. Facilities must also install equipment to monitor continuously operating parameters such as secondary chamber temperature and feed rates, as well as parameters related to the air pollution control devices. The rule also requires operator training and qualification, inspection, development of waste management plans, reporting, and recordkeeping.
The EPA rule adds significantly to the cost of operating an existing incinerator. For example, the capital cost of upgrading an existing 750 lb/hr (340 kg/hr) hospital incinerator with a heat recovery boiler is estimated at $450,000 (for secondary chamber retrofit, wet scrubber, and monitoring equipment). For this incinerator, the EPA rule also increases the annual cost by about $115,000 a year over and above the current operating costs; this additional cost includes operating costs of the wet scrubber, periodic stack testing, monitoring, and operator training/qualifications.
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Table 4-1 Emission Limits for Hospital/Medical/Infectious Waste Incinerators
Emission Limits
Pollutant Small Medium Large New Existing New Existing New Existing
Particulate Matter (mg/dscm) 69 115 34 69 34 34
Carbon Monoxide (ppmv) 40 40 40 40 40 40
Dioxins/Furans (ng/dscm total 125 or 2.3 125 or 2.3 25 or 0.6 125 or 2.3 25 or 0.6 125 or 2.3 or ng/dscm TEQ)
Hydrogen Chloride 15 or 99% 100 or 93% 15 or 99% 100 or 93% 15 or 99% 100 or 93% (ppmv or % reduction)
Sulphur Dioxide (ppmv) 55 55 55 55 55 55
Nitrogen Oxides (ppmv) 250 250 250 250 250 250
Lead (mg/dscm or 1.2 or 70% 1.2 or 70% 0.07 or 98% 1.2 or 70% 0.07 or 98% 1.2 or 70% % reduction)
Cadmium (mg/dscm or 0.16 or 65% 0.16 or 65% 0.04 or 90% 0.16 or 65% 0.04 or 90% 0.16 or 65% % reduction)
Mercury (mg/dscm or 0.55 or 85% 0.55 or 85% 0.55 or 85% 0.55 or 85% 0.55 or 85% 0.55 or 85% % reduction)
Note: New incinerators are those that commenced construction after June 20, 1996. Capacities are: small (less than or equal to 200 lb/hr (91 kg/hr)); medium (200 to 500 lb/hr (91 to 227 kg/hr)); and large (greater than 500 lb/hr (227 kg/hr)).
According to an American Hospital Association report in 1994, there were 2,233 hospitals in the U.S. with medical waste incinerators. (The EPA’s estimates are approximately 2,400 hospitals – The EPA 1997 Fact Sheet – www.epa.gov/ttn/uatw/129/hmiwi/hmiwifs.html) The breakdown of incinerators is as follows:
Capacity Number of Incinerators
Less than 500 pounds per hour (227 kg/hr) 1803
Between 500 and 1,000 pounds per hour (227 to 454 kg/hr) 256
Greater than 1,000 pounds per hour (454 kg/hr) 174
Total 2233
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The cost of compliance may compel as many as 80% of hospital incinerator owners in the United States to shut down their operations. Moreover, the EPA estimates that about 80% of new medical waste incinerators may not be constructed due to the rule. Already, in the first part of the 1990s, the annual sales of medical waste incinerators dropped markedly due to the threat of federal and state regulations. The EPA rule could also make off-site regional incineration more costly.
Utility representatives can play an important role in helping healthcare facilities meet the EPA rules by making hospitals and other affected healthcare facilities aware of alternative technologies for the treatment and disposal of medical waste, offering the services of consultants who can evaluate technology alternatives, and taking part in financial arrangements (such as cost avoidance sharing or funding demonstration projects) between the hospital and electrotechnology vendor.
For more information on the EPA regulations for medical waste incinerators, contact:
Mr. Rick Copland (919-541-5265) e-mail – [email protected] Emission Standards Division (MD-13) U.S. Environmental Protection Agency Research Triangle Park, NC 27711 www.epa.gov/ttn/uatw/129/hmiwi/rihmiwi.html
CAAA Title V Applications – Pollutants from Boilers and Other Sources
Under Title V of the Clean Air Act Amendments (CAAA), large facilities with the potential to emit 100 tons (90,720 kg) per year of criteria pollutants, 10 tons (9072 kg) per year of any hazardous air pollutants (186 compounds are being regulated under this category by the EPA), or 25 tons (22,680 kg) per year of a combination of hazardous air pollutants are required to submit Title V permit applications. Permits must include emission limits, compliance schedules, and monitoring and reporting requirements. Although states take the lead in issuing permits, each state must give EPA notice of all permit applications and applications for permit revisions. Facilities are also required to pay a permit fee which is of the order of $25 per ton ($0.03 per kg) of pollutant. Because emissions from electric utilities are high enough to be covered under Title V, utilities generally have staff personnel specializing in CAAA compliance who could assist any large healthcare facility that might fall under these regulations.
CAAA Title VI - Recovery of Refrigerants Requirements
The 1990 Clean Air Act Amendments require the recovery of all chloroflurocarbons (CFCs) and hydrochloroflurocarbons (HCFCs) from air-conditioning and refrigeration equipment to prepare owners for the phase-out of these ozone-depleting refrigerants.
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Hospitals, medical centers, and other healthcare facilities are major users of refrigerant cooling equipment.
The 1990 Clean Air Act Amendments (CAAA) prohibit the venting of CFCs and HCFCs to the atmosphere and require recovery and recycling of these refrigerants. Furthermore, owners of equipment with 50 lb (23 kg) or more of refrigerants must repair leaks, keep records of the quantity of refrigerant, use only certified technicians for servicing refrigeration equipment, and use certified recovery equipment. Fines for violations are up to $25,000 per occurrence. The problems related to CFC and HCFC refrigerants are discussed in greater detail in the Issues and Opportunities section.
Resource Conservation and Recovery Act
The Resource Conservation and Recovery Act (RCRA) requires “cradle-to-grave” management of hazardous waste. When RCRA was enacted in 1976, Congress gave the EPA authority to regulate medical waste. However, by the time EPA promulgated its final regulations under RCRA, it decided to defer action on infectious waste. Even though RCRA regulations do not cover medical waste, other types of waste generated in a healthcare facility are regulated by RCRA. These include common solvents such as methanol, chloroform, toluene, xylene, etc.; formaldehyde wastes; mercury wastes; etc. RCRA put in place a manifest system to track waste from facilities such as hospitals that generated the hazardous waste to the treatment, storage and disposal facility.
Comprehensive Environmental Response, Compensation, and Liability Act
The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA, also known as the Superfund Act) among other things led to regulations dealing with the response to accidental spills or leaks of toxic or hazardous substances. It also established liability of hazardous waste generators in the clean-up of contaminated sites as a result of releases of hazardous waste.
The Medical Waste Tracking Act
The Medical Waste Tracking Act (MWTA) amended RCRA and was partly in response to news reports in the late 1980s about medical waste mismanagement, such as syringes and other medical waste washing up on shores in New York, New Jersey, and in the Great Lakes, or left in an alleyway behind a healthcare facility in Indiana. The MWTA created the term “regulated medical waste” which the EPA categorized into seven classes. The statute served to demonstrate a comprehensive scheme for managing medical wastes involving tracking of infectious waste, minimum standards for segregation of waste, packaging, labeling, decontamination of reusable containers, and storage before transport to a treatment facility.
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The MWTA applied only to Connecticut, New York, New Jersey, Rhode Island, and Puerto Rico, and expired in June 1991. Two EPA reports to Congress on the results of the MWTA are available from the National Technical Information Service (NTIS) - (800) 553-6847 (document numbers - #PB90219874 – May 15, 1990, and #PB91130187 December 15, 1990). Although the act was only designed as a demonstration program, agencies may use it as a model for state and future federal regulations. For this reason, some pertinent requirements under the MWTA are summarized below:
• Segregation: wastes should be segregated according to three categories—sharps, fluid wastes greater than 20 cc, other regulated medical wastes; furthermore these wastes should be segregated as much as possible from hazardous, radioactive, and general wastes
• Packaging: containers for shipping waste must be rigid, leak-resistant, impervious to moisture, strong enough to prevent tearing or bursting under normal handling, and sealed to prevent leakage; sharps must be placed in puncture- and leak-resistant, rigid containers
• Storage: storage locations must be secure, protected from weather and animals, and able to maintain the integrity of packaging; refrigeration may be necessary to prevent putrescence
• Decontamination of Reusable Containers: reusable, rigid containers must be decontaminated which may be involve removal of visible contaminants, and exposure to hot water at least 82°C for 15 seconds or exposure to chemical disinfection in accordance to EPA-approved label directions
• Marking: all packages of regulated medical waste must be marked with a water- resistant tag with the following information—generator’s or intermediate handler’s name, state permit or identification number, transporter’s name, transporter’s address and/or state permit and ID number, date of transfer.
• Tracking System: Facilities generating more than 50 pounds (23 kg) of medical waste a month must complete a Medical Waste Tracking Form and a copy of the form from the disposal facility must be returned to the generator within 35 days. Copies of all tracking forms must be kept by the generator for at least three years. Facilities generating less than 50 pounds (23 kg) a month must maintain a record (log) of each shipment.
• Exemptions: Generators that transport less than 50 pounds (23 kg) of their own waste, that ship between generator facilities, or ship through the U.S. Postal Service must maintain logs.
• On-Site Destruction: Generators that destroy their own waste on-site must maintain certain records. On-site incinerator operators must maintain an operating log and 4-7 Regulations and Standards Affecting the Healthcare Industry
submit on-site incinerator reports summarizing operating data. Other documents are needed if the incinerator operator accepts waste from other generators.
In addition to these requirements for generators, the MWTA also had provisions for the transporter and the off-site disposal facility. As mentioned, the MWTA is no longer in effect but it may be used as a model by regulatory agencies.
Department of Transportation
Ensuring a fast, safe, efficient, accessible, and convenient transportation system that meets our vital national interests and enhances quality of life is the mission of the Department of Transportation. Safety, one of the department’s strategic goals, is to promote public health and safety by working toward the elimination of transportation- related deaths, injuries, and property damage.
HM-181 Regulations
A major federal regulation dealing with medical waste is the transportation rule for infectious waste finalized by the Research and Special Programs Administration of the Department of Transportation in September 1995. The regulation arose out of United Nations standards, including “Recommendations on the Transport of Dangerous Goods,” aimed at creating uniform transportation standards worldwide for different materials including biohazardous waste. The regulation was also prompted by public concern over rare but highly publicized accidents. For instance, a spill in Texas in 1994 left bloody red bags and syringes all over an interstate highway near the Oklahoma border and required the removal of several inches of topsoil on a median strip during the cleanup.
HM-181 defines infectious substances as microorganisms (also referred as etiological agents most of which are listed in Department of Health and Human Services regulations) which may cause disease in humans or animals. Regulated medical wastes—defined as wastes created during diagnosis, treatment, or research—include reusable material containing infectious substances, discarded diagnostic specimens, and biological products.
The regulations govern all modes of interstate transportation and may preempt state and local regulations. Key provisions are:
• Packaging requirements for infectious substances including
— High integrity, triple packaging
— Capability of passing the 30-foot (9 m) drop and penetration tests
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— Smallest external dimension at least 100 mm
• Packaging requirements for regulated medical waste including
— Non-bulk packaging (< 119 gal/400 kg) unless exempted
— UN standard marking and certified packaging
— Capability of passing the tests for 4-foot (1 m) drop, stacking, vibration and leakproofness (for liquids)
• Hazard communication requirements including
— Shipping papers
— Marking and labeling
— Emergency response information
• Other requirements
— Training of employees and maintenance of records
— Reporting of any spill incidents to CDC (800-232-0124)
• Quantity limitations for transport by air
— Specific quantities depending on type of aircraft or waste
• Exempted materials if they do not contain any other hazardous substances:
— Diagnostic specimens, biological products, treated material, household wastes, corpses and anatomical parts, animal waste
• Regulated medical waste is excepted from labeling and packaging requirements if it is properly packaged in rigid, non-bulk packagings, packaged and marked, and transported by private or contract carriers.
Department of Labor
The administration and enforcement of federal labor laws including minimum wage, unemployment insurance, workers’ compensation, freedom from employment discrimination, worker pension, collective bargaining, etc. fall under the Department of Labor. In addition to these functions, the one agency under the Department of Labor that strongly affects the healthcare industry is the Occupational Safety and Health
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Administration which deals with ensuring a safe and healthful working condition. The department also keeps track of data on employment and other national economic measurements and provides for job training programs.
Occupational Safety and Health Administration
The General Duty Clause of the Occupational Safety and Health Act of 1970 states that every employer must provide a working environment that is free from recognized hazards that may cause death or serious harm. The responsibility for complying with OSHA standards rests with the employer. The Occupational Safety and Health Administration (OSHA), established under the Act, is responsible for promulgating and enforcing standards in most workplaces including federal and private sector hospitals. Twenty-five states/territories have written and enforce their own occupational safety and health programs with the approval of federal OSHA. State OSHA plans must be at least as stringent and effective as the federal OSHA plans in providing a safe work environment. A few federal OSHA-approved state programs apply only to public employees or to state and local government employees. The states/territories with OSHA-approved occupational safety and health plans are: Alaska, Arizona, California, Connecticut, Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Oregon, Puerto Rico, South Carolina, Tennessee, Utah, Vermont, Virginia, Virgin Islands, Washington, and Wyoming.
OSHA has the authority to inspect workplaces in response to requests from workers or as part of a targeted or routine inspection. Citations and fines may be imposed for violations discovered during these inspections. Below are key OSHA rules or standards that specifically affect healthcare facilities:
Permissible Exposure Limits
OSHA has specific standards for hazards such as noise, ethylene oxide, mercury, and asbestos. In addition to general occupational safety standards applicable to many work environments, OSHA has also set permissible exposure limits (PELs) for chemical exposures in the workplace. Below are selected PELs for common chemicals found in a healthcare facility:
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Table 4-2 Examples of OSHA Exposure Limits for Chemicals Common in Healthcare Facilities
Chemical PELs Other Recommended Values
Acetone 750 ppm 1000 ppm STEL Chloroform 2 ppm 1000 ppm IDLH Ether 400 ppm 500 ppm STEL Ethylene Oxide 1 ppm 5 ppm (15-min excursion) Formaldehyde 1 ppm 2 ppm STEL Glutaraldehyde 0.2 ppm Isopropyl alcohol 400 ppm 500 ppm STEL Mercury (in air) 0.05 mg/m3 28 mg/m3 IDLH Methanol 200 ppm 250 ppm STEL Methylene Chloride 500 ppm Toluene 100 ppm 150 ppm STEL 1,1,2-Trichloroethane 10 ppm 1000 ppm IDLH Trichloroethylene 50 ppm 200 ppm STEL Xylene 100 ppm 150 ppm STEL, 1000 ppm IDLH
Notes: PELs are time-weighted average concentrations that may not be exceeded during any 8-hour work shift of a 40-hour week; STEL are short-term exposure limits designated as 15-minute time-weighted exposures that should not be exceeded at any time during a workday; IDLH are concentrations that are “immediately dangerous to life or health”
OSHA has also released work-practice guidelines for personnel dealing with cytotoxic drugs (also called anti-new growth, anticancer, or antineoplastic drugs). These are drugs used in cancer chemotherapy and are toxic to cells, hence potentially harmful to workers dealing with them. The OSHA guidelines deal with drug preparation, drug administration, patient care, waste disposal, spills, medical surveillance of employees, storage and transport, training, and information dissemination.
Bloodborne Pathogen Rule
The Bloodborne Pathogen Rule (29CFR 1910.1030), promulgated on December 1991, is designed to protect workers from exposure to bloodborne pathogens and follows the Centers for Disease Control and Prevention (CDC) Universal Precautions guidelines. Bloodborne pathogens of concern include human immunodeficiency virus (HIV) and
4-11 Regulations and Standards Affecting the Healthcare Industry hepatitis B virus (HBV). Under the OSHA rule, blood, certain body fluids (namely, amniotic fluid, pericardial fluid, peritoneal fluid, synovial fluid, cerebrospinal fluid, semen, and vaginal excretions), and any fluid visibly contaminated with blood from all patients must be considered potentially infectious. The basic concept is to assume that all patients are potentially infectious for HIV and other bloodborne pathogens. Healthcare workers are then required to take precautions to avoid exposure to these fluids.
Proposed Indoor Air Quality Standard
The proposed OSHA standard on indoor air quality requires that each employer assemble basic information on their building and operations, including schematics of HVAC and plumbing, space pressurization, building occupant work activities, an inventory of known air contaminants released in the work space, etc. In addition, the standards requires the facility to prepare a written maintenance plan, keep records of employee complaints, measure relative humidity and CO2 as criteria for building performance, and respond to employee complaints. Buildings systems will have to operate up to “original design specifications” and original code. Ventilation will have to be maintained during housekeeping activities, and early shut-downs or late starts for the purpose of cost reduction will be restricted. The proposed rule also sets standards for inspection, clean-up, and correction of problems associated with contaminants and other indoor air quality problems. Tobacco smoke is given a separate class and the rule proposes to ban all workplace smoking except in designated areas.
After proposed rulemaking was announced in April 1994 and the proposed standard was released for public review, numerous comments were received. Among the major issues that elicited the most response were: the requirements for separate ventilation of building spaces where smoking was allowed; the cost to businesses of complying with the proposed rule (estimated by OSHA at $16 billion initial cost plus $6.7 billion annual cost); and various technical issues. However, OSHA has had to relegate review of comments to the proposed standard to a low priority because of budgetary constraints placed by Congress. As of January 1999, the standard has not been finalized. Copies of the draft OSHA standard can be obtained by contacting the OSHA publication office (202-693-1888) and asking for Docket No. H-122. For further information, contact the OSHA Health Standards Office (202-693-1950).
Guidelines on Workplace Violence in a Healthcare Setting
The healthcare industry saw more than 100 assault-related worker deaths between 1980 and 1990. Healthcare workers are at higher than normal risk because they often face aggressive patients or dangerous situations in emergency departments. OSHA’s federal guidelines aimed at curbing violence in a healthcare setting were released on March 14, 1996. The voluntary guidelines offer both policy recommendations and practical
4-12 Regulations and Standards Affecting the Healthcare Industry suggestions to deter violence such as installing metal detectors, alarm systems, brighter lighting, etc. Utilities may be able to assist in helping implement some of these recommendations.
Department of Health and Human Services
The Department of Health and Human Services is a cabinet-level department of the federal government concerned with the nation’s health. There are four operating divisions: Administration on Aging, Administration for Children and Families, Social Security Administration, and the Public Health Service. Other important departments are the Substance Abuse and Mental Health Services Administration and the Health Care Financing Administration (HCFA). Some of these agencies and their activities are described below.
Substance Abuse and Mental Health Services Administration
Among other functions, this administration works with healthcare providers and organizations to improve the effectiveness of substance abuse treatment programs; supports activities to improve the administration, availability, organization, and financing of mental healthcare; and administers various block grants and other programs.
Health Care Financing Administration
Health Care Financing Administration (HCFA) was created to administer the oversight of the Medicare Program, the Federal portion of Medicaid, and related quality assurance activities. Today, HCFA serves one in four elderly, disabled, and poor Americans through Medicare and Medicaid.
The Medicare Program provides health insurance coverage for people 65 and over, younger people who are receiving social security disability benefits, and persons who need dialysis or kidney transplants for treatment of end-stage kidney disease. Beneficiaries can receive care either through the traditional fee-for-service delivery system or through coordinated care plans, such as HMOs and competitive medical plans. The Medicaid Program is a medical assistance program jointly financed by State and Federal governments for eligible low-income individuals.
The Medicare/Medicaid programs include a quality assurance focal point to carry out the quality assurance provisions of the Medicare and Medicaid programs, and the development and implementation of health and safety standards of care providers in Federal health programs. As a result, many hospitals and healthcare facilities providing Medicare and Medicaid services are affected by HCFA.
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Public Health Service
The Public Health Service has various agencies under it, some of which affect the healthcare industry directly or indirectly. These include: (1) Centers for Disease Control and Prevention, (2) Food and Drug Administration, (3) Health Resources and Services Administration, and (4) National Institutes of Health.
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is a federal public health agency based in Atlanta, Georgia. The CDC conducts surveillance and investigation of infectious diseases in hospitals, compiling data weekly on infectious diseases, control programs, and activities. The CDC also develops guidelines and recommendations for disease control. Some key guidelines are described below.
Guidelines for Protecting the Safety and Health of Healthcare Workers
These guidelines address hospital safety and health programs and make specific recommendations in the following areas:
• General Safety Hazards such as physical exertion, flammable material, etc.
• Specific Hazards by Hospital Department including Central Supply, Food Service, Housekeeping, Laundry, Maintenance, Patient Care, Pharmacy, Laboratories, Surgical Services, etc.
• Specific Non-Infectious Health Hazards including chemical hazards due to asbestos, disinfectants, antineoplastic drugs, ethylene oxide, formaldehyde, mercury, etc.; physical hazards due to heat, noise, and radiation; mutagenic and teratogenic hazards; hematological hazards; and stress.
• Infectious Disease Hazards
Guidelines for Prevention and Control of Nosocomial Infections
The Guidelines for Prevention and Control of Nosocomial Infections is a series of guidelines intended for hospital personnel responsible for infection surveillance and control in the healthcare facility. (Nosocomial infections refer to infections acquired by a patient as a result of hospitalization.) The guidelines include the following CDC guidelines: Isolation Precautions in Hospitals, Infection Control in Hospital Personnel, Handwashing and Hospital Environmental Control, and Prevention of Nosocomial Pneumonia. The guidelines provide detailed and specific recommendations and
4-14 Regulations and Standards Affecting the Healthcare Industry provide a ranking scheme whereby, for example, a Category I ranking means that the recommendation is strongly recommended for adoption by the healthcare facility.
“Isolation precautions” guidelines are steps for preventing the spread of an infectious agent from an infected person to another. Recommendations are made for various isolation categories such as strict isolation (for highly contagious or virulent infections such as viral hemorrhagic fever), contact isolation (for significant drug-resistant skin infections, group A streptococcal infections, etc.), respiratory isolation (for measles, meningitis, mumps, etc.), tuberculosis isolation, and other categories.
Guidelines and Recommendations for the Prevention and Control of Bloodborne Pathogens
In the late 1980s, the CDC estimated that 12,000 healthcare workers whose jobs entailed exposure to blood became infected with the hepatitis B virus every year, that 500-600 were hospitalized as a result, and that between 600-1,200 became carriers. Of the infected workers, about 250 died annually. The CDC also expressed concern over AIDS transmission to healthcare workers. In May 1995, the CDC reported 14,591 AIDS cases among healthcare workers, of which 133 may have been infected due to occupational exposure.
As of February 1999, OSHA estimates that 5.6 million healthcare workers and related occupations are at risk of occupational exposure to bloodborne pathogens including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C Virus (HCV), and others. Any worker handling sharp devices such as scalpels, sutures, hypodermic needles, blood collection devices, or phlebotomy devices is at risk. According to the National Institute for Occupational Safety and Health (NIOSH), it is estimated that 800,000 needlestick injuries occur annually in the hospital setting. Hospital studies show that as many as one-third of all sharp injuries have been reported to be related to the disposal process (www.osha-slc.gov/SLTC/needlestick/index.html).
In 1992, the CDC issued “Universal blood and body-fluid precautions” (better known as “Universal Precautions”) which were a set of precautions designed to prevent transmission of bloodborne pathogens. Under universal precautions, blood and certain body fluids of all patients are considered infectious. Universal precautions involved the use of protective barriers such as gloves, gown, masks, etc. as well as precautions to prevent injuries from needles, scalpels, and other sharp instruments. The universal precautions were discussed in three essential documents:
• Recommendations for Prevention of HIV Transmission in Health-Care Settings, 1987
• Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings, 1988
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• Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 1989
The last document was developed under the so-called AIDS Amendments (Health Omnibus Programs Extension Act) in 1989. As noted above, these Universal Precautions became the basis for OSHA’s Bloodborne Pathogen rule.
The following is a listing of the most current guidelines and recommendations available for the prevention and control of bloodborne pathogens (www.osha-slc.gov/SLTC/needlestick/index.html):
• Public Health Service (PHS) Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis. Morbidity and Mortality Weekly Report (MMWR), Recommendations and Reports, (1998, May 15), 47(RR-7);1-28. Current PHS recommendations for HCWs exposed to HIV, including postexposure prophylaxis:
— Appendix First-Line Drugs For HIV Postexposure Prophylaxis (PEP). (1998, May 15), 47(RR-7);29-30.
• Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. (1998, October 16), Vol. 47, No. RR-19;1-39. Provides guidelines for preventing transmission of HCV, identifying, counseling, and testing persons at risk for HCV infection, and appropriate medical evaluation and management of HCV-infected persons.
• Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) . (1997, December 26), 46(RR-18);1-42. This report summarizes recommendations of the ACIP concerning the use of certain immunizing agents in HCWs, and assists workers and administrators in optimizing infection prevention and control programs.
• How to Prevent Needlestick Injuries: Answers to Some Important Questions. OSHA Publication 3161, (Revised in 1999). This brochure looks at safer needle devices and how they can help employers create a safer workplace environment. Includes a sample Safety Feature Evaluation Form, developed by the Training for Development of Innovative Control Technology Project (TDICT), Trauma Foundation, San Francisco, CA (1993).
• Nonsocomial Hepatitis B virus Associated with Reusable Fingerstick Blood Sampling Devices- Ohio and NYC 1996. (1997, March 14), MMWR 46(10); 217-221. Alerts HCWs to the hazards of exposing patients to HBV through reusable fingerstick blood sampling devices. It emphasizes the need to restrict use of these devices to individual patients, and discard used parts appropriately.
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• Potential for Occupational Exposure to Bloodborne Pathogens From Cleaning Needles Used in Allergy Testing Procedures. OSHA Hazard Information Bulletin (1995, September 21), 5 pages. Alerts field personnel to the potential of occupational exposure to bloodborne pathogens from cleaning needles used in allergy testing procedures.
• Selecting, Evaluating, and Using Sharps Disposal Containers. NIOSH, (1998, January), 21 pages. NIOSH's safety performance criteria for selecting, evaluating, and using sharps disposal containers.
• Sharps Disposal Containers with Needle Removal Features. OSHA Hazard Information Bulletin (1993, March 12), 6 pages. Alerts field personnel to the possible safety and health risks that may arise with the use of some sharps disposal containers that incorporate an "unwinder" mechanism, to accomplish needle removal.
• Needlestick and Other Risks from Hypodermic Needles on Secondary I.V. Administration Sets - Piggyback and Intermittent I.V. FDA Safety Alert (1992, April 16), 2 pages. FDA urges the use of needleless systems or recessed needle systems to reduce the risk of needlestick injuries.
• Universal Precautions for the Prevention of Transmission of HIV and Other Bloodborne Infections. CDC (1998, May 28), 5 pages. General Precautions recommended to prevent transmission of bloodborne pathogens when providing first aid or health care. Includes precautions for safe needle handling and disposal.
• Post-Exposure Evaluation and Follow-Up Requirements Under OSHA's Standard for Occupational Exposure to Bloodborne Pathogens. American Dental Association. (1997, December), 30 pages. Provides guidance to dental employers about their responsibilities under the OSHA standard for providing post-exposure evaluation and follow-up for employees exposed to bloodborne pathogens.
• Infection Control Recommendations for the Dental Office and the Dental Laboratory. American Dental Association (1996), 10 pages. Safety Recommendations for control of bloodborne pathogen exposure in the dental office and laboratory.
Guidelines for Healthcare Workers Potentially Exposed to Tuberculosis
After decades of decrease in the number of TB cases reported annually in the United States, TB has emerged as a grave national problem with the number of new cases increasing by 14% from 1985 to 1993. During that period, 64,000 more cases were reported than would have been predicted from the declining trend of the previous years. Four major factors contributing to this dramatic increase were identified by the CDC: (1) the association of TB with the AIDS epidemic; (2) lack of healthcare among
4-17 Regulations and Standards Affecting the Healthcare Industry immigrants where TB is common; (3) a deterioration of the healthcare infrastructure; and (4) transmission of TB in prisons, homeless shelters, and healthcare facilities.
CDC issued guidelines to prevent TB transmission in 1994 (Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities) and in 1992 (Recommended guidelines for personal respiratory protection of workers in health care facilities potentially exposed to tuberculosis).
Food and Drug Administration
The Food and Drug Administration (FDA) is charged with protecting the nation’s health from unsafe and impure foods, drugs, cosmetics, and other potential hazards. Some of the key departments under FDA dealing with various aspects of work in healthcare facilities are:
Center for Drug Evaluation and Research
This center develops policy regarding safety, effectiveness, and labeling of all drug products and evaluates new drug applications. It also is responsible for standards for the safety and effectiveness of over-the-counter drugs.
Center for Biologics Evaluation and Research
This center regulates biological products including work on an AIDS vaccine. It conducts work on the safety of blood and blood products, and diagnostic reagents used in testing blood.
Center for Veterinary Medicine
This center has programs on the safety and efficacy of veterinary preparations and devices.
Center for Devices and Radiological Health
This center carries out a national program to control exposure of humans to x-rays and other ionizing radiation, as well as non-ionizing radiation from electronic products. The center also evaluates medical devices; it reviews medical device premarket applications, product development protocols, and exemption requests for investigational devices.
Medical Device Amendments and Safe Medical Devices Act of 1990 The Food and Drug Administration (FDA) has the authority to regulate medical devices under two statutes: (1) the Medical Device Amendments to the Federal Food, Drug &
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Cosmetic Act and (2) the Safe Medical Devices Act of 1990. The term "medical device" is defined broadly to include such wide-ranging products as wheelchairs, x-ray machines, pacemakers, glucometers, and sterilizers for reusable medical instruments.
The degree of regulation or control imposed by the FDA depends on the classification of the device. The FDA publishes proposals to recommend classification of a device in the Federal Register. After a public comment period and consideration of comments, the FDA issues a final regulation classifying the device. The three levels of class and their corresponding controls are shown below:
Class I General Controls Class II General and Specific Controls Class III Premarket Approval and General Controls
In general, all class of devices are subject to general controls which entail registration of each manufacturing location, listing of the device on the "Device Listing Form," compliance with the Good Manufacturing Practices (GMP) regulation, and submission of a Premarket Notification [510(k)] before marketing a new or significantly modified device.
At least 90 days before a firm intends to market a device for the first time, it must submit the “Premarket Notification” (also known as “510(k) submission”) to the FDA showing that the device is substantially equivalent to an existing, legally marketed device. Premarket Notification is also needed if a product has been significantly modified in a way that may significantly affect the safety or effectiveness of the device. Some Class I devices are exempted from the Premarket Notification and/or the Good Manufacturing Practices requirements.
Class II devices are subject to additional special controls which may include labeling requirements, mandatory performance standards, etc.
Class III devices require a Premarket Approval (PMA) application or a Premarket Notification [510(k)] or both. The requirements for Premarket Approval differ depending on whether the device is “preamendment” or “postamendment”. Preamendment devices are those in commercial distribution before May 28, 1976 when the Medical Device Amendments were implemented. Postamendment devices are those commercially distributed after that date.
An approved PMA application is somewhat tantamount to a “private license” to market the particular device. Class III devices cannot be marketed unless they have an approved Premarket Approval (PMA) application, or the FDA has determined from a Premarket Notification that the Class III device is substantially equivalent to a preamendment device. If a device is not substantially equivalent to a preamendment Class III device, a PMA is required or the firm may choose to petition to reclassify the
4-19 Regulations and Standards Affecting the Healthcare Industry device into Class I or Class II. Manufacturers of Class III postamendment devices that are not substantially equivalent to preamendment Class III devices are required to obtain PMA application approval.
The Food, Drug & Cosmetic Act authorizes the FDA to allow manufacturers of devices intended solely for investigational use to be exempt from certain requirements. This is known as the Investigational Device Exemption (IDE) and allows manufacturers to gather safety and effectiveness data using human subjects. However, if the device presents “significant risk,” testing must be supervised by an institutional review board, records must be kept, and an informed consent must be obtained. Devices with “nonsignificant risk” require institutional review board approval but submission of information to the FDA is not necessary.
The Safe Medical Devices Act of 1990 imposes a number of additional requirements. For example, under the Act, hospitals, nursing homes, ambulatory surgical facilities, outpatient treatment and diagnostic facilities, as well as the manufacturers and distributors of devices, must submit Medical Device Reports (MDRs) to report incidents that reasonably suggest that a medical device has caused or contributed to a death or serious injury. The Act also requires that manufacturers of certain devices must keep track of their devices, report certain removals or corrections of a device, and conduct postmarket surveillance. Maximum civil penalties for violations are specified in the Safe Medical Devices Act.
Health Resources and Services Administration
The Health Resources and Services Administration (HRSA), formerly the Health Resources Administration, has responsibility for general health and resources issues related to access, equity, quality, and cost of care. Among the many programs of the HRSA are:
• Supporting renovation of healthcare facilities serving AIDS patients
• Monitoring developments affecting health facilities and ensuring that previously aided institutions honor their commitments to provide uncompensated care
• Help coordinate government and private efforts related to rural health facilities
The HRSA also published the Minimum Requirements of Construction and Equipment for Hospital and Medical Facilities (HRSA 1979) with which hospitals receiving federal assistance must comply.
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HRSA’s Bureau of Health Resources Development
The Bureau of Health Resources Development under HRSA is responsible for various programs pertaining to healthcare facilities and is in charge of a national network associated with organ donations. Specifically, the bureau:
• Administers grant, loan guarantee, and interest subsidy programs related to the construction, modernization, conversion, and closure of healthcare organizations
• Develops program goals and objectives for healthcare facilities including trauma care and AIDS activities
• Develops and directs efforts to improve the management, operational effectiveness, and efficiency of healthcare systems, organizations, and facilities
• Administers the HRSA’s regional facility engineering and construction activities
National Institutes of Health
The National Institutes of Health (NIH) is the principal biomedical research agency of the federal government. NIH supports biomedical and behavioral research and conducts research on the quality of health care. Many of the institutes under NIH provide grants, cooperative agreements, and contracts to public and private research institutions and organizations in the healthcare industry for research , clinical investigations, training, institutional support, educational activities, etc.
Nuclear Regulatory Commission
The Atomic Energy Act of 1954 established a regulatory program for the use and disposal of radioactive materials. The Nuclear Regulatory Commission (NRC) adopts and enforces standards for departments of nuclear medicine in hospitals, although some states have agreements with the federal government to take over these responsibilities. In such cases, the responsible agency is usually the state health department.
The NRC regulates roentgenogram sources and all radioactive isotopes sources except radium, but does not have authority over naturally occurring radioactive materials such as radium and radon (the FDA is responsible for regulating those materials). NRC publishes and revises guidelines under its regulations, including detailed safety, handling, training, and recordkeeping requirements for radioactive materials. Most users of radioactive materials which generate low-level radioactive waste must receive a user license from the NRC or state agencies given that authority. Many hospitals, clinics, and other healthcare facilities generate low-level radioactive waste.
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Low-Level Radioactive Waste Policy Act and Amendments
The disposal of low-level radioactive waste is an issue for many healthcare institutions. Congress passed the Low Level Radioactive Waste Policy Act of 1980 and its subsequent amendments in 1985. The statute made states responsible for ensuring adequate disposal capacity for low-level radioactive waste generated within the state and encouraged states to enter into multi-state, regional compacts for the development of cost-effective disposal facilities. The statute also authorized states to restrict access to disposal facilities to the member states of the compact or to charge disposal surcharges to generators from non-sited states. One provision of the Act was to force states that have failed to provide low-level radioactive waste disposal capacity by January 1, 1996 to “take title” of the waste. This provision was declared unconstitutional by the Supreme Court in 1992 in a case involving the State of New York, but in doing so, the court left New York’s low-level radwaste generators in a difficult position: they could be denied access to existing disposal facilities but could not force the state to take title of the low-level radwaste.
In states where disposal facilities are not available, healthcare facilities have to assess alternative low-level radwaste management strategies such as on-site storage or use of commercial interim storage facilities. The situation is especially difficult for states that are not part of a compact with other states. As a result, more and more hospitals and biomedical facilities with extensive teaching or medical research work are facing the problem of what to do with their low-level radioactive waste stream. Several electrotechnology alternatives for treatment of medical waste are being developed or demonstrated for use with low-level radioactive waste.
Other Federal Agencies and Regulations
Other federal agencies affecting the healthcare industry are mentioned below.
Department of Veterans Affairs
The Department of Veterans Affairs administers programs to benefit veterans and members of their families. The Veterans Health Administration, formerly the Veterans Health Services and Research Administration, provides hospital, nursing home, domiciliary, and outpatient medical and dental care to eligible veterans. It operates a network of some 171 medical centers, 340 outpatient clinics, 127 nursing home units, and other healthcare facilities for veterans.
Americans With Disabilities Act of 1990
The Equal Employment Opportunity Commission investigates and attempts to conciliate charges under the Civil Rights Act of 1964 and the Americans With
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Disabilities Act of 1990 (ADA), with litigation conducted by the Department of Justice. The ADA has a direct impact on the healthcare industry. Under ADA, access must be provided by public and private facilities to people with disabilities. The definition of disability is broad, protecting not only the wheelchair-bound but also those with disabling conditions such as blindness, hearing impairment, arthritis, heart conditions, emphysema, short stature, amputated limbs, AIDS, etc. The ADA has five major sections or titles, each addressing a major aspect of the law such as employment, telecommunications, state and local government, and transportation.
A key section for healthcare facilities is Title III (Public Accommodations) which delineates the requirements for facilities to make their buildings and services more accessible. Basically, any public accommodation must remove architectural barriers whenever such removal can be accomplished without much difficulty or expense. If not, alternative methods must be offered to provide the goods, services, facilities, and accommodation. For a healthcare facility, this may mean a range of modifications, e.g. ramp entrances with a wider door at the entry, curb ramps on walkways around the facility, handicap parking space near the entrance, removal of over-hanging obstructions and other hazards for the visually impaired, beveled risers on stairs, accessible public telephones, means for decoding TV captions, wider entrances, visual fire alarms for hearing impaired, wheelchair lifts, accessible food services, etc.
ADA regulations specify accessibility guidelines including fire safety and communications systems with regards to new construction. Some programs exist to assist healthcare providers with ADA compliance (e.g., Child Care Law Center, San Francisco, California).
Department of Energy Schools and Hospitals Program
The Institutional Conservation Programs (ICP), also known as the Schools and Hospitals Program, under the Department of Energy (DOE) (202-586-8034) assists hospitals and schools in reducing their costs through energy savings measures. It is a federal matching grants program to which institutions can apply for Energy Conservation Measure grants. The goals of the program are to foster energy efficiency in hospitals and schools; to promote cost-sharing, joint-ventures, partnerships, and leveraging of non-federal funds; as well as to transfer DOE-developed technologies. In 1993, the State Energy Efficiency Programs Improvement Act was passed allowing ICP to fund technical assistance, program assistance, and marketing initiatives from the allocations. One of recent program enhancements is a flexibility to empower the states to partner with utilities and energy services companies (ESCOs) to meet the fundamental needs of healthcare institutions and schools.
Examples of projects funded through ICP are computer energy management systems, energy efficient lighting, insulation, air conditioning modifications, heat recovery
4-23 Regulations and Standards Affecting the Healthcare Industry systems for hot water, etc. A general program involves energy audits, technical assistance, and implementation of energy conservation measures.
State Regulatory Agencies
In varying ways, state health departments adopt and enforce regulations in the following areas: ionizing and non-ionizing diagnostic and therapeutic radiopharmaceuticals, infectious disease control, food handling, hazardous waste disposal, and medical waste disposal. In some states, the health department jointly accredits hospitals with the Joint Commission on Accreditation of Healthcare Organizations (see below). Also important are state planning agencies which approve construction and renovations in hospitals, such as Georgia’s Department of Health Planning or California’s Office of Statewide Health Planning and Development (OSHPAD). One of the more pressing issues for healthcare facilities is medical waste disposal.
Medical Waste Treatment Technology Efficacy Criteria
In April 1994, a consortium of state regulatory agencies came together to form the State and Territorial Association on Alternative Treatment Technologies. The purpose for this association was to recommend a uniform guideline or standard set of efficacy criteria dealing with new medical waste treatment methods. The uniform approach was viewed as facilitating state review processes, minimizing state liabilities, and enhancing cooperation between federal and state agencies. The following states were involved: California, Delaware, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Carolina, Texas, Virginia, Washington, and West Virginia. Also participating were Puerto Rico and Canada. The federal agencies represented were: CDC, FDA, NIH, DOT, and EPA.
The Association recommended that the following microbial inactivation criteria be met by all new and emerging medical waste treatment technologies:
• Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, and mycobacteria at a 6 Log10 reduction or greater; and
• Inactivation of B. stearothermophilus spores or B. subtilis spores at a 4 Log10 reduction or greater.
A 6 Log10 reduction is equivalent to one millionth survival probability in a microbial population or a 99.9999% reduction. Selected pathogen surrogates representing the above-mentioned microorganisms were also recommended to be used in testing. The association came up with a model state guideline for approval of medical waste treatment technologies which included efficacy testing protocols, technology approval
4-24 Regulations and Standards Affecting the Healthcare Industry process, site approval process, user verification, waste residue disposal, operator training, as well as provisions for small medical waste treatment devices and previously approved technologies. Generic application forms were also developed.
Specific State Regulations on Medical Waste Treatment
Table 4-3 gives a summary of which states have regulations on medical waste management, treatment and disposal. States which approve alternative treatment technologies or provide site-specific approvals for alternative technologies are also shown, in addition to states which require that medical waste be rendered unrecognizable. Summaries of these regulations as well as addresses and phone numbers of the key regulatory agencies are provided in Appendix B.
Table 4-3 State Regulations on Medical Waste
States with Approval as Site-specific Unrecognizability Specific Alternative Approvals Required Medwaste Regs Tech
Alabama * * Alaska * Arizona P P * Arkansas * * * * California * * Colorado * * Connecticut * * * Delaware * * * * District of Columbia Florida * * * Georgia * * * Hawaii * * Idaho * Illinois * * * Indiana * * * Iowa * * * Kansas * * * Kentucky * * * Louisiana * * * Maine * * * Maryland * * Massachusetts * * * Michigan * * * * Minnesota * * * Mississippi * * *
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States with Approval as Site-specific Unrecognizability Specific Alternative Approvals Required Medwaste Regs Tech
Missouri * * Montana * * * Nebraska * * * Nevada * * New Hampshire * * New Jersey * * * * New Mexico * * * New York * * * * North Carolina * * North Dakota * * * Ohio * * * Oklahoma * * Oregon * Pennsylvania * * * * Rhode Island * * * * South Carolina * * * South Dakota * * * Tennessee * * Texas * P * * Utah * * Vermont * * Virginia * * * * Washington West Virginia * * * Wisconsin * * * * Wyoming P = pending approval or regulation
County and Municipal Agencies
County and city health departments have jurisdiction over food handling and other hospital functions. Other departments deal with municipal solid waste disposal. Many local governments also assist in the evaluation of potential hazards in the workplace which are regulated at the state level.
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Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO or the Joint Commission) is a private, not-for-profit institution that evaluates and accredits more than 18,000 healthcare organizations in the United States. (Address: JCAHO, One Renaissance Boulevard, Oakbrook Terrace, IL 60181)
JCAHO accreditation is important to hospitals for the following reasons:
• It often fulfills all or some state licensure requirements for hospitals
• It may be used to meet certain Medicare certification requirements
• It expedites third-party payment
• It may improve access to and reduce the cost of liability insurance coverage
• It enhances access to managed care contracts
• It enhances medical staff recruitment
• It enhances community confidence
• It may favorably influence bond ratings and access to financial markets
• It assists organizations in improving their quality of care
• It provides a staff educational tool.
History
The idea of “hospital standardization” was first proposed in 1910 and was formulated in a “Minimum Standard for Hospitals” by the American College of Surgeons in 1917. The following year, on-site inspections of hospitals began and only 89 of 692 hospitals were found to meet the “Minimum Standard” requirements. By 1950, the standard of care had improved so much so that 3,200 hospitals were able to obtain approval under the “Minimum Standard” program.
In 1951, the American College of Surgeons, American College of Physicians, American Hospital Association, American Medical Association, and Canadian Medical Association (which later withdrew to form its own Canadian program) joined to form the Joint Commission on the Accreditation of Hospitals or JCAHO. The Joint Commission was created as an independent, not-for-profit organization whose primary purpose was to provide voluntary accreditation. 4-27 Regulations and Standards Affecting the Healthcare Industry
In 1965, Congress passed the Medicare Act with a provision that hospitals accredited by the Joint Commission are deemed to be in compliance with the conditions for participating in the Medicare and Medicaid Program. An accreditation program for long term care began in that same year.
The standards of the Joint Commission were revised in 1970 to represent optimal achievable levels of quality instead of minimum essential levels of quality. That same year, accreditation was expanded to include psychiatric hospitals, substance abuse programs, and community mental health programs. It was further expanded to include ambulatory healthcare facilities and managed care organizations in 1975; home care organizations in 1988; and the evaluation of healthcare delivery networks and hospice organizations in 1993.
To reflect the expanded scope of activities, the Commission changed its name to Joint Commission on Accreditation of Healthcare Organizations in 1987, at the same time launching its Agenda for Change designed to place the primary emphasis of accreditation on actual performance. In 1990, it moved to its current headquarters in Oakbrook Terrace, Illinois, 25 miles (40 km) west of downtown Chicago.
Scope of Accreditation Programs
The Joint Commission has accreditation programs for the following healthcare organizations:
• Hospitals…including general, psychiatric, rehabilitation, children’s and other specialty hospitals
• Long-term care facilities…including nursing homes and subacute care facilities
• Mental healthcare services…including those for chemical dependency and developmental disabilities
• Ambulatory care organizations…including outpatient surgery facilities and rehabilitation centers
• Healthcare networks…including HMOs, PPOs, and physician networks
• Home care organizations…including hospice and medical equipment services
• Clinical laboratories…including free-standing laboratories
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JCAHO Board and Staff
The Joint Commission is governed by a 28-member Board of Commissioners which includes nurses, physicians, consumers, medical directors, administrators, providers, employers, a labor representative, health plan leaders, quality experts, ethicists, a health insurance administrator, and educators.
The Joint Commission’s corporate members are the American College of Physicians– American Society of Internal Medicine, the American College of Surgeons, the American Dental Association, the American Hospital Association, and the American Medical Association.
Accreditation surveys are performed by about 550 personnel including physicians, nurses, healthcare administrators, and other professionals. These activities are supported by some 500 employees at the JCAHO headquarters near Chicago and at a small office in Washington, DC.
The Accreditation Process in Brief
This section summarizes what healthcare facilities have to go through to obtain accreditation. The process begins when an organization applies to the Joint Commission. The Commission then schedules an accreditation survey and notifies the organization four to six weeks in advance of an on-site visit. A specially-trained survey team is then put together to assess the organization’s compliance with applicable standards and provide the organization with information and guidance to help improve performance.
The survey begins with an opening conference with representatives of the organization’s administrative and clinical staff. After the conference, the surveyors may conduct “public information interviews” to offer the public and staff the opportunity to contribute information on the organization’s compliance with standards. The team then conducts staff and patient interviews, reviews documentation, observes patient care units, and tours selected departments within the facility. Each standard is scored on a five-point scale. After the on-site survey, the team meets with the organization’s leaders for an exit conference to summarize findings and recommendations.
The survey report forms are then sent to the Joint Commission for evaluation. The 14-member Accreditation Committee of the Board of Commissioners oversees the accreditation decision process.
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Types and Length of Accreditation
There are five possible accreditation decisions:
• Accreditation with Commendation
• Accreditation (with or without Type I recommendations)
• Provisional Accreditation
• Conditional Accreditation
• No Accreditation
Accreditation with commendation is given to an organization depending on its scores and if no Type I recommendation is made. A Type I recommendation is a recommendation or group of recommendations that address insufficient or unsatisfactory standards compliance in a specific performance area.
An organization may be given Type I recommendations if it is found to have serious standards compliance problems which are not severe enough to warrant an adverse decision. Such organizations may be given full accreditation but must act to remedy the problems within a specified period or risk losing accreditation. The Joint Commission follows up on recommendations through focused surveys, written documentation, or both.
An organization is eligible for a full survey if it has been providing care to patients or clients for six months prior to the survey. Provisional accreditation is given to newly opened organizations that have passed an initial survey under the JCAHO’s Early Survey Policy. It must complete the second (full) survey approximately six months later to receive full accreditation.
Conditional accreditation is given to organizations determined not to be in substantial compliance with standards but which the Joint Commission believes is capable of remedying the deficiencies within six months. The organization must develop a plan of correction and participate in a follow-up survey.
When there is pervasive and substantial noncompliance with standards, an immediate threat to health and safety, or failure to correct deficiencies within a required time frame, an organization is not given accreditation.
If an organization is found to be in substantial compliance with Joint Commission standards, it is awarded accreditation for three years. Accreditation is not automatically renewed. An organization must apply, participate in a survey, and demonstrate compliance with the standards once again to become accredited. 4-30 Regulations and Standards Affecting the Healthcare Industry
Since 1993, the Joint Commission has conducted unannounced one-day surveys of 5% (randomly chosen) of accredited organizations at the mid-point of their accreditation cycle.
Accreditation Standards
The hospital accreditation standards have shifted from those based on hospital departments to standards based on functions most critical to patient care. These functions are:
• Patient-Focused Functions…such as patient care, organizational ethics, etc.
• Organizational Functions…such as organizational performance, management of the environment and surveillance, prevention, and control of infection
• Structures with Functions…governance, management, medical staff, and nursing.
The hospital standards are supplemented by standards for pathology and clinical laboratory services. These standards relate to managerial personnel, space and equipment, communication, reports and records, quality control, and specific services including pathology, blood transfusion, clinical labs, etc.
The standards for long-term care organizations such as nursing homes involve direct care processes such as patient/resident assessment and continuity of care, and organizational requirements such as human resources. New standards have been developed for plant, technology, and safety management.
The accreditation standards for ambulatory health care organizations include standards dealing with services provided by urgent care centers, infection control, etc. The accreditation standards for mental health organizations are applicable to mental health centers, chemical dependency centers, residential treatment centers, outpatient clinics, and other organizations. The standards address functions directly related to patient care and organizational performance. The accreditation standards for home healthcare have also completed the transition from service-specific standards to those that foster teamwork, coordination, and continuity in the provision of home care services.
There are also accreditation standards for healthcare networks such as HMOs, PPOs, IPAs, etc. The standards address rights, responsibilities, and ethics; continuum of care; education and communication; leadership; management of resources; information management; and improving network performance.
In recent years, JCAHO has emphasized the Environment of Care (EC) Management standard which have become increasingly demanding. The objectives of the EC standard are to provide a safe, functional, and effective environment of care. The
4-31 Regulations and Standards Affecting the Healthcare Industry standard includes the areas of safety, security, control of hazardous materials, emergency preparedness, life safety, medical equipment, and utility systems. They require the involvement of plant, technology, and safety management staff in developing plans, performance indicators, standards, and implementation. Some of the areas where healthcare facilities have had difficulties include the Life Safety Code, emergency drills, documentation of management plans, and medical equipment maintenance, inspection, and testing. The EPRI Healthcare Initiative includes staff specialists and consultants that can provide assistance to healthcare facilities in meeting the requirements of JCAHO standards or preparing for JCAHO surveys.
National Fire Protection Association
The National Fire Protection Association (NFPA) promotes fire protection through research, public education, technical advisories, and the issuance of standards and codes. (Address: NFPA, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101) The NFPA has established criteria to minimize the hazards of fire, explosion, and electricity in healthcare facilities. The criteria include performance, maintenance, testing, and safe practice for facilities, material, equipment, and appliances.
By 1979, there were 12 separate NFPA documents addressing fire-related problems in and about healthcare facilities. A compilation of the latest version of each of these documents was completed in 1982 and was designated NFPA 99, Health Care Facilities Code. These codes have since been revised and new ones added. While NFPA itself does not approve, inspect, or certify installations, procedures, equipment, or material, all or portions of these and other codes are used by regulatory agencies and adopted by organizations such as OSHA, JCAHO, and HRSA as the industry standard.
Sections 3 to 11 of NFPA 99 are general requirements that apply to any healthcare facility. Sections 12 to 18 list requirements that apply to specific healthcare facilities. Section 19 deals with hyperbaric facilities where oxygen is used at elevated pressures. Below is a brief description of these sections: Section Title Description 3 Electrical Systems Covers performance, testing, and maintenance of various types of essential electrical systems 4 Gas and Vacuum Covers performance, maintenance, installation, Systems and testing of flammable or nonflammable medical and laboratory gas systems, vacuum systems, and their connections 5 Environmental Systems Covers performance, maintenance, and testing of ventilation in anesthetizing locations and laboratories, and laboratory hoods
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6 Materials Covers hazards associated with flammable and combustible materials 7 Electrical Equipment Covers performance, maintenance, and testing of electrical equipment such as adapters, extension cords, instrumentation and monitoring devices, appliances, laboratory equipment, etc. 8 Gas Equipment Covers performance, maintenance, and testing of gas equipment including cylinders, hand trucks, and other apparatus used for anesthesia and respiratory therapy 9 Manufacturer Covers requirements for manufacturers of Requirements equipment used in healthcare facilities 10 Laboratories Covers criteria to minimize hazards of fire and explosion in laboratories located in healthcare facilities; NFPA 45 (Fire Protection Standard for Laboratories Using Chemicals) covers construction, ventilation and fire protection 11 Health Care Emergency Covers minimum criteria for disaster Preparedness management in a healthcare facility 12 Requirements for hospitals 13 Requirements for ambulatory healthcare centers 14 Requirements for clinics 15 Requirements for medical and dental offices 16 Requirements for nursing homes 17 Requirements for limited care facilities 18 Requirements for electrical and gas equipment for home care 19 Requirements for hyperbaric facilities. The 1996 edition of NFPA 99 has informational annexes dealing with high-frequency electricity use (associated with electrosurgery, diathermy or the use of heat from the passage of current or electromagnetic fields in body tissue, hyperthermia, and medical lasers) and flammable anesthetizing locations.
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The key NFPA publications relevant to healthcare facilities include:
NFPA 45 Standard on Fire Protection for Laboratories Using Chemicals, 1991 NFPA 53 Guide on Fire Hazards in Oxygen-Enriched Atmospheres, 1994 NFPA 70 National Electrical Code, 1996 NFPA 90A Standard for the Installation of Air Conditioning and Ventilating Systems, 1993 NFPA 90B Standard for the Installation of Warm Air Heating and Air Conditioning Systems, 1993 NFPA 99 Healthcare Facilities Code NFPA 99B Standard for Hypobaric Facilities NFPA 101® Life Safety Code®, 1994 NFPA 110 Standard for Emergency and Standby Power Systems NFPA 325 Guide to Fire Hazard Properties of Flammable Liquids, Gases, and Volatile Solids, 1994 NFPA 801 Recommended Fire Protection Practice for Facilities Handling Radioactive Materials, 1991
American Society of Heating, Refrigerating, and Air-Conditioning Engineers
The American Society of Heating, Refrigerating, and Air Conditioning Engineers or ASHRAE (Address: 1791 Tullie Circle, NE, Atlanta, GA 30329-2305; (404) 636-8400; www.ashrae.org) is organized for the purpose of advancing the arts and science of heating, ventilation, air conditioning, and refrigeration for the public’s benefit through research, standard writing, continuing education and publications. The Society is revising two of its standards which affects the healthcare industry. Revisions to ASHRAE 62-1989 (Ventilation for Acceptable Indoor Air Quality) and ASHRAE 90.1-1989 (Energy Efficiency Design of New Buildings Except Low-rise Residential Buildings) are described below.
ASHRAE 62
ASHRAE is currently revising ANSI/ASHRAE Standard 62-1989 under its continuous maintenance procedures. The standard deals with ventilation for acceptable indoor air quality. The proposed addenda are written in code language to make it easier for code bodies to adopt the standard into their regulations. Five addenda are currently being considered for publication after public review ended in May 1998. Additionally, five addenda will be going out for public review on November 15, 1998, and closing on January 14, 1999. The SSPC is currently drafting six additional addenda that will go out for public review in early 1999. (For further information, contact Danny Halel at (404) 636-8400.)
4-34 Regulations and Standards Affecting the Healthcare Industry
ASHRAE 90.1
ASHRAE has been developing minimum energy-efficient requirements for designing and constructing new buildings. These requirements are found in the revised ASHRAE Standard 90.1-1989R which apply to the building envelope, HVAC, service water heating, electric power distribution, metering, electric motors, and lighting. Like ASHRAE 62, the draft is written in enforceable language making it easier for states and local governments to adopt it as a code. The proposed standard will raise efficiency levels for most mechanical equipment and include requirements for new categories of building systems and equipment, such as ground-source heat pumps, cooling towers, and absorption air conditioning units. Importantly, the proposed standard includes a higher efficiency tier which can be used by utilities in incentive programs. The updated standard is expected in 1999. (For further information, contact Doug Tucker at (404) 636-8400 x503.)
American Institute of Architects
The American Institute of Architects (AIA) (through their Committee on Architecture for Health) also has minimum guidelines for healthcare facility construction. (Address: AIA, 1735 New York Ave. NW, Washington, DC 20006-5292; (202) 626-7300; www.e-architect.com)
Guidelines for Design and Construction of Hospitals and Health Care Facilities
In July 31, 1996, AIA released its 1996-97 revised edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities (AIA Press). The new guidelines are a revision of the 1992-93 version. They address design and construction issues for general hospitals, nursing facilities, outpatient facilities, rehabilitation facilities, psychiatric hospitals, and mobile, transportable and relocatable units. An important addition to the guidelines is the material on infection control. Copies of the new guidelines can be ordered from AIA (Rizzoli Catalog Sales (888) 272-4115).
National Committee for Clinical Laboratory Standards
The National Committee for Clinical Laboratory Standards (NCCLS) develops voluntary consensus standards for clinical laboratory testing and is affiliated with the American National Standards Institute. (Address: NCCLS, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898) It has annual meetings and publishes various guidelines including:
GP17-T Guidelines for Laboratory Safety GP5-A Clinical Laboratory Waste Management
4-35 Regulations and Standards Affecting the Healthcare Industry
M29-T2 Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids, and Tissue.
National Safety Council
The National Safety Council (1121 Spring Lake Drive, Itasca, IL 60143-3201), with the purpose of promoting safety and accident prevention, provides general safety and health recommendations including recommendations regarding ethylene oxide. The Hospital Section of the Council prepares recommendations for hospitals. There are also Research and Development as well as Chemical Sections that develop recommendations dealing with laboratory safety.
4-36 5 ENERGY USE IN THE HEALTHCARE INDUSTRY
Typical Energy Use and Energy Intensities for Healthcare Facilities
According to Commercial Buildings Consumption and Expenditures published in October 1998 by the Energy Information Administration, U.S. Department of Energy (DOE), and which is based on the DOE’s most recently completed 1995 survey (a 1999 survey is underway), the annual overall energy use in the healthcare industry was 561 trillion BTUs in 1995, amounting to an annual energy expenditure in excess of $5.2 billion. That same study compared gross energy intensities and total energy consumption for various buildings in the commercial sector.
Figure 5-1 shows energy consumption and gross energy intensity in relation to other commercial buildings. Healthcare buildings ranked second in gross energy intensity in relation to other commercial buildings. Table 5-1 shows additional comparisons by building size.
Consumption Intensity
Figure 5-1 Energy Consumption and Intensity by Principal Building Activity, 1995
5-1 Energy Use in the Healthcare Industry
Table 5-1 Consumption and Gross Energy Intensity by Building Size for Sum of Major Fuels, 1995
Sum of Major Fuel Total Floorspace of Energy Intensity Consumption Buildings for Sum of Major Fuels (trillion Btu) (million square feet) (thousand Btu/sq. ft.)
10,001 10,001 10,001 1,001 to to Over 1,001 to to Over 1,001 to to Over Building 10,000 100,000 100,000 10,000 100,000 100,000 10,000 100,000 100,000 Characteristics Square Square Square Square Square Square Square Square Square Feet Feet Feet Feet Feet Feet Feet Feet Feet RSE Row RSE Column Factor: 1.4 1.0 1.2 1.0 0.8 0.8 1.2 0.8 1.0 Factor
All Buildings 1,332 2,152 1,838 13,869 27,261 17,643 96.0 78.9 104.2 5.80
Principal Building Activity
Education 71 352 191 654 4,623 2,464 108.1 76.1 77.7 11.73
Food Sales 78 59 Q 367 269 Q 212.6 217.2 Q 17.95
Food Service 265 66 Q 940 406 Q 281.5 161.9 Q 21.21
Health Care 36 82 443 294 556 1,483 122.4 148.2 298.3 16.60
Lodging 53 236 172 419 1,873 1,327 125.5 126.2 129.5 16.29
Mercantile and Service 363 396 214 4,043 5,393 3,292 89.7 73.4 65.1 14.78
Office 172 401 445 1,999 4,416 4,063 86.3 90.8 109.6 9.87
Public Assembly Q 193 115 1,098 1,924 925 Q 100.0 124.0 16.99
Public Order and Safety 22 63 Q 233 755 283 92.8 83.3 Q 30.58
Religious Worship 41 62 Q 964 1,797 Q 42.3 34.8 Q 16.57
Warehouse and Storage 65 136 123 1,798 3,842 2,842 36.2 35.4 43.4 16.79
Other Q 84 79 Q 531 308 Q 157.4 256.0 30.87
Vacant Q 23 Q 896 876 611 Q 26.5 Q 34.34
NF = No applicable RSE row factor.
Q = Data withheld because the Relative Standard Error (RSE) was greater than 50%, or data were reported for fewer than 20 buildings. Notes: To obtain the RSE percentage for any table cell, multiply the corresponding RSE column and RSE row factor. Source: Energy Information Administration, 1995 Commercial Buildings Energy Consumption Survey.
This information was based on data for 22,000 in-patient facilities (hospitals, mental health hospitals, and rehabilitation facilities) and 83,000 out-patient facilities (medical and dental clinics and veterinary facilities). The 31,000 skilled nursing facilities (nursing homes) are categorized under Lodging.
The breakdown according to facility type of total energy use, floorspace of buildings, and energy intensity for all fuels is given in Table 5-2.
5-2 Energy Use in the Healthcare Industry
Table 5-2 Floorspace, Consumption, Expenditures, Intensities of All Major Fuels for Healthcare Buildings
Total Major Fuels Electricity
Floor Total Total space Total Expenditures Intensity Total Expenditures (million Consumption (million (thousand Consumption (million Intensity ft2) (trillion Btu) dollars) Btu/ft2) (billion kWh) dollars) (kWh/ft2)
All Buildings 58,772 5,321 69,918 90.5 764 56,621 13.4
Health Care Activities
Outpatient Health Care 692 77 1,139 110.7 12 984 18.1
Inpatient Health Care 1,641 Q 4,122 295.1 49 2,917 30.1
Skilled Nursing 723 112 1,200 154.9 12 872 16.7
Q = Data withheld because the Relative Standard Error (RSE) was greater than 50%, or fewer than 20 buildings were sampled.
(Source: Energy Information Administration, 1995 Commercial Buildings Energy Consumption Survey, unpublished data.)
The breakdown of energy consumption in healthcare in trillion BTUs (1995 data) according to type of fuel is shown in Figure 5-2 and Table 5-3. Table 5-4 shows total energy expenditures by major fuel.
258 300 211 250 200 150 70 100 21 50 0 Electricity Natural Gas Fuel Oil District Heating
(Source: 1995 Commercial Building Energy Consumption Survey, Energy Information Administration, U.S. Department of Energy)
Figure 5-2 Breakdown of Energy Use in Trillion BTUs
5-3 Energy Use in the Healthcare Industry
Table 5-3 Total Energy Consumption by Major Fuel, 1995
All Buildings Total Energy Consumption (trillion Btu)
Floorspace Primary Number of (million Total of Electricity Building Buildings square Major Site Natural District (trillion Characteristics (thousand) feet) Fuels Electricity Gas Fuel Oil Heat Btu) RSE Row RSE Column Factor: 0.7 0.6 0.8 0.8 1.0 1.9 2.5 0.8 Factor
All Buildings 4,579 58,772 5,321 2,608 1,946 235 533 7,873 5.74
Building Floorspace (square feet)
1,001 to 5,000 2,399 6,338 708 380 264 44 Q 1,148 9.50
5,001 to 10,000 1,035 7,530 624 238 272 26 Q 718 14.90
10,001 to 25,000 745 11,617 824 384 356 45 38 1,161 12.29
25,001 to 50,000 213 7,676 630 316 231 28 55 954 9.79
50,001 to 100,000 115 7,968 698 363 243 31 60 1,097 10.41
100,001 to 200,000 48 6,776 687 337 244 21 84 1,017 11.84
200,001 to 500,000 19 5,553 636 307 211 25 94 927 13.65
Over 500,000 6 5,313 514 282 125 14 93 852 14.56
Principal Building Activity
Education 309 7,740 614 221 245 57 91 666 10.34
Food Sales 137 642 137 119 18 Q Q 358 20.58
Food Service 285 1,353 332 166 158 Q Q 502 20.94
Health Care 105 2,333 561 211 258 21 70 637 13.78
Lodging 158 3,618 461 187 213 Q 57 565 13.83
Mercantile and Service 1,289 12,728 973 508 395 49 Q 1,533 12.33
Office 705 10,478 1,019 676 239 28 75 2,039 11.11
Public Assembly 326 3,948 449 170 142 14 Q 514 17.28
Public Order and Safety 87 1,271 124 49 33 Q Q 148 30.10
Religious Worship 269 2,792 104 33 57 13 Q 99 13.80
Warehouse and Storage 580 8,481 325 176 106 10 Q 531 16.23
Other 67 1,004 173 75 55 Q Q 228 32.41
Vacant 261 2,384 51 18 26 5 Q 54 25.95
Q = Data withheld because the Relative Standard Error (RSE) was greater than 50%, or fewer than 20 buildings were sampled.
5-4 Energy Use in the Healthcare Industry
Table 5-4 Total Energy Expenditures by Major Fuel, 1995
All Buildings Total Energy Consumption (million dollars)
Floorspace Number of (million Total of Building Buildings square Major Natural District Characteristics (thousand) feet) Fuels Electricity Gas Fuel Oil Heat RSE Row RSE Column Factor: 0.7 0.6 0.7 0.7 1.0 2.0 2.4 Factor
All Buildings 4,579 58,772 69,918 56,621 9,018 1,175 3,103 5.62
Building Floorspace (square feet)
1,001 to 5,000 2,399 6,338 11,577 9,696 1,483 275 Q 9.81
5,001 to 10,000 1,035 7,530 8,063 6,055 1,439 153 Q 13.81
10,001 to 25,000 745 11,617 11,099 8,911 1,775 239 174 12.24
25,001 to 50,000 213 7,676 8,676 7,005 1,159 129 383 10.13
50,001 to 100,000 115 7,968 8,824 7,194 1,091 140 400 10.58
100,001 to 200,000 48 6,776 7,859 6,283 958 88 530 11.93
200,001 to 500,000 19 5,553 7,291 5,908 729 97 557 13.13
Over 500,000 6 5,313 6,530 5,568 385 56 521 15.34
Principal Building Activity
Education 309 7,740 7,129 5,168 1,117 249 595 11.60
Food Sales 137 642 2,634 2,532 97 Q Q 22.57
Food Service 285 1,353 4,817 3,931 851 Q Q 21.82
Health Care 105 2,333 5,261 3,901 838 94 428 14.73
Lodging 158 3,618 5,114 3,838 966 Q 291 14.89
Mercantile and Service 1,289 12,728 14,025 11,655 1,979 265 Q 12.05
Office 705 10,478 15,849 14,020 1,150 154 524 10.97
Public Assembly 326 3,948 4,988 3,604 675 75 Q 16.42
Public Order and Safety 87 1,271 1,551 1,131 167 Q Q 31.80
Religious Worship 269 2,792 1,337 953 303 69 Q 14.80
Warehouse and Storage 580 8,481 4,709 3,934 559 56 Q 17.57
Other 67 1,004 1,865 1,473 197 Q Q 34.95
Vacant 261 2,384 638 481 119 25 Q 24.91
Q = Data withheld because the Relative Standard Error (RSE) was greater than 50%, or fewer than 20 buildings were sampled.
5-5 Energy Use in the Healthcare Industry
For further statistical information, contact:
Martha Johnson, Survey Manager Energy Information Administration U.S. Department of Energy (202) 586-1135 (202) 586-0018 (Fax) www.eia.doc.gov/emeu
Typical Electrical Use for Healthcare Facilities
Data from two utilities (Figures 5-3 and 5-4) give examples of the breakdown of Healthcare electrical usage in the healthcare industry for their service territories.
Misc (6.6%) Refrigeration (3.6%) Cooking (2.7%) Water Heating (4.1%)
Space Heating (4.0%) A/C (40.5%)
Ventilation (11.8%)
Lighting (26.8%)
(Source: “Powerful Solutions,” Entergy, 1994)
Figure 5-3 Breakdown of Healthcare Electrical Usage, Arkansas Power & Light
5-6 Energy Use in the Healthcare Industry
Misc (6.2%) Refrigeration (4.5%) Cooking (3.2%) Water Heating (1.8%) Space Heating (5.2%) A/C (43.3%)
Ventilation (11.1%)
Lighting (24.7%)
(Source: “Powerful Solutions,” Entergy, 1994)
Figure 5-4 Breakdown of Healthcare Electrical Usage, Louisiana Power & Light
Typical Lighting Load Shape for Healthcare Facilities
Figure 5-5 shows hourly lighting load-shape data for a typical hospital and medical office in the Southern California Edison service territory. The lighting load profile reflects the differences in load due to changes in work shifts.
10 8 6 CENT 4 PER 2
6121824 HOUR
(Source: “A Review of Existing Commercial Energy Use Intensities and Load-Shape Studies,” H. Akbari, I. Turiel, J. Eto, K. Heinemeier, B. Lebot, and L. Rainer, Commercial Data, Design, and Technologies)
Figure 5-5 Typical Hourly Lighting Load Shape for a Hospital
5-7 blank page 6 PROCESSES AND OPPORTUNITIES IN HEALTHCARE FACILITIES
Primary Processes in Healthcare Facilities
Hospitals and other healthcare institutions are complex facilities supporting medical care of resident patients and/or outpatient services for non-resident patients. This section describes the primary processes in healthcare facilities. For the purpose of this section, processes are defined as those activities that use or can potentially use electricity or activities that have an important bearing on energy use.
Many of the processes in hospitals are similar to those of other types of establishments in the commercial sector. For example, with their resident patients, some processes in hospitals resemble those of lodging facilities such as college dormitories or hotels. Laundry operations are similar to those in a commercial laundry establishment. Similarly, hospital food service is similar to a traditional large commercial cooking facility. Also, the business office of a hospital is identical in operation to a medium commercial office, with clerical workers, computers, copiers, and other office equipment.
Many hospitals operate medical laboratories which have many things in common with a biomedical research or university laboratory in their use of chemicals, generation of hazardous waste, and electronic instrumentation. Hospitals produce a large amount of potentially infectious wastes in addition to a variety of hazardous chemicals and low- level radioactive wastes. In this regard, hospitals encounter some of the same problems that many establishments in the industrial sector face.
Despite similarities with other establishments in the commercial and industrial sectors, however, hospitals and other healthcare facilities have many distinctive characteristics that are unique to the healthcare industry. For example, the diagnostic and treatment units in a hospital contain sensitive electronic devices such as life-support equipment, computed tomography (CT) scanners, electrocardiogram (EKG) machines, and monitoring devices, whose functions are vital to maintaining human life or responding to life-threatening emergencies.
6-1 Processes and Opportunities in Healthcare Facilities
Compared with other commercial buildings, hospital HVAC operations are designed to meet stringent regulatory codes intended to prevent the spread of diseases and provide patient comfort. HVAC requirements in relations to isolation rooms and surgical suites, for example, are unique to the healthcare industry. In addition, hospitals operate exhaust hoods in their laboratories and pharmaceutical services. HVAC operation must also take into consideration the comfort of patients and healthcare providers.
With their extensive use of electrical equipment, intensive lighting, and 24-hour operation involving a high concentration of workers, hospitals consume more electricity per unit area than most other commercial segments. Lighting requirements may include special lamps, unusual optics, and unique lighting equipment for surgical suites (which require high light levels), laboratories, examination rooms, etc.
These processes may be grouped into several major processes as listed below. Based on these established processes, technology and service opportunities for utilities in the healthcare industry are identified in subsequent sections.
Facility Management
Power distribution and assurance Emergency generation Ventilation Air conditioning Space heating Hot water and steam production Lighting Water purification Maintenance Groundskeeping
Occupational Safety and Environmental Services
Infectious medical waste handling, treatment and disposal Hazardous waste handling, treatment and disposal Low-level radioactive waste handling, treatment and disposal Solid municipal waste (non hazardous) disposal Medical equipment sterilization Wastewater disposal Fire safety and life safety
6-2 Processes and Opportunities in Healthcare Facilities
Food Services
Cooking Food refrigeration and freezing Dishwashing Food delivery
Lodging Services
Laundry Housekeeping Patient movement
Administrative Services
Data processing Telecommunications Miscellaneous office processes (Faxing, photocopying, etc.) Security Material storage and movement
Clinical Services
Diagnostic processes Treatment processes Laboratory processes Miscellaneous clinical processes (pharmacy, etc.) Telemedicine
Identifying Issues and Opportunities
The illustrations below give examples of the electrotechnology and service opportunities associated with each of the major processes identified above. A discussion of these opportunities is presented in the next sections.
6-3 Processes and Opportunities in Healthcare Facilities
LIGHTING Delamping REFRIGERATION/CHILLERS Improved fluorescent fixtures Refrigerant substitution Compact sources High efficiency chillers Lighting controls Heat recovery Circadian lighting
EMERGENCY POWER Transfer switching Maintenance VENTILATION Demand control ventilation Isolation room ventilation INDOOR AIR QUALITY Humidity control/heat pipes Cold air distribution HEPA filtration Exhaust hoods UV germicidal irradiation IESF
COOLING TOWERS Ozonation Optimization
THERMAL ENERGY STORAGE Ice-thermal energy storage Chilled water storage Eutectic salt storage POWER QUALITY TES for space heating Audits of PQ and EMI problems PQtraining Pre-installation evaluation Equipment immunity, shielding Engineering controls
ENERGY MANAGEMENT Energy audits Energy management systems
Figure 6-1 Issues and Opportunities in Facility Management
6-4 Processes and Opportunities in Healthcare Facilities
MEDICAL WASTE TREATMENT
Pyrolysis/oxidation Microwave disinfection Plasma Infrared heating E-beam irradiation Induction tube heating Superheated steam reform ing Chemical-mechanical systems Steam-based sterilization
WA STE MAN AGEM EN T
Waste minimization Reverse osmosis for dialysis waste Solvent recovery Cation exchange and electrolytic recovery for x-ray waste Encapsulation technologies Ultrasound or steam cleaning to reduce disinfectant & cleaning wastes
Figure 6-2 Issues and Opportunities in Environmental Services and Occupational Safety
6-5 Processes and Opportunities in Healthcare Facilities
LODGING SERVICES
Ozone-based laundry M icrowave drying
CLINICAL SERVICES Medical Device Sterilization - Plasma systems - E-beam irradiation - Ozonation - Membrane separation for ETO Water Purification - UV disinfection Power quality issues Small generator treatment technologies for medical waste
ADMINISTRATIVE SERVICES Information systems Telecommunications/telemedicine
FOOD SERVIC ES Electric cooking technologies
Figure 6-3 Issues and Opportunities in Lodging, Clinical, Administrative and Food Services
6-6 Processes and Opportunities in Healthcare Facilities
Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Management
Profile of the Medical Waste Stream in Healthcare Facilities
In 1994, the U.S. Environmental Protection Agency reported that the United States’ 7,000 hospitals generated 2.4 million tons of total waste annually. The overall waste stream in hospitals varies considerably: about 50-70% cellulose material (paper and cloth items), 20-60% plastics, 10-20% glass, and 1-10% moisture including fluids.
The waste stream in hospitals and other healthcare facilities can be classified into four groups for the purpose of waste minimization or disposal: (1) general refuse waste stream, or municipal solid waste, that is non-infectious and non-hazardous; (2) infectious or biohazardous wastes; (3) hazardous wastes which fall under the federal Resource Conservation and Recovery Act and local regulations, but not including infectious wastes; and (4) low-level radioactive wastes.
Municipal Solid Waste
The municipal solid waste stream is similar to waste from hotels, restaurants, and other institutions with lodging-type services, food services, data processing and administration, and facility operations. Solid waste is generally collected in trash bins or dumpsters and removed by haulers for disposal in a municipal landfill. Hospitals account for about 1% of all the municipal solid waste generated in the United States. The composition for hospital municipal solid waste was presented at an American Hospital Association 1991 conference on hospitals and the environment; it is shown in Figure 6-4 below.
6-7 Processes and Opportunities in Healthcare Facilities
Wood Glass 3% 7%
Other 10%
Paper and 45% Paperboard Metals 10%
10% Food Waste
15% Plastics
(From R.C. Fenwick, American Hospital Association conference on hospitals and the environment, May 1991)
Figure 6-4 Municipal Solid Waste Composition for a Typical Hospital
Infectious Waste
Infectious waste is also referred to as biohazardous waste, red bag waste, regulated medical waste, or potentially infectious medical waste, with slightly varying definitions. In general, they are stored in red bags or in containers marked with the biohazard symbol and are usually segregated from the general waste stream. A typical hospital may classify about 15% of their waste stream as infectious waste. The following ten waste classes of infectious waste, frequently used in defining infectious or regulated medical waste, are based on the Environmental Protection Agency’s definitions in the Medical Waste Tracking Act:
6-8 Processes and Opportunities in Healthcare Facilities
Table 6-1 Ten Categories of Infectious Waste
Waste Class Description
Cultures and Stocks Cultures and stocks of infectious substances and associated biologicals
Anatomical Wastes Tissues, organs and body parts
Human Blood, Blood Products, Discarded human blood, products of blood, items saturated with and Other Bodily Fluids blood or caked with dried blood, and body fluids
Contaminated Sharps Used sharps including syringes, pipettes, scalpel blades, vials and needles
Animal Wastes Discarded material including carcasses and bedding from animals exposed to infectious substances
Isolation Wastes Discarded material contaminated with blood, excretions, etc. from humans isolated to protect others from communicable diseases
Contaminated Medical Equipment Medical equipment that was in contact with infectious substances
Surgery Wastes Discarded material including soiled dressings, sponges, drapes, gowns, gloves, etc.
Laboratory Wastes Wastes that were in contact with infectious substances such as slides and cover slips
Dialysis Wastes Effluent and equipment that was in contact with blood of patients undergoing dialysis
In 1994, the U.S. Environmental Protection Agency reported that the 7,000 U.S. hospitals generated 360,000 tons (3.3 × 108 kg) of infectious waste annually. An additional 144,000 tons (1.3 × 108 kg) of infectious waste were produced by thousands of smaller healthcare facilities such as nursing homes, medical laboratories, physician’s offices and clinics.
An issue facing nursing homes, doctors’ and dentists’ offices, clinics, blood banks, and other healthcare facilities is the potential for injury as a result of medical waste, especially blood-contaminated items and sharps. The bloodborne diseases, Hepatitis B and C virus and human immunodeficiency virus (HIV), have been at the center of concern in the healthcare industry. According to the American Liver Foundation, as many as 10,000 healthcare workers may be infected with HBV every year, resulting in 125 to 190 deaths annually. The Centers for Disease Control and Prevention (CDC) is aware of at least 133 cases of human immunodeficiency virus (HIV) among healthcare
6-9 Processes and Opportunities in Healthcare Facilities workers, many of whom are known to have acquired HIV infection or AIDS through occupational exposures. Most of the documented cases are due to puncture injuries and exposure to HIV-infected blood.
Nursing homes generate a variety of medical waste, including sharps, blood and blood products, dialysis waste, and pathological wastes, depending on the type and extent of services they provide. Nursing homes may also generate chemotherapy and solvent wastes. The kinds of waste generated by physicians’ offices depend on the medical practice. Sharps and blood or blood products are common to almost all specialties. Clinical laboratories and biomedical research facilities produce blood and blood products, sharps, cultures and stocks of infectious agents, pathological waste, and animal wastes. Dental offices also deal with sharps and items in contact with blood, as well as chemical wastes from x-ray equipment.
Hazardous Waste
Because healthcare institutions use toxic and hazardous materials in many diagnostic and treatment functions as well as in facility management operations, different types of hazardous wastes are generated at these facilities. The healthcare industry, especially general medical and surgical hospitals, generates hazardous waste in small volumes relative to industrial facilities but their wastes are of a wide variety.
Table 6-2 lists hazardous wastes generated at healthcare facilities. Xylene, methanol and acetone are among the most frequently used solvents. Chemotherapy wastes account for the largest volume of hazardous waste in some hospitals. Table 6-2 also includes toxic gases as well as special wastes which may be subject to the Clean Air Act and other laws.
6-10 Processes and Opportunities in Healthcare Facilities
Table 6-2 Hazardous Wastes Generated in Healthcare Facilities
Types of Wastes Primary Sources Examples
Solvents Pathology, histology, embalming, Xylene, toluene, chloroform, laboratories, ER, OR, pharmacy, methylene chloride, TCE, TCA, facility engineering; clinics, and acetone, methanol, ethanol, nursing homes isopropanol, ethylene acetate, acetonitrile
Formaldehyde wastes Pathology, autopsy, dialysis, Formalin solutions embalming, nursing units, ER, OR; and clinics
Antineoplastic or Oncology/chemotherapy, nursing Chlorambucil, Cytoxin, Daunomycin, cytotoxic agents units, and pharmacy Mitomycin C
Photographic chemicals Radiology; CT Scan; dental offices Silver, hydroquinone, potassium hydroxide, acetic acid
Mercury wastes General including dental offices, Mercury in broken or obsolete clinics, and nursing homes equipment such as thermometers, blood pressure gauges, etc.
Ethylene oxide Sterilizers in central supply, Ethylene oxide gas released through respiratory therapy, operating sterilizer aerator ducts and fugitive rooms; clinics emissions
Anesthetic gases OR, ER; clinics, and dental offices Nitrous oxide, halothane, enflurane, isoflurane
Disinfecting solutions General including housekeeping, Glutaraldehyde, phenol-based dental offices, clinics, and nursing cleaning solutions, ethanol, homes isopropanol
Maintenance and utility Facility engineering; clinics, and Waste oils, degreasers, paint wastes, wastes nursing homes pesticides, boiler wastes
Special toxic wastes Facility engineering; clinics, and Asbestos, PCBs nursing homes
In the particular case of dental offices and clinics, the waste stream includes sharps, items in contact with blood, photographic chemicals associated with x-ray equipment, mercury waste, anesthetic gases, and disinfecting solutions. In addition, the wastewater stream from dental facilities includes mercury from amalgams, silver from photographic fixers and amalgams, and copper from amalgams.
6-11 Processes and Opportunities in Healthcare Facilities
Radioactive Waste
Low-level radioactive wastes are generated in hospitals, clinics, and testing laboratories. Radioactive substances are commonly used in nuclear medicine and clinical testing. Table 6-3 below lists the most common radioactive materials used in hospitals and their physical and effective half-lives.
Table 6-3 Radioactive Materials Used In Hospitals
Radionuclides Physical Half-Life Effective Half-Life
Carbon-14 5,730 yrs 12 days
Phosphorus 14 days 14 days
Chromium-51 28 days 27 days
Gallium-67 78 hrs --
Technetium-99 6 hrs 5 hrs
Indium-111 2.8 days --
Iodine-125 60 days 42 days
Tritium 12.3 yrs 12 days
Iodine-131 8 days 8 days
Cesium-137 30 yrs 70 days
Barium-137m 2.5 min --
Iridium-192 74 days --
Radium-226 1,600 yrs 44 yrs
Cobalt-609 5.27 yrs 10 days
Physical half-life is the time required for half of the original number of atoms to decay. The effective half- life is a combination of physical half-life and biological half-life (the time required for half the atoms to be excreted from the body).
The most commonly used radioactive materials in research hospitals are tritium, iodine-125, and carbon-14. Radium-226, used in cancer treatment, may be the most hazardous of the radionuclides in the list because of its long effective half-life and unstable decay products.
6-12 Processes and Opportunities in Healthcare Facilities
Issues and Opportunities in Occupational Safety and Environmental Services: Waste Minimization for Healthcare Facilities
More and more hospitals and other healthcare facilities are becoming concerned about waste minimization. Utility representatives can help by providing useful resources and information on the subject. Basic definitions and fundamental principles of waste minimization are covered in this section.
Waste minimization is defined as the reduction, to the extent feasible, of waste generated at a facility or waste subsequently treated, stored, or disposed of. Waste minimization results in the reduction of total volume or quantity of waste, the reduction of toxicity (or biohazard) of the waste, or both—with the goal of minimizing current and future threats to human health and the environment.
Waste minimization employs two major techniques: source reduction and recycling. Source reduction is any activity that reduces or eliminates the generation of waste at the source itself, usually within a process. Recycling is the use, reuse, or reclamation of materials from a waste stream. In general, because lowering waste generation at the source is desirable in the first place, source reduction is given preference over recycling in regulatory guidelines.
The benefits of minimizing waste include: environmental protection, enhanced occupational safety and health, economic gain through cost reductions, reduced liability, compliance with environmental regulations, and improved community relations. Among the side benefits that have come from hospital waste minimization programs are improved staff morale and increased employee consciousness of cost- containment.
There are four basic stages in the development of a waste minimization program. These are: planning and organization, assessment, feasibility analysis, and implementation. Several references listed in the References section provide detailed description of these basic stages, as well as waste minimization assessment worksheets, lists of general waste minimization options to consider, and examples of economic evaluations.
Recommended Waste Minimization Options
Table 6-4 shows the areas in a hospital where recyclable municipal solid waste is generated and the types of common recyclable found.
6-13 Processes and Opportunities in Healthcare Facilities
Table 6-4 Sources and Types of Common Recyclable Waste in a Hospital
Sources OCC NP MG WP CP CPO Al/M G P1 P2 P5 P6 PP Other
Shipping/Recvg x x x x x x 1
Food Service x x x x x x 2
Laboratory x x x x x x x x
Patient Carexxxxxx xx xx
Admin. Officesxxxxxx
Radiology, CT x x x x x x 3
Surgery x xxx x xxx
Pharmacyxxxxxx
Dialysis x x x x x x
Doctors’ Offices xxxx x
Medical Records x x x x x
Housekeeping x x x 4
Facility Mgt x x x x 5
Public Areas x x x x
Hospital-wide 6 Legend: OCC - corrugated cardboard packaging NP - newspaper MG - magazines WP - white office paper CP - colored ledger paper CPO - computer printout paper (greenbar, bluebar) Al/M - aluminum and metal beverage, food, and other cans G - glass including clear glass P1 - PETE plastics (soda bottles) P2 - HDPE (milk jugs, dialysis solutions, food stuffs, cleaning solutions) P5 - polypropylene (sterile irrigation fluid bottles) P6 - polystyrene (food service and supply packaging) PP - polystyrene (styrofoam) packaging peanuts Other: 1 - stretch wrap; 2 - grease, organic food waste, aerosol cans; 3 - film, silver recovery; 4 - aerosol cans; 5 - wood, aerosol cans, construction & demolition debris, palettes; 6 - other recyclables found hospital-wide include durable goods such as furnishings, clipboards, old computer equipment, desks, drapes, mattresses, carpets, binders, dishware, phone directories, printer cartridges, etc.
6-14 Processes and Opportunities in Healthcare Facilities
Many healthcare facilities already segregate out infectious waste, but an extra effort needs to be invested in segregating recyclable from non-recyclable waste. The facility should develop an internal system for collecting paper, glass, plastics, aluminum, and other recyclables. The facility can contract with recycling and waste-hauling companies to provide recycling services.
Minimization of hazardous waste involves source reduction through good operating practices and recycling programs. Some overall strategies include the following:
• Keep hazardous waste, infectious waste, and radioactive waste segregated from each other and from non-hazardous general waste
• Make sure that all hazardous wastes are clearly marked
• Monitor drug and chemical flows from receipt of raw material to disposal
• Centralize purchasing and dispensing of drugs and hazardous materials
• Improve inventory control
• Apportion waste management costs to the departments generating the waste
• Provide employee training in waste minimization
• Test new materials in small quantities before purchasing in bulk
• Establish an internal recycling program
• Work with drug and chemical suppliers as responsible partners in a waste minimization program
Table 6-5 shows examples of waste minimization options, compiled from various sources, for specific types of hazardous wastes from healthcare facilities.
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Table 6-5 Waste Minimization Options for Hazardous Wastes
(partial list)
Types of Wastes Some Waste Minimization Options
Solvents Recover/reuse solvents through on-site or off-site distillation; e.g., use fractional distillation to separate xylene from ethanol in histology waste. Substitute less hazardous solvents. Minimize sizes of cultures and specimens in pathology, histology and labs.
Formaldehyde Use reverse osmosis water treatment to reduce dialysis cleaning demands. wastes Minimize strength of formaldehyde solutions. Develop standards for formalin solutions to determine minimum cleaning frequency and solution concentrations. Use a chemical additive (e.g., Isolyser’s Aldex) that reacts with and cross-links waste formaldehyde solutions to form a non-hazardous end product.
Antineoplastic Substitute degradable drugs for environmentally persistent drugs. agents Optimize drug container sizes in purchasing and buy according to need.
Photographic Recover silver using cation exchange and electrolytic recovery instead of steel chemicals wool filtration units. Ensure proper storage conditions to increase shelf life and test expired material for usefulness; return off-spec developer to manufacturer. Use a chemical additive (e.g., Isolyser’s Raysorb XFT) that neutralizes spent fixer and developer waste and permanently binds silver to a solid matrix.
Mercury wastes Substitute electronic sensing devices for mercury-containing devices.
Ethylene oxide Consider electrotechnology alternatives to ETO sterilization.
Anesthetic gases Replace old anesthetic equipment with low-leakage equipment; test daily for leakage and monitor periodically for gas levels.
Disinfecting Use ultrasonic or steam cleaning instead of alcohol-based disinfectants. solutions Use a chemical additive (e.g., Isolyser’s Aldex) that reacts with and cross-links glutaraldehyde wastewater to form a non-hazardous end product.
Maintenance and Use ultrasonic or steam cleaning instead of aqueous or chemical-based cleaners; utility wastes use biodegradable cleaners instead of solvent-based cleaners. Replace oil-based paints with water-based paints. Use non-chemical pesticide control methods.
(Electrotechnology opportunities are shown in italics)
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In a waste characterization study of dental offices, the following were identified as potential technologies for the removal of metals, especially mercury, from the wastewater stream of dental facilities:
• Filtration and settling tanks
• Ion exchange resins
• Centrifuge removal units.
Some overall strategies and waste minimization options for low-level radioactive waste include:
• Keep hazardous waste, infectious waste, and radioactive waste segregated from each other and from non-hazardous general waste.
• Make sure that all radioactive wastes are clearly marked.
• Use less hazardous isotopes when possible; e.g., replace radium-226 needles with iridium-192 or cesium-127 needles.
• Segregate and label short-lived wastes and store them on-site until decay to acceptably low levels permits safer disposal.
With infectious waste, one minimization option is to use degradable products. Isolyzer’s OREX® Degradable™ (4405 International Blvd. NW, GA 30093; 770-717-1994) are disposable surgical drapes, gowns, bedding, etc. which can be dissolved in hot water (over 200°F (93°C)) in an on-site processor and discarded down the drain. This new technology can reduce the amount of infectious waste from surgical units that has to be treated in an incinerator or other treatment process. Many of the alternative medical waste treatment technologies discussed in the next section achieve significant volume and mass reduction, thereby minimizing waste that will be buried in landfills. Finally, it should be mentioned that some facilities have begun investigating and addressing the problem of over-classification whereby healthcare workers tend to include non-infectious waste in the infectious waste stream.
Some of the same technology alternatives for infectious waste can be applied to low- level radioactive waste. Most of the current applications being studied are in the energy and defense industries which generate large quantities of low-level radwaste. Those technologies include: KVS/EPI Plasma Arc Furnace, Plasma Energy Applied Technology, and Vance IDS.
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Issues Regarding Waste Minimization
Some controversies exist in the healthcare industry which influence decisions regarding waste minimization. One centers on the debate over reusables versus single-use disposable products. Disposables, which are a standard in many hospitals, are seen as convenient, cheaper, safer, and preferred by staff. Journal articles have appeared on this debate in relation to the use of surgical textiles, hospital linens, and body wraps, among others. Healthcare facilities need to re-evaluate their decisions regarding reusable materials, weighing many factors including actual costs of purchase and disposal, infection control, quality, ease of use and time savings, reprocessing capacity, etc. The answers are not often clear-cut and ultimately, some combination of reusables and disposables may be needed.
Another controversy has to do with bulk packaging to ensure safety and sterility of medical products versus minimal packaging to reduce waste. The solution may lie in collaborative efforts between manufacturers and the healthcare industry.
The involvement of a healthcare institution in on-site treatment of their hazardous waste, such as recovery of spent solvents or tertiary treatment of waste streams, may require specific permits under state or federal regulations. In contrast, the use of chemical additives to neutralize, transform or solidify hazardous wastes into non- hazardous end products is relatively simple, cost effective and environmentally beneficial.
Resources and References
A valuable resource called An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities was published in 1993 by the American Society of Healthcare Environmental Services. The EPRI Healthcare Initiative has published a more detailed version of this chapter in “Waste Minimization in the Healthcare Industry: A Resource Guide,” May 1996. These and other key resources are listed below:
C.L. Bisson, G. McRae, and H.G. Shaner. An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities. American Society for Healthcare Environmental Services (American Hospital Association), Chicago, IL, 1993.
Colorado Hospitals and the Environment. Colorado Hospital Association, Denver, CO, 1992.
Developing a Recycling Program: A Guide for Hospitals. New Jersey Hospital Association, Princeton, NJ, 1991.
Jorge Emmanuel. “Medical Waste Management.” Facilities Engineering and Management Handbook, McGraw-Hill, in publication.
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Jorge Emmanuel. “Waste Minimization in the Healthcare Industry: A Resource Guide.” EPRI Healthcare Initiative, Report CR-106627, May 1996.
“Guides to Pollution Prevention: Selected Hospital Waste Streams” (formerly titled “Guide to Waste Minimization in Selected Hospital Waste Streams”). EPA/625/7- 90/009, U.S. Environmental Protection Agency, Risk Reduction Engineering Laboratory, Cincinnati, OH, June 1990.
Hospitals and the Environment. American Hospital Association, Chicago, IL, 1992.
R. Linett. “Hospital Pollution Prevention Study.” EPA/600/2-91/024, Department of Veterans Affairs, Washington, D.C. and Risk Reduction Engineering Laboratory, Office of Research and Development, Cincinnati, OH, July 1991.
Patricia McClearn. “Survey of Chemical Use in Colorado Hospitals.” Report, Colorado Hospitals for a Healthy Environment, Denver, CO, June 1996.
Medical Waste Management: Recycling, Reusables, and New Technologies. PTSM-820, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 1991.
The New Three R’s: A Solid Waste Management & Recycling Guide for Indiana Hospitals. Indiana Hospital Association, Indianapolis, IN, (no date).
Pollution Prevention in Hospital and Medical Facilities. Washington State Department of Ecology, Pub. No. 93-39, 1993.
“Recycling Revisited: A Comprehensive Recycling Manual for Hospitals.” Ohio Hospital Association, 1995.
“Waste Audit Study: General Medical and Surgical Hospitals.” California Department of Health Services, Alternative Technology Section, Toxic Substances Control Division, August 1988.
The Waste Not Book. Public Affairs Division, Minnesota Hospital Association, Minneapolis, MN, 1993.
Waste Reduction Activities for Hospitals. California Integrated Waste Management Board, Sacramento, California, August 1994.
Cynthia Welland. “Dental Office Waste Stream Characterization Study.” Municipality of Metropolitan Seattle, September 1991.
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Other Resources:
“Announcing a Revolutionary Way to Dissolve Your Waste Disposal Problems.” (vendor literature), OREX® Degradables™, Isolyser Company, Inc., Norcross, GA.
“Colorado Hospitals for a Healthy Environment.” Colorado Hospital Association, 2140 South Holly Street, Denver, CO 80222-5607; (303) 758-1630.
“Good Medicine for Wasteful Ways: A Prescription for Success.” Video on hospital waste recycling, City of Oakland, CA (11 minutes).
Health Facilities Management. Published monthly by the American Hospital Publishing, Inc., Chicago, IL; contains practical articles about hospital environmental issues.
“Stay in the Loop.” Video companion to Health Waste Reduction: A Step-by-Step Guide to a Healthier Environment. New Jersey Hospitals for a Health Environment, New Jersey Hospital Association; video guide to hospital waste minimization (14 minutes).
“Waste Not.” Video companion to The Waste Not Book. Minnesota Hospital Association, Minneapolis, MN (10 minutes).
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Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Treatment
The Problem of Medical Waste
Beginning in 1988, articles dealing with the mismanagement of medical waste appeared in newspapers around the country. Syringes were found washed up in beaches in New York and New Jersey and around the Great Lakes. Children were found playing with discarded medical waste near a healthcare facility in Indiana. A hospital in the West Coast was fined for disposing recognizable medical waste in a regular landfill instead of a landfill designated for infectious waste. All this served to heighten public concern and regulatory pressure pertaining to medical waste.
Adapted from The Far Side original cartoon by Gary Larson
Meanwhile, OSHA’s Bloodborne Pathogen Rule increased the amount of waste from healthcare facilities that needed to be treated as potentially infectious. To make matters worse, the two traditional methods of disposal—incineration and landfilling—may no longer be options for many hospitals in the near future. In 1995, the U.S. Environmental Protection Agency proposed medical waste incinerator rules under the 1990 Clean Air Act Amendments. The new rules, finalized on September 15, 1997, limit emissions of specific pollutants from hospital incinerators, among other requirements. Because of these factors—the high cost of adding pollution control devices to meet new EPA limits, a decrease in landfill capacity in some states, and anticipated price escalations and hidden costs of hauling medical waste—many hospitals are now looking at alternative treatment technologies.
According to the AHA, there are 2,233 hospitals in the U.S. with medical waste incinerators. (EPA put the figure at 2,400 hospitals.) Of the 2,233 hospitals, 1,803 have 6-21 Processes and Opportunities in Healthcare Facilities incinerators that have capacities of 500 pounds (227 kg) per hour or less; 256 hospitals have incinerators with capacities between 500 and 1,000 pounds (227 to 454 kg) per hour; and 174 hospitals have incinerator capacities greater than 1,000 pounds (454 kg) per hour. (A listing of these incinerators can be found in the November 1994 report “Reassessment of Maximum Achievable Control Technology (MACT) Floors for Existing Medical Waste Incinerators,” prepared by Doucet & Mainka for the American Hospital Association.)
Utilities can assist hospitals in dealing with the impact of EPA regulations on medical waste incinerators. Healthcare Initiative consultants have conducted evaluations of hospital waste streams, screened new technologies, and performed comparative economic evaluations on the various alternatives. Some of these have been done as tailored collaboration projects.
Determining the best technologies for a specific healthcare facility on the nature of the medical waste stream (amount of infectious and hazardous waste generated, breakdown of the types of waste), the interest of the facility in trying an emerging process versus a fully commercialized technology, and openness of administration and staff to a new technology. In general, the following criteria should also be considered:
Biological inactivation efficacy Capacity Types of medical waste treated Environmental emissions: air emissions, solid and liquid residues Regulatory acceptance Extent of reduction of volume and mass Compact design for on-site use Degree of automation and simplicity of operation Occupational safety and health Energy consumption Amount of maintenance required Availability of technical support Public acceptance Degree of commercialization Reliability and track record Cost effectiveness
Alternative Treatment Technologies For Medical Waste
Broad Categories of Treatment Processes
New and emerging technologies make use of six types of processes to treat different kinds of medical waste. The six processes are:
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• Low heat thermal processes
— Autoclaves and autoclave-type processes
— Dry heat processes
• High heat thermal processes
• Irradiation
• Chemical treatment
• Biological processes
• Mechanical processes.
These processes are described below. Some technologies use a combination of two or more of these processes.
Low Heat Thermal Processes
Low heat thermal processes are those that use thermal energy (heat) to decontaminate the waste but at temperatures insufficient to support combustion or pyrolysis. In general, thermal technologies using low heat operate between 205°F (96°C), just below the boiling point of water at atmospheric pressure, to 350°F (177°C), just below the ignition point of paper (365°F or 183°C). However, some low heat thermal processes can operate as high as 480°F (249°C) without sustaining combustion depending on the waste composition and the conditions in the treatment chamber, such as the level of oxygen and moisture. Two basic categories of low heat thermal processes are (1) autoclave or autoclave-type processes and (2) dry heat processes.
Autoclaving, a standard processes in hospitals, uses steam to disinfect reusable instruments and other medical devices. Some autoclave manufacturers now offer autoclave systems for treating medical waste. The autoclave-based systems generally operate between 205°F (96°C) to over 300°F (150°C) of pressurized steam. The typical autoclave unit operates around 250° to 270°F (121° to 132°C), corresponding to pressures between 15 to 27 psig (103 to 186 kPa). Since autoclaving does not physically break down the waste, a mechanical process is needed to physically alter the waste if the waste is to be rendered unrecognizable. Examples of autoclave-based processes are vacuum-autoclave-compaction and autoclave-shredding. Since air acts as an insulator, the advantage of pulling a vacuum before injecting steam is to improve heat transfer. Microwave treatment is an autoclave-type process since disinfection occurs through the action of steam as the microwave energy is used to heat up water in the waste and generate steam.
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In dry heat processes, no steam is added to the waste. Instead, the waste is heated by convection and/or thermal radiation using infrared or resistance heaters to temperatures between 300° to 500°F (150° to 260°C). Higher temperatures are avoided to prevent destruction of the waste by pyrolysis or combustion. The fluidized bed dryer using high velocity heated air is an example of an alternative technology using dry heat.
High Heat Thermal Processes
High heat thermal processes generally operate in temperatures ranging from around 1000°F (540°C) to 15,000°F (8,300°C) or higher. Heating is provided by electrical resistance, induction, natural gas, and/or plasma energy. High heat processes involve chemical and physical changes resulting in total destruction of the waste. A significant reduction in the mass and volume of the waste also occurs. Depending on the level of oxygen in the treatment chamber, combustion or pyrolysis dominates the process.
If the waste is heated to these high temperatures in the presence of air, combustion or burning takes place and varying amounts of heat are released depending on the BTU content of the waste. Traditional incineration falls in this category. In the primary chamber of a typical dual-chamber incinerator, a slow-burn, oxygen-starved combustion process takes place. Hydrocarbons in the waste are converted to carbon dioxide and water. Because of the nature of incineration, however, products of incomplete combustion are formed, such as carbon monoxide and soot (as particulate matter). Byproducts such as hydrogen chloride gas (HCl), dioxins, and furans are also formed due to the presence of chlorine from chlorinated plastics and other sources in medical waste. Nitrogen in the air and any sulfur in the waste result in NOx and SOx emissions, respectively. One alternative technology uses a “flash burn” oxygen-rich combustion process followed by a rapid quench; this advanced thermal oxidation technology reportedly minimizes the aforementioned pollutant emissions.
If the waste is heated to high temperatures in the absence of air or in the presence of an inert gas, pyrolysis or thermal decomposition takes place. Like combustion, carbon monoxide and particulate matter are also produced. However, unlike combustion, pyrolysis produces other different products of reaction, such as methane and hydrogen. Because of the absence of air, much lower levels of NOx and SOx are emitted. The chlorinated plastics in the waste produce HCl but the production of dioxins and furans is apparently minimized. If acid gases and particulates are removed, the result is an off- gas with a low to medium BTU content which can be used as supplemental fuel.
Various alternative technologies use pyrolysis in the presence of nitrogen, superheated steam, argon, helium, or other inert gases. Very high volume and mass reductions are achieved. Some technologies utilize plasma-based pyrolysis, which operates at much higher temperatures than incineration or other types of pyrolysis. As such, glass and other inorganic material from the waste are melted and turned into a nonleachable vitrified slag. Plasma pyrolysis utilizes a plasma torch which converts the gas medium 6-24 Processes and Opportunities in Healthcare Facilities into a partially ionized gas called a plasma. In the plasma state, the gas conducts electric current but due to the high resistance, the electrical energy is converted to heat at very high temperatures. Another form of pyrolysis is heating in the presence of superheated steam (“steam detoxification”) involving steam-reforming reactions which produce a low BTU gas. Another alternative technology uses pyrolysis and controlled oxidation in tandem.
Irradiation
Although some irradiation-based technologies may use Cobalt-60 isotopes (gamma irradiation), UV germicidal irradiation, or “macrowave treatment” in their processes, this report will focus primarily on electron beam irradiation. These technologies use an electron shower to destroy microorganisms in the waste by causing chemical dissociation of organic matter and the rupture of cell walls. The pathogen destruction efficacy depends on the dose absorbed by the mass of waste which in turn is related to waste density and electron energy. Electron accelerators are used to generate the high- energy electrons and a magnet is used to focus the electron beam at the waste target.
Unlike high-temperature processes, electron beam irradiation does not alter the waste physically and would require a grinder or compactor to render the waste unrecognizable. Small amounts of ozone are produced and the temperature of the waste may increase by several degrees but, unlike incineration, no combustion byproducts are generated. Electron beam irradiation does not have residual radiation which is an advantage over irradiation by radioactive isotopes.
Chemical Processes
Chemical processes employ disinfectants such as chlorine dioxide, bleach (sodium hypochlorite), peracetic acid, or dry inorganic chemicals. Some technologies are designed to handle only a specific waste stream such as contaminated needles and syringes. The hypochlorite systems, and to a lesser extent the chlorine dioxide processes, are a source of concern to regulators and environmentalists because they can lead to the formation of toxic chlorinated byproducts in the wastewater, such as trihalomethanes (in particular, chloroform), chloramines (formed in the presence of ammonia), and dioxins. Like autoclaves, many chemical processes are well-established technologies.
Chemical compounds have also been used for encapsulation of sharps or biohazardous fluids. These encapsulating compounds solidify sharps waste, blood, or other body fluids into a gel or solid matrix which can then be discarded; they may or may not contain disinfecting agents. One novel chemical-based technology being developed uses ozone to treat medical waste. Wet oxidation using catalysts is also being tested for
6-25 Processes and Opportunities in Healthcare Facilities waste treatment. Another novel system uses alkali to hydrolyze tissues in stainless steel tanks.
Biological Processes
Biological processes use enzymes to treat medical waste. These enzymes reportedly destroy organic constituents in the waste including pathogens. In the early 1990s, a system was developed by SciMed Technologies, Inc. but no current information is available.
Mechanical Processes
Mechanical destruction (such as shredding, grinding, cutting, hammermill processing, or compaction) is a supplementary process used in conjunction with the other processes. Mechanical destruction can render the waste unrecognizable and can make needles and syringes unusable. Other mechanical processes, such as agitation and mixing, serve to improve the rate of heat transfer or to help expose more surfaces to chemical disinfectants. However, a mechanical process cannot be considered a treatment process in and of itself. Some states specifically require that disinfection should take place before any mechanical destruction, unless the mechanical process is integral to a closed treatment system.
Table 6-6 gives examples of each broad category of treatment process.
Table 6-6 Alternative Treatment Technologies for Medical Waste
Technology Vendors Capacities (lb/hr) Low Heat Thermal Process Vacuum-Autoclave-Shredding Ecolotec (Cherry Hill, NJ) 5.5 cu ft/hr Vacuum-Autoclave EnviroSafe/Safety Disposal Sys. (Opa Locka, FL) 150-1000 Vacuum-Autoclave-Compaction San-I-Pak (Tracy, CA) 25-1000 Vacuum-Autoclave-Drying Tuttnauer (Ronkonkoma, NY) up to 1500 Microwave Treatment* MWD 20/IMC (Colorado Springs, CO) 22-30 Microwave Treatment Redloc/Roatan Medical Technologies (Dallas, TX) 50-500 Microwave Treatment Sanitec (West Caldwell, NJ) 220-550 Microwave Treatment Sintion/CMB (Graz, Austria) 60 Rotating-Autoclave-Grinding Rotoclave/Tempico (Madisonville, LA) 318-500 Shredding-Autoclave-Mixing-Chem. Chem-Clav/STI (West Chester, PA) 400-2000 Shredding-Autoclave-Agitation JYD/Aegis Bio-Systems (Edmond, OK) 1500 Steam Sterilization-Maceration SSM-150/Anteus (Hunt Valley, MD) 150 Autoclave-Agitation Hydroclave/SteriLogic Waste Sys. (Kempton, PA) 400-4000 Autoclave Mark-Costello (Carson, CA) 225-940
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Technology Vendors Capacities (lb/hr) Autoclave Sierra Industries (Santa Ana, CA) up to 2000 Electro-thermal Deactivation Stericycle (Deerfield, IL) 1000-6000 Fluidized Bed/Dry Heat* KC MediWaste (Dallas, TX) 200 Infrared Heating/Dry Heat MedClean-M/PMA Services (Yorba Linda, CA) 5 cu ft/90 min Resistance Heating/Dry Heat Demolizer/DOCC (New York, NY) 1 gal/2.5 hr High Heat Thermal Process Pyrolysis-Oxidation Bio-Oxidation (Annapolis, MD) 100-1250 Plasma Pyrolysis* DayStar/Prometron (Tokyo, Japan) 200 Plasma Pyrolysis* DC Graphite Arc (Electro-Pyrolysis, Inc., Wayne, PA; 750 Svedala Ind., Danville, PA) Plasma Pyrolysis* MSE Tech. Appl. (Butte, MT; Fairfax Sta., VA) 350 Plasma Pyrolysis* PBPV/HI Disposal System (Indianapolis, IN) 3000 Plasma Pyrolysis* PEM/Integrated Environmental Systems (Richland, WA) 5-15 tons/day Plasma Pyrolysis* Plasma Pyrolysis Systems (Stuyvesant Falls, NY) na Plasma Pyrolysis* Skygas/Unitel (Mt. Prospect, IL) na Plasma Pyrolysis* Startech (Wilton, CT) na Plasma Pyrolysis* Vance IDS (Largo, FL) 400 Advanced Thermal Oxidation* TurboClean/NCE Corp. (Carrollton, TX) 500-750 Induction Heating* Vanish (Braintree, MA) 280 Thermal Gasification* Leslie Technologies (Tallahassee, FL) 100-600 Vitrification ToxGon (Seattle, WA; Dunkirk, NY) na Irradiation Process Electron Beam Biosiris/BioSterile Tech. (Fort Wayne, IN) 400 Electron Beam-Shredding U. Miami E-Beam (Coral Gables, FL) 400 Chemical Process Alkaline Hydrolysis WR2 (Indianapolis, IN) 5-150 gal Chlorine Dioxide-Shredding Encore/Med Compliance Services (El Paso, TX) 2500-3000 Chlorine Dioxide-Shredding Condor/WESCO (Ramona, CA) 600 Dry Inorganic Chemical-Shredding PMT/Premier Medical Technology (Houston, TX) 600-900 Dry Inorganic Chemical-Shredding MMT 3000/Positive Impact Waste Solutions (Pearland, up to 2000 TX) Ozonation* Lynntech (College Station, TX) 220 lb/cycle Peracetic Acid-Grinding Ecocycle/STERIS Corp. (Mentor, OH) 8 lb/10 min Proprietary Disinfectant-Shredder SteriMed/MCM Environmental Tech. (Israel) 20 gal/15 min Sodium-Hypochlorite-Hammermill Circle Medical Products (Indianapolis, IN) 250-3000 Sodium Hypochlorite-Shredding American Delphi/EDS (Westminster, CA) na Electrocatalytic Wet Oxidation* MeDETOX/Delphi Research (Albuquerque, NM) na Encapsulation Isolyser (Norcross, GA) Needle-Eater/SPS (Roselle, NJ) Medzam/Safetec (Buffalo, NY) *Developing technology (Source: Jorge Emmanuel. “Medical Waste Management,” Facilities Engineering and Management Handbook, McGraw-Hill, not yet published.)
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The technologies range from portable units designed primarily for treating a small volume of waste per hour to large permanent installations capable of treating waste at a rate of several tons per day. In general, the technologies range from well-established technologies with a good track record, to new technologies that have just been commercialized, to emerging technologies ready for full-scale demonstration or beta testing, to experimental systems. Also included are technologies specifically for small- volume generators such as nursing homes, clinics, doctors’ and dentists’ offices, and blood banks. These smaller technologies may be helpful in preventing “needle sticks” and the spread of Hepatitis B virus and HIV as well as other occupational injuries among healthcare workers.
For a more comprehensive review of medical waste treatment technologies, as well as EPRI status sheets of selected technologies describing the principles of operation, technical specifications, types of waste treated, emissions, energy consumption, features, estimated capital and operating costs, current stage of permitting and commercialization, and vendor contacts, refer to EPRI’s publication “New and Emerging Technologies for Medical Waste Treatment” Report CR-107836-R1, January 1999. Technical status sheets are revised and updated on a regular basis and are available to members from the EPRI Healthcare Initiative.
Comparisons of Selected Treatment Technologies
Table 6-7 compares some of these technologies according to their capacities, the type of treatment process involved, approximate energy use, and percent volume reduction.
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Table 6-7 Comparison of Selected Treatment Technologies
Technology Capacity Treatment Process Energy Use Volume lb/hr (kg/hr) kWh/lb (kWh/kg) Reduction Bio-Oxidizer 100,1000,1250 pyrolysis-oxidation 0.6-1.2 (1-2.6) up to 99% (45, 454, 567) heat recovery Biosiris 500 electron beam irradiation- 0.035 80% (227) shredding (0.077) Chem-Clav 400 to 2,000 shredding-autoclave-mixing- 45 to 55 kWh/hr 85-90% (181 to 907) chemical disinfection-compaction Circle Medical 250, 1800, 3000 shredding-chemical disinfection 10, 75 and 90 kWh/hr 80-90% Products (113, 816, 1360) EPI/Svedala 750 plasma pyrolysis 0.75 90% (340) (1.6) KC MediWaste 200 shredding-dry heat (fluidized 0.31 80% (91) bed) (0.69) MWD 20 25 shredding-microwave heating 0.2 80% (11) (0.4) Roatan Redloc 50 - 500 microwave heating-shredding 20-40 kWh/hr up to 80% (23-227) San-I-Pak 25-1000 vacuum autoclave-compaction 0.33-1 75-84% (11-454) (0.73-2.2) Sanitec 220, 550 shredding-microwave heating 0.1 80% (100, 250) (0.2) Tempico 318 - 500 autoclave-agitation 0.02 - 0.038 up to 85% Rotoclave (144 - 227) (0.04 - 0.08) TurboClean 500, 750 advanced thermal oxidation 0.09 - 0.13 97-99.9% (227 - 340) (0.2 - 0.3) Tuttnauer up to 1500 vacuum autoclave-drying- 20 kWh/hr about 70-80% (680) shredding or compaction U. Miami E-Beam 400 electron beam irradiation - 0.04 85% (180) shredding (0.09) Vance IDS 400 shredding - plasma pyrolysis 0.365 (0.805) about 99% (180) heat recovery Vanish 280 induction heating 0.8 (1.8) over 90% (127) heat recovery
Vendor addresses and telephone numbers for these and other alternative technologies are provided in Appendix C.
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Economic Evaluation Using MATES
Should a healthcare facility upgrade its incinerator so as to meet the 1997 EPA requirement? Or should it shut down the incinerator and pay a hauler to take the medical waste? Or should the facility consider an alternative treatment technology? MATES helps hospital clients answer these questions.
The EPRI Healthcare Initiative has developed MATES (MedWaste Alternative Technology Evaluation System), a unique evaluation tool available only through the Initiative. MATES provides a full-cycle cost analysis including year-by-year cashflow projections and financial statistics in order to compare treatment technologies. MATES is an Excel spreadsheet that runs on IBM PC, Apple Macintosh, or DOS systems running Windows. It was developed in 1993 for use as a screening tool to help identify possible alternative technologies that a facility should consider.
MATES has just been upgraded to a new version available for 1999. The new MATES has seven new technologies added to its database and updated cost data on existing technologies. The user can now choose from about 30 specific models. MATES also computes cost estimates of siting and installation for each technology. Importantly, MATES has the added capability of estimating the cost of upgrading an incinerator based on EPA’s national averages, and the overall cost of hauling and off-site treatment, including hidden costs.
MATES is a valuable tool for working with healthcare clients faced with problems regarding medical waste disposal. The user must first compile data specific to the hospital. Calculations are based on site-specific data (such as waste generation, waste composition, labor rates, landfill costs, etc.) and data internal to MATES that were obtained from vendors and users (such as rated throughput, typical downtime, and maintenance costs). MATES calculates annual operating costs broken down into various categories (labor, utilities, parts and supplies, amortized debt, landfill costs, etc.) and the costs per pound of waste treated for the lifetime of the equipment. The program has graphics capabilities and can also compute Net Present Value and Return on Investment figures. A graph or a series of tables comparing cost estimates for some or all of the above options can be printed out. This information may help convince a healthcare facility to consider the installation of an alternative technology instead of upgrading an existing incinerator.
MATES is a valuable tool in determining the most cost-effective technologies that a particular healthcare facility should consider. The spreadsheet is available only to members of the Healthcare Initiative.
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Resources and References
F. L . Cross, Jr., H. E. Hesketh, and P.K. Rykowski. Infectious Waste Management. Technomic Publishing Co., Lancaster, PA, 1990.
Jorge Emmanuel. “Medical Waste Management.” Facilities Engineering and Management Handbook. McGraw-Hill, in publication.
Jorge Emmanuel. “New and Emerging Technologies for Medical Waste Treatment.” Report CR-107836-R1, EPRI Healthcare Initiative, Riverdale, NY, January 1999.
“Facts about HIV/AIDS and Health Care Workers.” Centers for Disease Control and Prevention, May 1995.
J. W. Jordan. “Incineration Alternatives in the Treatment of Medical Waste.” 94-RA123A.01, presented at the 87th Annual Meeting & Exhibition, Air & Waste Management Association, June 19-24, 1994.
V. J. Landrum, R.G. Barton, et al. Medical Waste Management and Disposal. U.S. Environmental Protection Agency, Noyes Data Corporation, Park Ridge, NJ, 1991.
“Medical Waste Disposal.” Journal of the Air & Waste Management Association, Vol. 44, October 1994.
“Medical Waste Management: Regulatory and Technical Background Report.” Electric Power Research Institute, EPRI TR-100978, September 1992.
“Medical Waste Treatment Technologies for Low-Volume Generators.” TechCommentary, EPRI Community Environmental Center, Riverdale, NY, 1996.
“The Public Health Implications of Medical Waste: A Report to Congress.” Public Health Service, U.S. Department of Health and Human Services, September 1990.
Status sheets on alternative and emerging medical waste treatment alternatives, EPRI, Palo Alto, CA.
“Study of Non-Burn Technologies for the Treatment of Infectious and Pathological Waste and Siting Consideration.” Minnesota Healthcare Partners, St. Paul, MN, April 15, 1992.
T. Traum. “Alternative Technologies Surveys.” Prepared for the National Institutes of Health (Bethesda, MD) by the Public Health Service, Division of Federal Occupational Health, Region III, Philadelphia, PA, March 1, 1995.
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“What is Your Risk of Getting AIDS or Hepatitis B on the Job?” American Liver Foundation, June 1994.
E. Weisman. “Incinerator Rule Ignites Interest in Alternative Waste Methods.” Health Facilities Management, 8 (2), February 1995.
6-32 Processes and Opportunities in Healthcare Facilities
Issues and Opportunities in Occupational Safety and Environmental Services: Medical Device Sterilization
Steam (autoclave) sterilization and ethylene oxide gas sterilization are the two traditional methods for the sterilization of reusable medical devices. The main problem with autoclave sterilization is its high temperature since many medical devices are susceptible to heat. Other materials are affected by moisture. Steam corrodes some metals and can degrade other materials after repeated exposure. Also, steam sterilization requires precise control of temperature, pressure, and time to ensure the destruction of microorganisms.
Gas sterilization, introduced as a low-temperature alternative to autoclave sterilization, became a common addition to hospitals by the 1970s. An estimated 5,000 hospitals across the country use ETO to sterilize reusable medical instruments. Gas sterilizers having capacities up to 10 cubic feet (0.28 m3) can use 100% ethylene oxide (ETO). Larger sterilizers use a mixture of ETO and a nonflammable carrier gas such as carbon dioxide, hydrochlorofluorocarbons (HCFCs), or chlorofluorocarbons (CFCs). Mixtures of 10-12% ETO and 88-90% HCFCs or CFCs (commonly referred to as 10/90 or 12/88 ETO) are the most frequently used. ETO blends that contain CFCs are being phased out; however, 12/88 ETO/CFC will be available for a limited time. ETO sterilization takes place at temperatures between 29° to 65°C (84° to 150°F) and processing times are typically 10 to 17 hours. The long processing time limits the number of sterilization cycles that can be run in a hospital.
ETO has major occupational safety and environmental problems associated with its use. ETO is flammable and explosive, and must be stored in a sealed container in a well- ventilated area away from heat, sparks, or flame. ETO is also toxic: it affects the central nervous system and respiratory tract, irritates the eyes and skin, and is believed to cause adverse reproductive effects. ETO is also a probable cancer-causing agent in humans. The Occupational Safety and Health Administration (OSHA) classifies ETO as a carcinogenic, mutagenic, reproductive, and neurologic hazard, among other dangers. According to OSHA regulations, no employee should be exposed to ETO in excess of 1 ppm in air (as an 8-hour time-weighted average) or in excess of 5 ppm over any 15-minute period.
In addition, ETO is listed as a hazardous air pollutant under the 1990 Clean Air Act Amendments by the EPA. As such, the EPA requires a 99% reduction in emissions for certain commercial sterilization operations. Some states, such as California, New York, and Michigan, require between 90% to 99.9% reductions in ETO emissions for hospitals and other health-related facilities. Another environmental problem with ETO sterilization is the use of CFCs as a carrier gas. Production of CFCs, which are known to deplete the protective ozone layer, has been banned after 1995 and their HCFC substitutes will be phased out in the next few decades.
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Other low-temperature alternatives are being considered such as 100% ETO sterilization (which avoids the problem of CFC use) and sterilization using vapor phase hydrogen peroxide. Other alternative chemical gas sterilants include chlorine dioxide, formaldehyde, and peracetic acid. In general, the problems of existing sterilization methods and their chemical alternatives have to do with material incompatibility, toxicity, and/or pollutant emissions.
Table 6-8 shows some of the advantages and disadvantages of different traditional sterilization methods as well as chemical gas alternatives. (For a more complete discussion, see “New Technologies for Medical Device Sterilization: A Resource Guide,” Jorge Emmanuel, EPRI Healthcare Initiative, EPRI Community Environmental Center PowerPrescription, CR-106942, September, 1996.)
Table 6-8 Advantages and Disadvantages of Various Sterilization Methods
Technology Advantages Disadvantages Steam Sterilization • non-toxic • heat-sensitive materials cannot be • penetrates fabrics processed • very effective at killing microorganisms • moisture-sensitive materials cannot be including spores processed • well established technology • results in corrosion or degradation of some metals and other materials ETO-CFC Sterilization • useful for materials susceptible to heat • potential hazard to staff and patients • very effective at killing microorganisms • lengthy exposure and aeration time • penetrates medical packaging and many • ETO is flammable plastics • ETO is toxic, a probable carcinogen and • compatible with most medical materials mutagen • production of CFCs banned Chlorine Dioxide • useful for materials susceptible to heat • corrodes aluminum, copper, brass, • more environmentally friendly than certain stainless steels, and chrome hypochlorite (bleach) Peracetic Acid • useful for materials susceptible to heat • corrodes copper, plain steel, and other • environmentally friendly metals • effective against all microorganisms • limited to immersible instruments used at once • fast processing time • few instruments processed at a time Formaldehyde or • useful for materials susceptible to heat • irritating and pungent odors at low levels Formaldehyde-Alcohol • destroys a wide range of • toxic and carcinogenic microorganisms • a hazardous air pollutant • OSHA limits exposures (Sources: William Rutala, “Disinfection, Sterilization, and Waste Disposal,” Chapter 27 in Prevention and Control of Nosocomial Infections, Ed. by Richard P. Wenzel, 3rd edition, Williams & Wilkins, Baltimore, MD, 1997; William A. Rutala and David J. Weber, Infection Control and Hospital Epidemiology 17, 87-91 (1996); D. Stephen Robins, “State-of-the-art sterilization,” Health Facilities Management, May 1996.)
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Alternative Technologies for Medical Device Sterilization
Two technologies are now available as low-temperature alternatives to steam and ethylene oxide sterilization: hydrogen peroxide plasma sterilization (Sterrad) and mixed chemical plasma sterilization. Peracetic acid sterile processing, ozonation sterilization (Karlson), and electron beam irradiation (BIOSIRIS) are other alternative technologies. Another irradiation system (Titan Scan) is available for medical product manufacturers and commercial sterilization facilities. These commercial and emerging alternative technologies offer many advantages including environmentally friendly emissions, significantly reduced occupational hazards, and short sterilization cycle times. These technologies are briefly described here; a more detailed version of this section can be found in a Healthcare Initiative publication on medical device sterilization.
Hydrogen Peroxide Plasma Sterilization
A low-temperature plasma is generated using radio frequency energy. In the plasma environment, hydrogen peroxide generates very reactive molecular species, called free radicals, as well as ultraviolet (UV) radiation. The free radicals, UV radiation, and hydrogen peroxide, each capable of destroying microorganisms on their own, act together to inactivate a broad spectrum of microorganisms. After about 15 minutes of exposure, the chamber is restored to atmospheric pressure and the air is flushed. The total processing time is about 75 minutes.
This short operation allows many more loads to be run per shift. Another important feature of hydrogen peroxide plasma sterilization is its environmental benefit: the primary emission by-products are oxygen and water. As currently designed, the hydrogen peroxide plasma sterilization system cannot be used to treat cellulose-based materials such as paper and linen, liquids, and devices with lumens smaller than 1/4 inches (6.4 mm) or longer than 12 inches (305 mm). (Lumens refer to the inner open space of any tubular-shaped device as one finds in an endoscope.)
Advanced Sterilization Products (ASP), a division of Johnson & Johnson, offers the STERRAD 100 Sterilizer which was given U.S. Food and Drug Administration (FDA) clearance to market in the United States on October 1, 1993. The sterilizer is transportable and can be plugged into a 208V, 20A, 3-phase electrical outlet. The sterilizer has a 100-liter capacity (other sizes are under consideration). The base price is about $115,000 which includes on-site training. Hydrogen peroxide “cassettes” and other supplies are available from the vendor. Over 2000 hospitals nationwide now have the STERRAD system.
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Mixed Chemical Plasma Sterilization
In a mixed chemical plasma system, sterilization takes place in two phases which are repeated. In the first phase, a 5% solution of the chemical sterilant (peracetic acid with hydrogen peroxide) is fed into the sterilizing chamber to begin the process of sterilization. During the second phase, a nonflammable gas mixture of argon, hydrogen, and oxygen is exposed in a separate chamber to microwave energy thereby creating a plasma of highly reactive free radicals. The plasma then flows through the sterilization chamber. The dual phase cycle involving peracetic acid followed by plasma gas is repeated for a total of six times. The entire process takes place at a temperature of 57°C (135°F) and lasts four to five hours.
The system is environmentally friendly since the breakdown products of peracetic acid are hydrogen, oxygen, and acetic acid. There are no constraints on wrapping materials with this process but it may not be indicated for use with lumened or hinged instruments.
Healthcare facilities should exercise caution in selecting the types of medical instruments to be treated in plasma-based systems, especially those made of brass, copper, zinc or those which have been soldered. The disinfection process may cause deposits of copper and zinc salts on the instruments; copper compounds are toxic to the eye. Other studies suggest not using the process for sterilizing cardiac balloon catheters.
Peracetic Acid Sterile Processing
Sterile 1 is a peracetic acid-based sterile processing system by STERIS Corporation (Mentor, Ohio). It may be used for immersible surgical and diagnostic devices. Using a sterilant concentrate composed of peracetic acid and a proprietary anti-corrosion agent, it disinfects reusable medical instruments at low temperature in about 30 minutes. The system consists of a tabletop, microprocessor controls, and multiple instrument processing trays and containers.
Ozonation Sterilization
Ozone is a powerful oxidant which can destroy microorganisms. Because it converts quickly to molecular oxygen, ozone offers an environmentally friendly sterilization alternative. Ozone sterilization cycles last between 30 minutes to two hours.
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The Karlson Ozone Sterilizer Model 100B, developed by Dr. Eskil Karlson of Life Support, Inc., is available from Ozone Sterilization Products, Inc., 501 Route 304, New City, NY 10956; (800) 423-8348. While the original model was given FDA approval, the company is currently working on FDA clearance for newer models which they hope to market soon. Prototypes are being tested in the U.S. and at the Tecksol Co. in Quebec, Canada.
Electron Beam Irradiation
For large-scale sterilization of medical devices, electron beam (e-beam) technology is another emerging alternative. A shower of electrons can destroy microorganisms by causing chemical dissociation of organic matter and the rupture of cell walls. The technology is currently being developed for infectious waste treatment but two manufacturers are considering adapting the technology for medical device sterilization as well. However, shielding, mechanical interlocks, and other radiation safety systems are needed to protect workers during operation.
BioSterile Technology, Inc. has developed the BIOSIRIS© E-Beam Sterilizer for use in hospitals and other commercial and industrial applications. The system can be used with linen, most plastic devices, surgical instruments, and other items. Electrons are accelerated in a compact accelerator using UHF power; the energy of the electrons range from 3.5 to 5.1 MeV. A dose measurement system automatically verifies and records each load. The sterilization cycle time is less than 5 minutes. A 208V, 3-phase power supply is required. The Sterile Beam 5000 is also available from BioSterile for small medical device sterilization for industrial use. It has not as yet received FDA approval for use in hospitals.
Titan Scan Systems has developed the patented SureBeam system which is distributed by Varian Medical Systems and is designed for commercial sterilizing facilities and medical products manufacturers. The 15 kW system uses a 10 MeV linear accelerator which can penetrate 80 cm (30 in) of material. The system is designed with materials handling, controls, and support equipment including containment shielding.
Issues and Organizations
The decision whether and when to replace ethylene oxide sterilizers depends on many factors many of which are specific to each facility. Among the factors for consideration in selecting an appropriate alternative technology are:
• FDA approval and acceptance by regulatory, accreditation, scientific, and professional organizations
• Biological inactivation efficacy
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• Environmental protection
• Occupational safety and health, and safety to patients
• Cost effectiveness
• Compatibility with materials to be sterilized
• Sterilization cycle time, chamber size, and the effect on productivity
• Footprint and availability of space
• Compactness and possible point-of-use installation
• Easy validation of sterilization process and acceptability of biological indicators to verify sterilizing efficacy
• Documentation of sterilization process data
• Degree of automation and ease of operation
• Reliability and amount of maintenance required
• Level of worker training needed and availability of technical support
• Track record.
The following professional societies and trade associations are actively involved in the issues of medical device sterilization:
• Association for the Advancement of Medical Instrumentation (AAMI) 3330 Washington Blvd., Suite 400 Arlington, VA 22201 Phone: (703)-525-4890 Web: www.aami.com
• Health Industry Manufacturers Association (HIMA) 1200 G Street N.W., Suite 400 Washington, D.C., 20005-3814 Phone: (202) 783-8700 Web: www.himanet.com
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• American Society for Healthcare Central Service Personnel (ASHCSP) One N. Franklin 31st Floor Chicago, IL 60606 Phone: (312)-422-3750 Web: www.ashcsp.org
• International Association of Healthcare Central Service Material Management 213 W. Institute Place, Suite 307 Chicago, IL 60610 Phone: (312) 440-0078 Web: www.iahcsmm.com
• Association for Professionals in Infection Control and Epidemiology, Inc. 1275 K Street NW, Suite 1000 Washington, D.C., 20005-4006 Phone: (202) 789-1890 Web: www.apic.org
• Association of Operating Room Nurses (AORN) 2170 S. Parker Rd., Suite 300 Denver, CO 80231-5711 Phone: (800) 755-2676 Web: www.aorn.org
• Society of Gastroenterology Nurses and Associates 401 N. Michigan Ave. Chicago, IL 60611-4267 Phone: (800) 245-7462 Web: www.sgna.org
The AORN, APIC and AAMI issue guidelines, standards, and recommended practices related to medical device sterilization, among others. Federal, state, and independent accreditation agencies are also involved in promoting or monitoring compliance with sterilization guidelines and practices. .The relevant agencies are:
• U.S. Department of Health and Human Services:
— U.S. Food and Drug Administration (FDA)
— Centers for Disease Control and Prevention (CDC)
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• U.S. Department of Labor:
— Occupational Safety and Health Administration (OSHA)
• U.S. Environmental Protection Agency
• State and local departments of health
• State and local environmental agencies
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The FDA approves sterilization devices for marketing in the U.S. based on demonstrated effectiveness and safety; this is referred to as a 510K clearance to market a device. OSHA as well as federal and state environmental agencies are concerned with worker safety and environmental emissions. The JCAHO Standard IC.1-IC.6.2 deals with “Surveillance, Prevention and Control of Infection.” JCAHO expects facilities to follow CDC, AORN, AAMI and APIC guidelines.
Vendor Contacts
Membrane Technology & Research 1360 Willow Road #103 Menlo Park, CA 94025 Phone: (415) 328-2228 Web: www.doe.gov/html/fe/mtr.html
Advanced Sterilization Products 33 Technology Drive Irvine, CA 92618 Phone: (800) 755-5900 Web: www.sterrad.com
AbTox Inc. 104 Terrace Drive Mundelein, IL 60060-3826 Phone: (847) 949-0552 Web: www.devicelink.com/company98/a/a00225.html
Life Support Inc. 2926 State St. Erie, PA 16508 Phone: (814) 455-7849
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BioSterile Technology, Inc. 4104 Merchant Road Fort Wayne, IN 46818 Phone: (219) 489-2962, (888) 710-3792 Web: www.biosterile.com
Titan Scan Systems/Varian Medical Systems, Inc. 3100 Hansen Way Palo Alto, CA 94304-1000 Phone: (650) 493-4000, (800) 544-4636 Web: www.varian.com
Resources and References
“1999 Hospital Accreditation Standards.” Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 1999.
Advances in Sterilization: News and Opinion in the Adoption of New Generation Sterilization Technology. 1 (1, 2), Communicore, Newport Beach, CA, 1995.
M.J. Alfa, P. DeGagne, N. Olson, and T. Puchalski. “Comparison of Ion Plasma, Vaporized Hydrogen Peroxide, and 100% Ethylene Oxide Sterilizers to the 12/88 Ethylene Oxide Gas Sterilizer.” Infection Control and Hospital Epidemiology, 17 (2), February 1996.
Nancy G. Chobin. “Cost Analysis of Three Low-temperature Sterilization Systems at Saint Barnabas Medical Center.” Journal of Healthcare Materiel Management. 12 (8), August 1994.
Sue Crow and John H. Smith III. “Gas Plasma Sterilization — Application of Space-Age Technology.” Infection Control and Hospital Epidemiology. 16 (8), August 1995.
J. Emmanuel. “New Technologies for Medical Device Sterilization: A Resource Guide.” EPRI Healthcare Initiative Power Prescription Publication, September 1996.
Paul T. Jacobs. “A New Technology for Instrument Sterilization.” Advanced Sterilization Products, Division of Johnson & Johnson Medical, Inc., Irvine, CA, October 1994.
Patrick J. McCormick and Jonathan A. Wilder, “Gas Plasma Sterilization.” Marilyn M. Lynch, “Gas Plasma Sterilization.” Esther Lagergren, “Gas Plasma Sterilization.” Barbara J. Goodman and Zoe Z. Aler, “Guidelines for Evaluating New Sterilization Technologies.” Nancy G. Chobin, “What Does it Take to Protect Workers?” Cynthia C.
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Spry, “Sterilization Regulations — Who’s in Charge Here?” Surgical Services Management. 1 (2), July 1995.
“Membrane Vapor Separation Treatment of Hospital Sterilizer Exhaust.” TechApplication. EPRI Community Environmental Center, No. 5, 1995.
D. Stephen Robbins, “State-of-the-art Sterilization: New technologies for the ‘90s and Beyond.” Health Facilities Management, May 1996.
William A. Rutala. “Disinfection and Sterilization.” Hospital Epidemiology and Infection Control. Chapter 69. Edited by C.G. Mayhall, Williams & Wilkins, Baltimore, Maryland, 1996.
William A. Rutala. “Disinfection, Sterilization, and Waste Disposal.” Chapter 27. Prevention and Control of Nosocomial Infections. 3rd edition, Edited by Richard P. Wenzel, Williams & Wilkins, Baltimore, MD, 1997.
William A. Rutala. “Low-Temperature Sterilization Technologies: Do We Need to Redefine “Sterilization?” Infection Control and Hospital Epidemiology. 17 (2), February 1996.
Vendor literature.
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Issues and Opportunities in Facilities Engineering and Management: Efficient Lighting
Lighting accounts for about a third of electricity costs for a typical hospital. Recently, the Environmental Protection Agency targeted healthcare facilities in its effort to promote Green Lights, a voluntary program aimed at improving energy efficiency through the installation of energy-efficient lighting (Health Facilities Management, May 1996). Since 1991, 200 hospitals have joined Green Lights. Many have found that their lighting bills have been cut by more than half, with savings from 20 cents to $1 per square foot ($2.15 to $10.76 per m2) and payback periods of two to three years. Pennsylvania Hospital in Philadelphia, for example, upgraded 450,000 square feet (41,805 m2) of its facility and now saves $101,000 annually. Similarly, Haywood County Hospital in Haywood, North Carolina saves $58,000 annually by upgrading 187,000 square feet (17,372 m2) of its facility.
A lighting retrofit program can result in energy savings ranging from 25% to 75%. New retrofit lighting technologies can be achieved in the following general areas:
1. Upgrading fluorescent fixtures with:
• Improved fluorescent lamps
• Electronic ballasts
• Fluorescent reflectors
• Lenses or louvers
2. Delamping or using current limiters
3. Replacing incandescent lamps with efficient compact sources
4. Installing lighting controls
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Upgrading Fluorescent Systems
Fluorescent Lamps
Upgrading fluorescent fixtures with improved components can lead to energy savings of 40% or greater. Compared to the conventional T-12 fluorescent lamps, the following advanced-technology fluorescent lamps are more efficient and offer improved color rendering:
• 40-Watt T-12 Tri-Phosphor Lamps
• 42-Watt T-10 Tri-Phosphor Lamps
• 32-Watt T-8 Tri-Phosphor Lamps
Electronic Ballasts
Electronic ballasts typically cost 60-75% more than premium magnetic ballasts but payback on this investment comes within one to three years. Electronic ballasts offer the following advantages:
• Improved efficiency . . . up to 25% reduction in energy use while retaining a high percentage of previous light levels of a standard T-12 system
• Reduced lamp flicker . . . most electronic ballasts incorporate 60-Hz filters thereby producing virtually no flicker
• Reliability . . . while the earlier models of electronic ballasts had premature failure problems, most electronic ballasts today show improved reliability
• Other benefits include reduced audible noise and, in some cases, integral dimming capabilities.
In selecting ballasts, several factors must be considered, such as compatibility with lamp types, color rendering ability, wiring configurations, harmonics generation which may produce electromagnetic interference, efficiency and light output, lamp life, and cost.
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Case Study: Alta Bates Medical Center, Berkeley, California Old System: • 47,000 sq. ft. (4366 m2) office space • 686 lensed fixtures • T-12 lamps with magnetic ballasts • Manual switching New System: • 561 parabolic deep-cell louver fixtures • T-8 lamps with electronic ballasts • Central controls plus occupancy sensors Savings: • Cut lighting hours by 61% • Cut energy costs by 90% Cost/Payback: • $115,000 cost • $16,000 utility rebate • 1 year payback
Fluorescent Reflectors
Light undergoes multiple diffuse reflections in a conventional fixture and loses intensity by the time it leaves the fixture. Fluorescent reflectors use a specular (mirror-like) surface that is highly reflective. These surfaces can be shaped to improve directional control of the light, thereby reducing light loss.
Fluorescent reflectors concentrate the light downward. One effect of this downward concentration is a decrease in glare at higher viewing angles, which may improve visual comfort within the working environment. However, this light redistribution may also result in darker-appearing walls and reduced uniformity of illumination within a room.
Lenses and Louvers
Most indoor commercial fluorescent fixtures use either a lens or louver to present direct sight of the lamps at most angles. Lenses or louvers differ in their light output, uniformity of shielding, level of glare control and visual comfort, and cost. The choice of lenses or louvers depends on the tasks being performed in the lighted space.
Clean lenses…are highly efficient, delivering the most light output and uniformity, and are much less expensive than louvers. However, they produce high-angle glare which can impair visual performance and comfort.
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Louvers…provide superior glare control and high visual comfort but allow less light output. Shallow parabolic louvers with small cell sizes maximize glare control but they reduce light levels, cause shadows in walls, and reduce uniformity. Moreover, they can darken ceilings making spaces appear gloomy to some people.
The most common commercial retrofit is to eliminate glare on computer screens using shallow parabolic louvers with 1/2 in., 1 in. and 1-1/2 in. (12.7 mm, 25.4 mm and 38.1 mm) cell sizes. To lessen the side effects of darkening, larger cell retrofit louvers, compatible with some fixture designs, may be available.
Delamping or Current Limiters
In overlit spaces, installing a well-designed reflector and removing half the lamps in a fixture along with their corresponding ballasts can lead to a net 50% savings in energy with a 25-40% reduction in fixture light output. By relocating the two remaining lamps to the center of each side of the fixture, the reflectors can produce multiple images of the two lamps, making the fixture appear to have its full complement of lamps. To recover about a third of the 25-40% light output reduction as a result of 50% delamping, higher output T-10 lamps could be installed.
As an alternate to delamping, current limiters are retrofit devices for fluorescent fixtures to achieve light-output reductions. Most current limiters are designed to attain pre-set light output reductions of 20, 33 or 50%. Current limiters result in a corresponding reduction in energy consumption and have the added benefit of extending lamp life. Unlike delamping and using reflectors, however, current limiters do not improve efficiency.
Replacing Incandescents With Compact Sources
Although incandescent bulbs are relatively inexpensive to purchase, they may be the most expensive lighting sources when operating costs and lamp life are taken into account. A variety of high-efficiency, high-quality light sources with longer operating life is now available.
Conventional incandescents can be replaced with the following compact sources depending on the application: compact fluorescent lamps, compact halogen lamps, or elliptical reflector lamps.
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Based on an original cartoon by Ziegler
The selection of retrofit compact sources depends on starting and operating temperatures, dimming requirements or beam control requirements if any, projection distance, fixture configuration, color quality, and cost.
Case Study: Desert Samaritan Hospital
Old System: • 60W patient bathroom light • 680 fixtures • 12 hours per day • 750-hour life New System: • 13W compact fluorescent lamp in each fixture Savings: • 125,000 kWh/year reduction • $8,100/year energy cost reduction • $900/year lamp replacement savings Cost/Payback: • $10,200 cost • 1.1 year payback
Compact fluorescent lamps…are found in a range of shapes and types. When replacing incandescents, compact fluorescent lamps can save energy by 60-75%. The most common retrofit application is in replacing open fixtures with mounting lights less than 12 feet (3.65 m).
Compact lamps with excellent color rendering capabilities are recommended for indoor applications. Potential problems may exist in lamps exposed to freezing temperatures,
6-47 Processes and Opportunities in Healthcare Facilities in enclosed fixtures, in dimming applications, in small fixture types which may not be large enough, and in applications requiring good beam control.
Compact halogen lamps…are incandescent lamps that use halogen gas to produce a whiter, brighter light with higher efficiency and longer life. They can save energy by 40-60%. An optional infrared (IR) coating on compact halogen lamps can result in 60% wattage reductions over standard incandescent lamps with equivalent illumination and no change in lamp life.
Applications include dimming lamps, accent lighting, downlighting, “instant-on” power floodlighting, and applications requiring tight control of beam spread.
Elliptical reflector lamps…are specifically designed for recessed incandescent fixtures. As much as 50% energy savings are possible with essentially unchanged light levels and appearances, and no change in lamp life.
In addition to compact fluorescents, compact halogen lamps, and elliptical reflector lamps, the following compact sources may also be used especially for new construction or remodeling projects:
• Low voltage halogen lamps
• Compact metal halide lamps
• High pressure sodium lamps.
Lighting Controls
The purpose of lighting controls is to eliminate unnecessary use of lights, thereby reducing energy consumption. The following approaches should be considered in developing lighting control strategies:
• Occupancy sensors
• Scheduling
• Dimming controls
Occupancy sensors …detect motion and activate controller devices to turn on light fixtures or to turn off lights if motion is not sensed within a specified period of time. Compared to manual switching, occupancy sensors can reduce lighting consumption by 15-30%. Common applications are conference rooms, offices, computer rooms, selected corridors, waiting rooms, examination rooms, laboratories, medication stations, doctors’
6-48 Processes and Opportunities in Healthcare Facilities or nurses’ lounges, locker rooms, linen rooms, storage rooms, public restrooms, and some open areas.
Case Study: Kaiser Permanente Medical Centers in Southern and Northern California Regions
• 12 full-service medical centers (300 to 600 beds each) • 29 outpatient medical and administrative facilities Old System: • no occupancy sensors New System: • 4200 ceiling sensors installed • 2500 wall sensor switches installed Energy Savings: • Offices - 33% • Conference rooms - 35% • Corridors - 39% • Waiting rooms - 39% • Nourishment/medication stations - 50% • Patient/doctors’/nurses’ lounges - 58% • Locker rooms - 50% • Linen rooms - 50% • Laboratories - 31% • Examination rooms - 26% • Special procedure rooms - 31% • Equipment/utility/storage/records rooms - 75% • Total energy reduction: over 5,317,000 kWh annually • Total cost savings: about $475,000 annually Payback: • average payback period of 20 months
Scheduling…refers to simple time controls to ensure that lighting systems are turned off during predictable operation periods. Devices range from simple time switches to programmable “sweep” systems. Time switches may be used to control lights in corridors, outdoor signs, and security lighting. Programmable time switches can take into account different weekend and weekday schedules. Sweep systems can establish a programmed schedule for sequentially turning off lights within a floor or building section. One feature provides warning to occupants to allow them to override the sweep.
Dimming controls…allow light output to be adjusted to the requirements of a particular space either by manual control or by devices that can adjust for existing light levels, daylight, or occupancy. Daylighting controls automatically dim lights near windows or skylights such as in offices or lobbies in proportion to available daylight. Another
6-49 Processes and Opportunities in Healthcare Facilities dimming control scheme adjusts the light levels on task surfaces. Yet another approach, called “tuning,” involves manually adjusting light outputs of individual fixtures or groups of fixtures to match visual requirements in the area.
Resources and References
“Compact Fluorescent Lamps.” CU.2042R.4.93, Electric Power Research Institute, Palo Alto, CA, 1993.
Karl F. Johnson. “Energy-Effective Lighting for Hospitals.” Customer Systems Division, EPRI presentation, 1994.
“Occupancy Sensors.” BR-100323, Electric Power Research Institute, Palo Alto, CA, 1992.
“Retrofit Lighting Technologies.” CU.3040R.6.92, Electric Power Research Institute, Palo Alto, CA, 1992.
“Specular Retrofit Reflectors.” CU.2046R.6.92, Electric Power Research Institute, Palo Alto, CA, 1992.
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Issues and Opportunities in Facilities Engineering and Management: Power Quality
PQ and EMI
Power quality (PQ) and electromagnetic interference (EMI) problems in a healthcare setting can have serious consequences—reduced power to diagnostic systems, shutdown of computer-controlled treatment devices, or failure of life-support equipment. These could lead to incorrect diagnoses of illnesses, lower quality of patient care, or even loss of life.
A survey of hospitals conducted in 1995 and sponsored by EPRI and American Hospital Association’s American Society of Healthcare Engineering found the following:
• A high level of interest in PQ and EMI issues
• A desire for more information on PQ and EMI
• PQ and EMI incidents have been observed at all locations in a medical facility
• Electric utilities are perceived to be responsible for a significant number of those incidents.
There are five general categories of PQ and EMI problems:
1. Voltage sags and surges
2. Voltage transients
3. Outages or momentary loss of power
4. Harmonic distortions
5. Radio frequency interference.
The solutions to PQ problems may be on the utility side or the customer side. There are basically two types of solutions to PQ problems: wiring intensive and equipment intensive solutions. Wiring intensive solutions include wiring upgrades to larger conductors, upgrading grounding and bonding, and isolating equipment loads that cause PQ problems from those that are susceptible to them. Equipment intensive solutions include surge suppressers, voltage regulators, isolation transformers, and battery backup units. Utilities can provide a service to healthcare facilities by assisting them in understanding and dealing with power quality problems.
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Based on a “Charlie” cartoon; original cartoon appeared in Sunday Punch San Francisco Chronicle and Examiner, October 24, 1993
The Hospital Electrical Environment
Hospitals have numerous high-power intermittent loads related to diagnostic and treatment functions. These loads cause voltage sags.
X-ray machines pulse their x-ray tubes on and off during which there is a high current draw for several cycles. Voltage sags could produce lower quality images. Consequently, an incorrect diagnosis may be made or a second x-ray may be required thereby subjecting the patient to higher radiation doses. Voltage sags could damage the equipment by drawing currents higher than what the machine is designed for, or, in the case of a shutdown, by momentary high voltage discharges due to the machine’s inductances.
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Actual Cases of PQ/EMI Problems • A Magnetic Resonance Imaging (MRI) system on a van outside an Idaho hospital kept experiencing image quality problems, software lockups, and component failures. The problem was traced to a silicon-controlled rectifier device in the hospital which was causing an electrical disturbance in the power line connected to the MRI system. • An Electrocardiograph (ECG) connected to a patient with a Urine Output Monitor (UOM) showed low-frequency artifacts on the ECG plots because of device-to-device electromagnetic interference. The EMI-caused artifact resembled an abnormal cardiac condition resulting in a misdiagnosis. • A CT scanner and digital fluoroscopy system in an Arkansas hospital were experiencing intermittent software lockups. Transients created by a large industrial facility were being propagated through the power system to the hospital. • The patient positioning unit of a Lithotripter machine (for breaking up kidney stones) would go out of control as a result of high electromagnetic fields from a nearby MRI system. • Some electrically-powered wheelchairs have been found to react to various radiated electromagnetic fields causing the wheels to rotate as much as 35 rpm. In one case, a patient was thrown off a cliff. • Another MRI system in New Mexico suffered software lockups and image quality problems because of impulses from infrared heaters in the building HVAC and periodic outages. • The CT scanner in a Kentucky hospital experienced repeated errors in the control section which worsened during the summer months. Variable-speed drives in the hospital HVAC system were creating transients on the line powering the CT scanner and this was exacerbated by poor earth grounding which was worse during summer when soil around the grounding system dried.
(Sources: PQTN Solution, EPRI Power Electronics Applications Center, No. 5, March 1996; “What Should I Know About Electromagnetic Compatibility & Power Quality in Healthcare Facilities?” Philip F. Keebler, EPRI Healthcare Initiative Workshops, EPRI Power Electronics Applications Center, Knoxville, Tennessee, 1996.)
Computerized tomography (CT) scanners use pulses of about two seconds. The microcomputer controlling the scanner and processing the images makes the CT scanner more vulnerable to PQ problems than x-ray machines. As with x-ray machines, voltage sags can trip the scanner’s low voltage protective device and reduce the life of the x-ray tube.
A heart catheter is used for diagnosis and treatment of cardiovascular diseases. The procedure requires continuous x-ray imaging, electrocardiogram monitors, video recording, and other sensitive electronic equipment. Voltage sags could cause the same problems in heart catheter systems as with x-rays and CT scanners.
The linear accelerator is another important medical tool. It is used in radiation treatment of cancers and other diseases. Linear accelerators draw constant high currents with intermittent pulses.
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In addition to these medical loads unique to the hospital electrical environment are other loads common to large commercial buildings. These include computer systems needed for maintaining patient records and accounting.
Harmonic-producing loads include electronic power supplies, fluorescent lighting, chillers and adjustable speed drives in HVAC applications. Startup of chillers can cause problems with CT scanners and other hospital equipment due to motor starting voltage sag.
Table 6-9 lists many hospital equipment according to their susceptibility to PQ and EMI problems (V = victims) as well as their probability of causing PQ and EMI problems (C = culprits) for other sensitive equipment on the same electrical circuit. Equipment are rated as low, medium, or high (L, M, or H) as either victims or culprits for various types of power problems.
Table 6-9 PQ/EMI Rating of Common Hospital Equipment
(V = Victim; C = Culprit; L = Low; M = Medium; H = High)
Sags/ Equipment Surges Transients Outages Noise Harmonics VCVCVCVCVC Air-Conditioning Unit L H L M L L L M M L Audio System LLMLLLHLLL Bar Code Scanner M L H L M L M L L M Blood Pressure Cuff LLHLLLLLLL Cash Register M L H L H L M L L L Chemical Analyzer H L H L H L H L L L Computerized Cooking Equip. M M H M H L M M L M Conventional Oven L H L H L L L L L L Copy Machine MMMM L L LM L L Digital Scales LLHLLLLLLM Digital Thermostat L L M L M L M L L L EEG Machine L L M L M L H L L L EKG Machine L L M L M L H L L L Energy Management System L L M L M L H L L L Elevator L H L M L L L L M L Fax Machine L L H L M L H L L M Fire/Security System M L H L M L M L L L
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Sags/ Equipment Surges Transients Outages Noise Harmonics Gamma Counter H L H L H L H L L L HVAC Equipment L H L H L L L M H L In-Room Television MLHLLLHLLL Lighting Control L M L H L L L L L H Main/Personal Computer M M H L H L M L L H Maintenance Equipment L H L M L L L H L L Microwave Oven L M M M L L L M L L Pharmacy Computer M L H L H L M L L M Phone System M L H L H L H L L M Point-of-Sale Terminal M L H L H L M L L M Refrigeration Control L L M L M L M L L L Refrigeration Equipment L H L H L L L M H L Time Card Unit LLMLMLLLLL Trash Compactor L H L H L L L M M L Vital Signs Monitor H L H L H L H L L L Water Cooler LHLML L L LML X-ray Equipment L H L M L L L H L L
(Source: Power Quality in Your Life/Health Care Facility, Edison Electric Institute, Washington, DC, 1990)
Power Quality Solutions for Healthcare Facilities
A utility can assist hospitals in following four basic steps towards resolving PQ problems:
Step 1: Develop an equipment inventory including a chart showing which electrical panel is feeding each piece of equipment
Step 2: Document symptoms of PQ problems experienced with the equipment including the nature of the problem and when it occurs
Step 3: Determine which solutions apply for each PQ problem
Step 4: Use expert assistance especially if the solution requires new equipment.
References are available which provide checklists of sensitive equipment typically found in hospitals. Table 6-10 is an equipment isolation chart; it gives examples of
6-55 Processes and Opportunities in Healthcare Facilities equipment known to experience PQ and EMI problems when connected to other equipment in the same circuit.
With the increased prevalence of digital pagers, cellular phones, hand-held radios, and other wireless technologies in the healthcare setting, the greater the possibility of EMI among devices. Sensitive patient care equipment such as monitors and ventilators may be affected by infusion pumps, portable x-rays, electrosurgery units, etc. Portable pumps and monitors within 15 to 20 feet (4.6 to 6.1 m) of cellular phones are susceptible to interference.
An analysis of 101 reports to the FDA of EMI involving medical devices shows the major sources of interference. (See Figure 6-5.) EMI threats in a hospital environment are either fixed or mobile, internal or external, and hospital-owned or nonhospital- owned EMI solutions include training, policy restrictions or bans on use, pre- installation evaluation, providing equipment immunity, shielding or engineering controls, signage and design, and audits and surveillance.
EPRI’s Power Quality Business Unit (415-855-2980) has developed a PQ Database for the hospital customer. The database addresses power quality requirements, equipment sensitivity and susceptibility, and mitigating solutions for the application of advanced medical devices. Case studies include EMI monitoring data from critical hospital locations, results of special PQ and EMI tests, evaluation of conducted and radiated interactions between hospital environments and between new and existing medical electronic devices, PQ and EMI standards for medical devices, and guidelines for use of wireless communication. The PQ Database is available to utility members in CD-ROM and Internet versions.
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Table 6-10 Hospital Equipment Isolation Chart
Do not connect equipment in the victim column of this chart into the same circuit as devices in the corresponding culprit column.
Problem Victim Culprit
SAGS and SURGES Chemistry Analyzer Air-conditioning Unit Gamma Counter Conventional Oven Main/Personal Computer HVAC Equipment Pharmacy Computer Maintenance Equipment Vital Signs Monitor Refrigeration Equipment Trash Compactor Water Cooler X-ray Equipment
Transients Bar Code Scanner Conventional Oven Blood Pressure Cuff Copy Machine Cash Register HVAC Equipment Chemistry Analyzer Industrial Mixer Computerized Cooking Equip. Lighting Control Digital Scale Meat Cutter/Grinder EEG/EKG Machine Refrigeration Equipment Fax Machine Trash Compactor Fire/Security System Gamma Counter In-Room Television Main/Personal Computer Pharmacy Computer Phone System Point-of-Sale Terminal Vital Signs Monitor
Noise Audio System Copy Machine Chemistry Analyzer HVAC Equipment EEG/EKG Machine Maintenance Equipment Energy Management System Refrigeration Equipment Fax Machine X-ray Equipment Gamma Counter Phone System Vital Signs Monitor
(Source: Power Quality in Your Life/Health Care Facility, Edison Electric Institute, Washington, DC, 1990)
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Motors (2) Cellular Phones (3) Magnetic Fields (Stereos, Speakers, TV) (3) Unknown or Unspecified (6) Other Medical Electrostatic Devices (36) Discharge (12)
Body text Electricity, Wiring, Weather, Lighting (14)
Two-Way Radio, Walkie-Talkies, CB (26)
(Source: Food and Drug Administration database)
Figure 6-5 Sources of Reported EMI With Medical Devices
A study prepared for the American Society of Hospital Engineering recommends the following:
• Medical staff should be made aware of the potential for EMI and, in the event of an EMI occurrence, should quickly scan the surroundings for sources
• Relocating or removing equipment, or adjusting leads and cables may mitigate the problem
• Facilities should assess their areas for outside sources
• Policies regarding use of nonhospital-owned equipment and appliances should be reviewed and enforced
• Electromagnetic compatibility data should be requested from vendors as a requirement of prepurchase agreements
• A careful field survey should be performed when considering installing new wireless technology.
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Resources and References
Britton Berek. “Electromagnetic Interference: Causes and Concerns in the Health Care Environment.” Healthcare Facilities Management Series, American Society for Healthcare Engineering (American Hospital Association), August 1994.
Siddharth Bhatt, Britton Berek, and Don White. “EPRI/AHA Power Quality & EMI Survey of Hospitals.” Presented at the EPRI Healthcare Initiative meeting, Providence, Rhode Island, July 13, 1995.
“CDRH’s War on Electromagnetic Interference: An Interview with Donald Witters.” Medical Device & Diagnostic Industry, February 1995.
“Electromagnetic Compatibility for Healthcare,” BR-112113 and “Power Quality for the Healthcare Industry,” BR-108466, January 1997, EPRI Power Electronics Applications Center for the EPRI Healthcare Initiative.
“Electromagnetic Interference With Medical Devices.” FDA Medical Bulletin, 24 (2), September 1994.
“Is it safe? PEAC Looks at EMC in the Healthcare Industry.” System Compatibility Research News. EPRI Power Electronics Applications Center, Special Issue, No. 3, No. 1, March 1996.
Ward T. Jewell. “The Effects of Voltage Sags in Hospitals.” In PQA ‘93/PECON IV Conference Proceedings, San Diego, November 1993.
Philip F. Keebler. “What Should I Know About Electromagnetic Compatibility & Power Quality in Healthcare Facilities?” EPRI Healthcare Initiative Workshops, EPRI Power Electronics Applications Center, Knoxville, TN, 1996.
W. Kimmel and D. Gerke. Electromagnetic Compatibility in Medical Equipment: A Guide for Designers and Installers. Interpharm Press, Buffalo Grove, IL, 1995.
W. D. Paperman, Y. David, and K. McKee. “Electromagnetic Interference: Causes and Concerns in the Health Care Environment.” Texas Children’s Hospital, Houston, TX, August 1994.
“Power Quality in Your Life/Health Care Facility.” Edison Electric Institute, Washington, DC, 1990.
Marek Samotyj and Jeff Lamoree. “Power Quality Consideration for Hospitals.” Presented at the EPRI Healthcare Initiative meeting, New Orleans, LA, February 10, 1994.
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“Solving Power Quality Problems in Medical Imaging Systems.” PQTN Solution. EPRI Power Electronics Applications Center, No. 5, March 1996.
Craig Waterman. “Medical Facility Power Quality Problems Can Be Deadly.” Power Quality Magazine. Premier II, 1990.
Rebecca Williams. “Keeping Medical Devices Safe From Electromagnetic Interference.” FDA Consumer. 29 (4), May 1995.
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Issues and Opportunities in Facilities Engineering and Management: Emergency Power
In the event of a power outage, hospitals and other healthcare facilities need to maintain critical life-support systems, electrical equipment used during surgery, devices that continuously monitor vital signs, and other processes which are essential for life safety. This emergency electrical distribution system or “essential electrical system” is powered by an on-site generator as required by codes. Emergency generators, such as diesel-, gas-, or gasoline-fueled generator sets, need to be regularly maintained and periodically tested for 30 minutes to an hour or more every few weeks at partial or full load, depending on applicable state or local regulations. The emergency power system also includes a transfer switch which senses when normal power is lost and switches the load over to the generator.
The Joint Commission (JCAHO) requires weekly visual inspections of the engines, fuel source, batteries, etc.; and monthly testing under actual load (the 30/50 rule). To be considered successful, the load must be the greater of 30% of the manufacturer’s rating for the generator or 50% of the connected load, and the test must run for at least 30 continuous minutes per month. National Fire Protection Association standards for testing of emergency generators are found in Chapter 3 of NFPA 99 and in NFPA 110. They include requirements for transfer switches.
One of the problems facing many healthcare facilities is the adverse impact of generator testing on sensitive areas of their facilities such as intensive care units and operating rooms. Also, many facility managers have difficulty understanding the JCAHO and NFPA standards. The EPRI Healthcare Initiative recently published a valuable resource (PowerPrescriptions TechBrief) explaining generator testing to ensure patient safety and comply with code requirements.
Load Transfer Devices
In general , there are four commercially available options for load transfer: (1) closed transition/non-synchronizing transfer switches, (2) conventional open transition transfer switches, (3) paralleling load transfer systems, and (4) utility paralleling systems.
In commercial and industrial sectors, such as water treatment plants or data processing establishment, non-load break (closed transition) transfer switching systems are used to exercise generator sets without a total power interruption. However, they do not prevent power disturbances during transferring nor do they prevent power failure when a source fails. The NFPA Subcommittee on Essential Electrical Systems in Health Care Facilities recommends against closed transition transfer in healthcare institutions
6-61 Processes and Opportunities in Healthcare Facilities because such operations do not adequately test the capability of the emergency system to re-energize using a standby source.
Conventional or open transition transfer (automatic transfer) switching, on the other hand, is relatively inexpensive and easiest to use for emergency generation. However, it requires a fixed open time (as much as a half to three seconds) to allow the arc caused by opening contacts to decay. Open transition transfer switching can be used with uninterruptible power supply (UPS) equipment or with integral bypass/isolation capabilities to provide continuous service to critical loads during emergency generator testing. Also, if the load generated voltage and the “new” source voltage are not synchronized at the instant of connection, large current surges can be induced at the load device. The use of an in-phase monitor does not always work since it cannot control or predict the phase relationship between the load-generated voltage and the new source voltage.
Paralleling load transfer equipment practically eliminates transients on transfer during tests of the emergency generator. It also minimizes stress on generator sets but is more complex and can be costly. Utility paralleling allows the on-site generator set to synchronize and remain in parallel with the utility service, thereby eliminating the disruption to customer service. However, protection of the utility and on-site equipment is more difficult.
Companies such as Atlantic Power Generation (11101 Nations Ford Road, Charlotte, NC 28273) and Cummins/Onan (1400 73rd Avenue NE, Minneapolis, MN 55432), divisions of Cummins Atlantic, Inc. (800-343-5038) , specialize in design and production of generators, controls, transfer switches, and paralleling switchgear. Automatic Switch Company (Hanover Road, Florham Park, NJ 07932, 800-937-ASCO, www.asco.com) offers automatic transfer switches, closed transition transfer switches, soft load closed transfer switches, bypass isolation switches, solid state transfer switches, etc. Zenith Controls, Inc. (830 W. 40th Street, Chicago, IL 60609, 773-247-6400, www.zenithcontrols.com) offers a line of emergency power and control equipment including its ZTS automatic transfer switches.
Uninterruptible Power Supplies
There are many power protection devices to shield critical equipment, the most sophisticated of which are uninterruptible power supplies (UPSs). For critical loads that are sensitive to even a small break in power supply such as during generator testing, a combination of an emergency generator and UPS may be appropriate.
Standby or off-line UPSs offer a low cost solution to equipment, such as personal computers, that require minimal power protection; they do not regulate voltage and frequency changes except during severe conditions such as outages. A line-interactive UPS provides enhanced power protection by providing some voltage regulation during 6-62 Processes and Opportunities in Healthcare Facilities spikes and surges. On-line UPSs are suited for critical equipment sensitive to power fluctuations including centralized computing and telecommunications equipment. Many critical healthcare loads in a hospital have built-in UPS capability. The most common load in a hospital supplied by an external UPS is the computer system.
Depending on the application, UPSs can come with surge protection for phone and computer networking environments, fully automatic bypass, redundant power supplies, user-replaceable batteries, remote monitoring capabilities, modular design, and space-saving rack-mount designs. UPS sizes are available from a fraction to several hundred kVA. UPS software packages can provide unattended shutdown supervision, remote access, battery self-testing, alarm management, and other features.
EPRI’s Power Quality Business Unit (415-855-2980) has developed a new, low-cost rotating UPS based on the award-winning Written Pole™ technology. It is used as a motor-generator set and functions as a highly efficient and reliable advanced UPS for critical applications in hospitals. The medium-voltage Written Pole™ motor-generator set operates on both AC and DC.
Resources and References
“BGE & SPCO Develop Innovative Product to Improve Power Quality and Reliability.” Press release, Silicon Power Networks, March 27, 1995.
“Generator Testing for Full Compliance.” PowerPrescriptions™ TechBrief TB-106695. EPRI Northeast Regional Community Environmental Center, NY, 1996.
Jim Iverson. “Position Paper: Closed Transition Transfer.” Technical Topics. Publication No. 900-0252, Cummins/Onan, June 1989.
Ward Jewell. “The Effects of Voltage Sags in Hospitals.” Proceedings: Power Quality - Issues and Opportunities PQA ‘93, EPRI TR-104581, June 1995.
Gary Olson. “Evaluating Installations Using Non-Load Break Transfer Equipment.” IAEI News, 64 (5), International Association of Electrical Inspectors, September/October 1992.
Gary Olson. “Power Transfer Systems for Interruptible Applications.” Technical Topics. Publication No. 900-0359, Cummins/Onan, February 1992.
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Issues and Opportunities in Facilities Engineering and Management: Indoor Air Quality
Indoor Air Quality Problems in Healthcare Facilities
The definition of “acceptable indoor air quality” by the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) involves both health and comfort. Acceptable indoor air quality (IAQ) is defined as:
… [A]ir in which there are no known contaminants at harmful concentrations as determined by cognizant authorities and with which a substantial majority (80% or more) of the people exposed do not express dissatisfaction. [ASHRAE Standard 62-1989, Ventilation for Acceptable Indoor Air Quality].
While indoor air quality is a concern in many occupational setting, healthcare facilities have one on the most sensitive indoor air quality issues for two main reasons: (1) healthcare facilities treat many patients whose weakened immune systems make them especially vulnerable to airborne contaminants; and (2) healthcare facilities contain many sources of indoor air pollutants such as infectious patients and chemical vapors.
The major indoor air pollutants in the healthcare field are:
1. Airborne infectious agents
2. Medicated aerosols
3. Gases and fumes
4. Other pollutant particles.
Airborne diseases are transmitted by microorganisms contained in “droplet nuclei”— microscopic particles 1 to 5 µm (microns) in diameter and containing one or more active disease-carrying organisms or pathogens. These nuclei are expelled into the air when an infectious person coughs, sneezes, or speaks. Some dangerous bacteria can also be found in water, which, if dispersed in minute drops or aerosols as in a fine spray, can contaminate the air. Once airborne, these microscopic particles tend to remain suspended in air and are carried around by air currents. Fungal spores, typically 2 to 5 µm in diameter, are also spread by the airborne route and are capable of causing infections.
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Hospital workers and patients alike can also be exposed to toxic chemical contaminants such as medicated aerosols and solvent vapors. These exposures can lead to short-term or long-term health effects.
Airborne Diseases
Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis which usually affects the lungs. It was thought to have been virtually eradicated in the United States. TB remains a killer in developing countries with higher incidences in sub- Saharan Africa, Southeast Asia and Eastern Europe. Seven to eight million people worldwide become sick with TB each year, accounting for two to three million deaths annually. It has been making a comeback in the U.S. In 1997, there were 19,851 reported cases. The situation is worsened by the emergence of highly contagious forms of TB and multiple drug-resistant strains, and the spread of HIV. TB is often the cause of death of AIDS patients.
Legionnaires’ Disease (Legionella) and Pontiac Fever are diseases caused by inhaling aerosolized water contaminated with the Legionella bacteria. About 25,000 people in the U.S. are affected annually, resulting in the deaths of several thousand. Although low-level contamination of water with Legionella is common in nature, certain conditions (namely, warm temperature and stagnant water) can cause the bacteria to proliferate. If this contaminated water is dispersed in a fine mist or aerosol, the risk of human infection increases. Cooling towers, humidifiers, showers, respiratory therapy devices, and atomizers have been associated with Legionella outbreaks. These sources of potentially contaminated, aerosolized water are commonly found in hospitals.
Other diseases spread by droplet nuclei are: the common cold (influenza), measles, chicken pox (varicella), and disseminated varicella zoster.
Medicated Aerosols
Aerosols are a source of chemical exposures. The main problem is medicated aerosols used for preventing or treating diseases, such as antibiotic therapy for pneumonia.
Gases and Fumes
Anesthetic gases are administered during surgical procedures. The common anesthetic gases are nitrous oxide, halothane, enflurane, and isoflurane. Poorly designed or maintained systems can create indoor air quality problems that can have short-term effects on workers involved in critical procedures or can lead to long-term effects such as reproductive disorders.
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Other gases and fumes come from chemical solvents and disinfectants used in a hospital environment. Solvents such as xylene, toluene, acetone, and methanol; formaldehyde used in pathology and embalming; and disinfectants such as glutaraldehyde and isopropanol can accumulate in work spaces if ventilation is inadequate or improperly designed.
Ethylene oxide or ETO, a commonly used gas for sterilizing medical equipment, presents a special problem. The gas can escape through leaks or be released through sterilizer aerator ducts. ETO is highly toxic substance and causes cancer in animals.
Other Pollutant Particles
Hospitals treat many patients with asthma and other respiratory diseases. Asthma attacks can be triggered by dust, dust mites, pollen, smoke, and other airborne allergens. Odors can also be a problem in a hospital.
Electrotechnologies for Indoor Air Quality
The most common method of removing airborne contaminants is to dilute the concentration of pathogens by increasing the amount of clean air flowing through a room. Ventilation is measured in terms of air changes per hour (ACH). Since many air changes per hour are needed to significantly reduce pathogen concentrations, the cost of increasing ventilation (heating and cooling of makeup air and fan operation) can be prohibitive. Another approach is to isolate infectious individuals in negative pressure isolation rooms where air is vented to the outside thereby keeping a lower pressure in the isolation rooms than in the rest of the facility. Isolation rooms are widely used in hospitals but negative pressure alone cannot protect healthcare workers while they are in the room and the purpose of negative pressure can be defeated by opening and closing doors and windows.
As alternatives or supplements to ventilation and negative pressure, three technologies are available for dealing with indoor air quality problems:
• HEPA filtration
• Ultraviolet Germicidal Irradiation and
• Ionizing Electrically Stimulated Filtration.
HEPA (High Efficiency Particulate Air) filtration is an efficient way of reducing airborne pathogens and are already used by many hospitals. HEPA filters vary in effectiveness but generally remove 99.7% or more of airborne particles as small as 0.3 µm. The HEPA filter can be designed and installed as part of the facility’s HVAC
6-66 Processes and Opportunities in Healthcare Facilities system or it can be used as a free-standing unit for use in isolation rooms. Some systems include computer controlled variable exhaust with automatic compensation for filter loading, wind gusts, door openings, and other pressure disturbances. Because pathogens are not destroyed by the filter, the used filters must be treated as infectious waste.
Supply Exhaust HEPA Filter
Supply Exhaust HEPA Filter
HEPA Filter & UVGI unit
Figure 6-6 HEPA Filtration Installed in Ventilation or as a Stand-Alone Unit
Ultraviolet Germicidal Irradiation (UVGI) is an alternative to increased ventilation or filtration. UV-C or ultraviolet radiation in the C range (253.7 nm wavelength) is capable of destroying DNA and eventually killing the cell under the proper conditions of UV intensity and time of exposure to the radiation. Unlike UV-A which tans the skin or UV- B which is responsible for skin cancer and cataracts, UV-C is not present in sunlight and is known as germicidal or shortwave UV. Ultraviolet-C radiation is generated in special low-pressure mercury vapor lamps that look like standard fluorescent tubes ranging in size from several inches to several feet in length.
UVGI units can be mounted to a wall, suspended from the ceiling, installed inside ventilation shafts (in-duct mounted), or enclosed in HEPA units to supplement HEPA 6-67 Processes and Opportunities in Healthcare Facilities filtration. For upper room irradiation, the units are usually mounted seven feet above floor level. Unlike HEPA filtration, UVGI is not as widely used in healthcare facilities for several reasons: some question its efficacy and its potential eye, skin and other health problems due to overexposure to UV radiation. EPRI, Consolidated Edison Company of New York, and other utilities have joined Harvard University, St. Vincent’s Hospital and other public health organizations in forming the National Tuberculosis Coalition. The Coalition’s goals include field tests to determine the safety and efficacy of UVGI.
8' 7'
Figure 6-7 Examples of UVGI Placement
Ionizing Electrically Stimulated Filtration (IESF) is an emerging technology for enhancing the capability of HEPA filters to capture airborne particles while destroying bacteria. IESF retrofit packages can be incorporated into negative pressure isolation rooms to give added protection against airborne pathogens.
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Resources and References
“Engineering Controls for Infectious Airborne Organisms,” TechCommentary. EPRI Community Environmental Center Publication, No. 1, EPRI Northeast Regional Community Environmental Center, Riverdale, NY, 1995.
Kenneth Gill. “HVAC Design for Isolation Rooms.” Heating/Piping/Air Conditioning. February 1994.
“Global Tuberculosis Programme, Tuberculosis Fact Sheet.” World Health Organization (www.who.ch).
Pat Heinsohn. Tuberculosis Resource Guide. EPRI Community Environmental Center Report CR-1016146, January 1996.
“Indoor Air Quality,” EPRI CU.3001R.7.92, Electric Power Research Institute, Palo Alto, CA, 1992.
Michael Iseman. “What Can We Do To Curtail Intrainstitutional Transmission of Tuberculosis?” Annals of Internal Medicine. 117 (3), American College of Physicians, August 1992.
Paul Jensen. “Tuberculosis Control: Ultraviolet Germicidal Irradiation.” National Institute for Occupational Safety and Health, presented at the EPRI Healthcare Initiative meeting, Providence, Rhode Island, July 13, 1995.
Mike Linscomb. “AIDS Clinic HVAC System Limits Spread of TB.” Heating/Piping/Air Conditioning. February 1994.
E.A. Nardell, et al. Letter to the Editor, New England Journal of Medicine, 327 (16), October 1992.
PowerPrescriptions™ Indoor Air Quality Issues. INvironment publication published by EPRI Northeast Regional Community Environmental Center, Riverdale, NY, (issued beginning in April 1996).
R.L Riley and E. A. Nardell. “Clearing the Air — The Theory and Application of Ultraviolet Air Disinfection.” American Review Respiratory Diseases: State-of-the-Art Paper, Vol. 138, 1989.
Richard Riley and Edward Nardell. “Controlling Transmission of Tuberculosis in Health Care Facilities: Ventilation, Filtration, and Ultraviolet Air Disinfection.” Plant Technology and Safety Management Series. 1993.
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Andrew Streifel. “Ventilation Design for Control of Airborne Infectious Agents.” Infection Control & Sterilization Technology. May 1995.
“Summary of Notifiable Diseases, United States 1997.” Morbidity and Mortality Weekly Report. 46 (54), November 20, 1998.
Dean Tompkins, Marty Kanarek, and Michael Hodgson. Indoor Air Quality Health Effects Primer. EPRI Community Environmental Center Report CR-106639, June 1996.
“UVGI for Infection Control in Hospitals.” TechApplication, EPRI Community Environmental Center TA-106887, 1996.
Ellen Weisman. “Engineering Controls and TB: What Works and How Well?” Health Facilities Management. 7 (2), February 1994.
Vendor and Other Literature
“The Battle Against Tuberculosis.” Brochure, National Tuberculosis Coalition, c/o Lighting Research Institute, 120 Wall Street, 17 Floor, New York, NY 10005-4001; 212-248-5000.
INvironment® Professional and INvironment®: the Newsletter of Building Management and Indoor Air Quality, publications on indoor air quality of the Chelsea Group, Ltd., Itasca, IL. (INvironment, 6402 Odana Rd., Madison, WI 53719; 800-722-9093)
The Handbook of Building Management and Indoor Air Quality. INvironment, Chelsea Group, Ltd., Itasca, IL.
“Ultraviolet Supplemental Air Disinfection” and “Ultraviolet Induct Air Disinfection.” Lumalier/Commercial Lighting Design, Inc., 743 S. Dudley, Memphis, TN 38104; 901-774-5771.
“Ultraviolet-C Facts” and “Understanding and Applying Ultraviolet Germicidal Irradiation (UVGI).” Lumalier/Commercial Lighting Design, Inc., Memphis, TN.
“VIOTEC UV-C Air Disinfectors.” UV Technologies, JJI Lighting Group, 67 Holly Hill Lane, Greenwich, CT 06830; 203-869-9330.
“Indoor Air Quality.” Profile of Services, Clayton Environmental Consultants, 1252 Quarry Lane, Pleasanton, CA 94566; 510-426-2600.
“In-Room HEPA Filtration Devices (HFD): An Effective and Economical TB Control Option.” William Wagner, Abatement Technologies, Lawrenceville, GA.
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“HEPA-CARE® Air Filtration Systems.” Abatement Technologies, 1705 Belle Meade Court, Suite 160, Lawrenceville, GA 30243; 800-634-9091 or 404-339-2600.
Vendor brochure on Hepaport™, Modern Medical Systems Company, 800-426-5304.
“PurAir UV Germicidal System™.” The Pure Water/Clean Air Group, NA, Mt. Vernon, NY 10552 .
“HEPA Filtration Products for Healthcare.” Airo Clean, Inc., 110 Summit Drive, Exton, PA 19341.
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Issues and Opportunities in Facilities Engineering and Management: Ozonation for Cooling Towers
Large hospitals and medical centers use water as a means of controlling temperatures in air conditioning systems, heat exchangers, and condensers. Cooling towers are used to efficiently remove heat absorbed by the water so that it can be reused. The warm, damp conditions within the cooling towers provide breeding grounds for biological growth which can lead to disease-carrying bacteria.
Problems Associated With Cooling Towers
In 1976, more than 200 people attending an American Legion Convention in Philadelphia acquired a severe respiratory illness that led to 34 deaths. The disease was caused by a bacterial strain that was traced to cooling tower drift that had entered the hotel’s ventilation system. The bacteria has since been named Legionella pneumophila and the disease is now known as Legionnaires’ Disease. The Legionella bacteria is found in many places but it thrives in warm, damp conditions such as in cooling towers where evaporation helps concentrate the food sources for the bacteria and areas of stagnant water provide a place for reproduction of the organism. The U.S. EPA and National Institute for Occupational Safety and Health (NIOSH) recognize improperly maintained cooling towers as a source of indoor air pollution.
Water is used as a non-contact cooling stream to absorb excess heat from various heat sources, such as the air conditioning system of a facility. The heated water then flows through a cooling tower to remove the heat absorbed so that the water can be reused. Heat is removed through evaporation, transferring the heat to the surrounding air. Typically, the heated water enters the tower through a pipe near the top and is sprayed as small droplets onto wet-decking surfaces where most of the heat transfer occurs. The droplets eventually fall into a cold water basin. The warm air exits the top of the tower into the atmosphere while cooled water in the basin is recirculated. A so-called drift elimination system is used to reduce water loss due to droplets escaping from the top of the tower.
The cooling water must be treated to inhibit the formation of biological growth, corrosion, and scaling on the heat transfer surfaces. Corrosion and scaling cause metal degradation, water flow problems, a reduction in the heat transfer efficiency, and equipment failure. As cooling tower efficiency decreases, operating and maintenance costs including water usage increase.
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Traditional Treatment Methods
The traditional method of treating cooling towers is the addition of a combination of corrosion inhibitors, scale control chemicals, and biocides to inhibit biological growth. The common corrosion inhibitors include phosphorus and zinc compounds. Scale control chemicals are dispersants or scale inhibitors that prevent material from adhering to metal surfaces and forming deposits, or that stop salts from precipitating out of hard water. Chlorine is the most widely used biocide. Year ago, chromate was a common additive because of its effectiveness in scale, corrosion, and microbial control. However, chromate is now banned for use in comfort cooling towers because of its toxic health effects.
Another traditional method used in conjunction with chemical treatment is the periodic discharging of water, called blowdown, to prevent the accumulation of minerals, chemicals, and other impurities. Because blowdown flows can consume millions of gallons of water, blowdown flows are restricted in some parts of the country. Furthermore, blowdowns can carry environmentally harmful chemicals into the environment.
Ozonation as an Alternative
NASA began testing the use of ozone for cooling tower water treatment in the 1970s and found positive results. At that time, however, the economics of traditional methods were favorable. Today, issues of water conservation, health effects from chemical exposures, the environmental impact of wastewater discharge, chemical disposal restrictions, and indoor air quality have made ozonation a viable alternative. Ozonation systems are now widely available as computer-controlled, self-contained systems. In 1992, there were a minimum of 500 ozonated cooling towers; others estimate between 700 to 1,000 cooling towers with ozone systems.
The advantages of ozonation are:
• Effectiveness as a biocide…ozone is the most powerful biocide available for water treatment, killing waterborne bacteria within seconds of contact and destroying accumulated biomass in cooling towers within a few days; ozone has a stronger biocidal effect on Legionella and other bacteria than chemicals
• Reduction in blowdown…ozone apparently destroys gluey organic matter that binds together inorganic particles to form large deposits; since ozone allows smaller particles to stay in suspension longer, blowdown can be reduced by 50 to 90%
• Savings in water and sewerage costs…ozonation cuts down on water use and on water discharge by reducing blowdown
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• Lessened environmental impact from blowdown…ozone decomposes into its more stable form—oxygen—within 5 to 20 minutes of being injected in water, and hence does not concentrate in the system; with ozonation, the discharged blowdown is free of accumulated biocidal chemicals
• Enhanced worker safety…since employee handling of biocidal chemicals are eliminated
Other possible benefits include:
• Ozone may be a scale inhibitor . . . its effectiveness as a scaling inhibitor is still debated: proponents argue that ozone causes scale to fall off from surfaces or destroy organic gluing agents (such as oil, grease, and microorganisms) thereby inhibiting scaling, but others do not believe ozone prevents scale formation.
• Ozone may inhibit corrosion…its effectiveness as a corrosion inhibitor is still debated: proponents believe that ozone forms a passive oxide film on metals thereby inhibiting corrosion, while others believe that ozone-treated water may be more corrosive. However, ozone has been shown to destroy microorganisms that convert iron salts to rust and thus, ozonation does prevent microbiological-induced corrosion (estimated to account for 10% of corrosion) but may or may not prevent galvanic corrosion.
• Economics may favor ozonation…ozonation may result in lower labor and maintenance costs, and lower operating costs with regards to makeup water, blowdown disposal, and chemicals.
Possible disadvantages of ozonation are:
• Ozonation system design and operation are more complex and specialized than conventional systems and may require additional technical resources
• Ozonation may still require supplemental corrosion and scale inhibitors but these additives must be ozone-compatible such as molybdate and inorganic phosphate additives
• Too much ozone may result in off-gasing which may accumulate in poorly ventilated spaces; ambient monitoring is necessary to ensure that ozone levels do not exceed health-based standards. In some areas, an ozone off-gas destruction unit may be needed.
• Ozone may degrade gaskets and elastomers found in fittings, valve liners, pump seals, etc. It may also attack certain metals and alloys. This could be a problem when high concentrations of ozone are used.
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• More debris is removed during cooling tower basin cleaning since blowdown is reduced, i.e., with less need for frequent flushing, the basin will accumulate more precipitated hardness, dirt, and other solids that find their way into the water.
• Ozonation may require sand filtration to lessen basin accumulation of solids.
Proper water management is still key in cooling tower operation whether in a conventional system or cooling tower ozonation. By carefully monitoring the level of scaling ions in the water and properly scheduling blowdown and cooling tower cleaning, cooling tower efficiency can be maintained.
Principles of Operation
There are four main parts of an ozonation system for cooling towers: (1) air preparation system, (2) ozone generator, (3) ozone-water mixing system, and (4) monitoring and control systems.
Ozone Blowdown Generator Cooling To w e r Air/ Heat ozone Contactor Exchanger
Air Preparation Sensor Makeup Water Computer
Figure 6-8 Ozonation System for Cooling Towers
The air preparation system is typically an air compressor and dryer to pretreat the air used to form ozone. The pretreated air is then sent to the ozone generator in which air is ionized in an electric corona in an enclosed system. The corona discharge is formed between two metal electrodes separated by an air gap and a dielectric (insulating) material. The electric discharge causes oxygen molecules to separate into free oxygen atoms some of which recombine to form the less stable, triatomic state or ozone.
The ozone is mixed with cooling tower water using bubble diffusers, turbine contactors, or venturi injectors. Continuous injection and thorough mixing are needed to maintain a residual concentration of ozone in the water. Ideally, the mixing system should be
6-75 Processes and Opportunities in Healthcare Facilities independent of the main tower recirculation loop so that ozonation can be controlled separately from the tower system; off-gasing from the water should be vented away from tower equipment and people; and the mixing system should be designed to prevent tower water from backing-up in the system.
Precise control and maintenance is important for ozonation to be effective. The proper ozone dose is essential: too little ozone will be ineffective in treating cooling water, too much ozone may degrade rubber fittings, metals, etc. and lead to high levels of ozone off-gasing. Parameters typically monitored are oxidation reduction potential and conductivity. Computer-based systems continuously monitor these and other parameters and control system performance.
Economics of Ozonation
Installation of an ozonation system entails purchase or lease. Cost evaluations should be performed before a hospital switches from a multi-chemical system to ozonation. The economic analysis would depend on site-specific parameters including raw water quality, cost of makeup water, cost of blowdown disposal, and electricity costs. In general, ozonation may result in lower labor and maintenance costs in addition to improved cooling tower efficiency. Decreased water consumption due to reduced blowdown and reduction or elimination of chemicals usage often offset any increases in electricity costs, resulting in a net savings in operational expenses.
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Case Study: Major Hospital in the Eastern United States
(Data from Ahlgren Associates of Waukesha, Wisconsin, and Advanced Oxidation Systems of Wayne, New Jersey)
In 1991, a major eastern hospital began using ozone for treating cooling water in a 700-ton cooling tower used for air conditioning. The reduction in labor costs reflects the elimination of company labor to maintain the chemical treatment system. Maintenance costs for the ozonation system are included in the service contract. Equipment costs are based on annual lease of the ozonation system and turnkey monitoring and control/maintenance services. The hospital determined that it did not require the use of supplemental chemicals for corrosion or scale control. A comparison is provided below:
Chemical Ozonation Treatment System
Water Usage and Water Discharge: Cycles of Concentration 3 20 Makeup Water gal./yr (m3/yr) 12,220,200 (46,258) 8,731,530 (33,052) Blowdown gal./yr (m3/yr) 3,942,000 (14,922) 453,330 (1716)
Annual Operating Costs: Electricity 0 $300 Labor $6,250 0 Equipment Lease/Service Contract 0 $15,200 Makeup Water $12,220 $8,730 Blowdown Disposal $9,850 $1,130 Chemical Treatment $5,500 0
Total Annual Cost $33,820 $25,360
Resources and References
Robert Burger. “Know Your Cooling Tower.” Power. March 1979.
“Control of Legionella in Cooling Towers.” Department of Health & Social Services, Division of Health, State of WI, June 1987.
Joseph Echols and Sherman Mayne. “Cooling Tower Management Using Ozone Instead of Multichemicals.” ASHRAE Journal. June 1990.
Donald Finnegan and Timothy Brophy. “Process Design and Operation Considerations for Cooling Tower Ozonation Systems.” Presented at the 56th Annual Meeting of the American Power Conference, Chicago, IL, April 26, 1994.
“Legionnaire’s Disease as a Health Concern.” PowerPresecription™ TechBrief TB-106891, Northeast Regional EPRI Community Environmental Center, NY, 1996.
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John McCallon. “Ozone: Cooling Water Cure-All?” Chemical Processing. September 1991.
Amanda Meitz. “Cooling Tower Water Treatment in the 1990s.” ASHRAE Journal. June 1990.
Charles Middleton. “Review of R&D Opportunities in Ozone Technology.” Pacific Gas & Electric, San Ramon, CA, 1990.
“Ozonation of Cooling Tower Water.” TechApplication. No. 3, Electric Power Research Institute, Palo Alto, CA, 1992.
“Ozonation of Cooling Tower Water in Food Processing.” TechApplication. 4 (4), Electric Power Research Institute, Palo Alto, CA, 1992.
“Ozonation of Cooling Tower Water: An Alternative Treatment Technology.” BR-100426, Electric Power Research Institute, Palo Alto, CA, 1992.
Rip Rice. Ozone Reference Guide. EPRI Community Environmental Center, St. Louis, MO, April 1996.
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Issues and Opportunities in Facilities Engineering and Management: Space Conditioning and Distribution Systems
There are different ventilation and space conditioning requirements in a healthcare facility. These requirements depend on whether the space is a patient room, isolation room, operating room, emergency room, laboratory, cafeteria, or an office, among others. Surgical suites, for example, require considerable cooling, often down to temperatures of 62 to 68°F (17 to 20°C) while maintaining a low relative humidity to prevent microbiological growth. ASHRAE provides specific design criteria (temperature, relative humidity, pressurization, etc.) for specific areas in a hospital, nursing home, or outpatient care facility, such as surgical departments, nursing, central sterile supply, etc. These varied air quality requirements have to be met simultaneously while avoiding cross-contamination to prevent the spread of diseases. In general, the factors that influence space-conditioning requirements in a hospital or in a clinic are:
• Indoor air quality
• Ability to meet regulated ventilation rates and high air-exchange rates
• Ability to provide space-conditioning control in each room to meet individual patient comfort and medical needs
• Ability to meet varying requirements of different spaces without cross- contamination of zones
• High degree of reliability and built-in redundancy
• Good acoustical qualities.
Distribution systems deliver heat, cooling, and dehumidification to spaces using air or water. There are two general types of air distribution systems: constant-air-volume (CAV) and variable-air-volume (VAV) systems. CAV systems deliver supply air at a constant rate; temperature control is done by changing the dry bulb temperature of the supply air while humidity is controlled by reheating the supply air before it enters the space. These systems tend to be energy-intensive. VAV systems, on the other hand, use air with a constant dry bulb temperature; the space temperature and humidity are controlled by varying the amount of supply air delivered to the space. VAV systems are more energy efficient than CAV systems. Parallel with the air distribution system in a healthcare facility is a multiple-pipe hydronic (water) distribution system. The water distribution system delivers chilled water, hot water, and steam, each with its own supply and return piping arrangement.
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Energy-Efficient Space-Conditioning Technologies
Some of the conventional space-conditioning and distribution systems used in commercial facilities are: constant-air-volume unitary air conditioners including rooftop air conditioners; packaged terminal air conditioners; VAV positive displacement chillers; and VAV centrifugal chillers. These systems typically use resistance or gas heating.
Table 6-11 is a list of 16 energy-efficient space-conditioning alternatives for hospitals and clinics. An entry of “excellent” means that the space-conditioning system is highly compatible and meets the typical HVAC requirement for this building type, and is commonly installed. “Good” means the space-conditioning system is compatible with the building type and has been demonstrated to meet basic HVAC requirements. “Satisfactory” means the space-conditioning system is a potential consideration but may be appropriate for particular situations (such as humid climate). The “-” entry means the space-conditioning equipment is usually not used for this building type. The initial, operating, and maintenance costs have been considered in making these assessments. (See also EPRI’s Space-Conditioning System Selection Guide, December 1993.) These systems can be used to achieve load-shaping objectives. For example, heat recovery heat pumps can provide valley filling and most of the systems can be interrupted during their cooling cycle by direct load control to provide peak clipping.
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Table 6-11 Space-Conditioning Systems for Clinics and Hospitals
Space-Conditioning System * Clinics Hospitals
Chiller Systems High-Efficiency Chiller G/E - Heat Recovery Chiller S - Ice Cool Storage E E Ice Cool Storage/Cold Air Distribution G E Eutectic Salts Cool Storage S S Chilled Water Cool Storage S S Dehumidification Technologies Single-Path Dehumidification E E Dual-Path Dehumidification E E Ice Cool Storage/Dual-Path Dehumidification E E
Heat Pumps Water-Loop G - Ground-Source G - Groundwater-Source S - Commercial Unitary G/E S Dual-Fuel G/E S Packaged Terminal - - Heat Recovery - E
* Only the primary mechanical system is shown.
(Source: Table 3 in Space-Conditioning System Selection Guide, TR-103329, Electric Power Research Institute, Palo Alto, CA, December 1993.)
Overall building air management systems exist to control sensible heat, latent heat, and make-up air in a complex facility. For example, ClimateMaster® (7300 S.W. 44th Street, Oklahoma City, OK 73179; 405-745-6000; www.clinemaster.com) offers a Total Building Air Management system for healthcare facilities with the ability to allow each zone to be individually pressurized while preventing cross contamination and maintaining tight temperature tolerances in each zone. ClimateMaster combines its Total Building Air
Management system with CO2 sensors, HEPA filtration, water-source heat pump
6-81 Processes and Opportunities in Healthcare Facilities technology developed in conjunction with EPRI, dual-path dehumidification, non- HCFC refrigerants, and other “Green Building” options.
Demand-Control Ventilation
Demand-controlled ventilation (DCV) refers to various approaches wherein the quantity of ventilation provided to conditioned spaces is modified in response to changes in occupant distribution. DCV is especially helpful in zones with highly variable and unpredictable occupancy patterns such as hospital waiting areas, cafeteria, auditorium, healthcare staff lounges, public areas, etc.
In its simplest form, DCV monitors one component of indoor air, such as carbon dioxide concentration, as an indicator of occupancy. Outdoor air dampers are then modulated to adjust the amount of ventilation according to occupancy. More sophisticated systems use continuous multi-point monitoring of both carbon dioxide and dew point. (An area is underventilated if peak CO2 concentrations are higher than 800 or 1000 ppm—the figure varies according to regulatory agency; others recommend 20 cfm (9438 cm3/s) of outside air per person.) The monitoring system provides continuous evaluation not only of the adequacy of ventilation but also the time needed to purge the previous day’s contaminants, any distribution inefficiencies, identification of system leakages, and possible outside air contamination problems.
Some of the advantages of DCV are: (1) automatic supply of maximum amounts of ventilation during periods of highest occupancy; (2) energy savings during minimal occupancy intervals; (3) elimination of the uncertainty of outdoor air damper positioning; and (4) the ability to assess and fine-tune or balance the ventilation system using DCV. A sophisticated DCV system with continuous multi-point monitoring of
CO2 concentrations may be able to identify indoor air quality problems almost instantaneously, allowing the facility manager to respond quickly before patients or staff are affected.
DCV can effectively deal with the problem of over- or under-supplying outside air with VAV systems depending on climate. VAV systems vary the delivery of total volume of supply air according to changes in heating and cooling loads. So during an overcast day, the supply air would be reduced to a fraction of that delivered during a sunny day, but the minimum outdoor air may need to be increased to a higher percentage of the total supply air. DCV provides a direct way of determining the appropriate minimum quantity of outdoor air.
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Room Pressure Measurement and Control
Many hospital room pressure products now exist to provide accurate measurements and reports of room pressure. These monitors are often combined with controllers to both monitor and control negative and positive pressure in a hospital room. More sophisticated systems not only continuously measure and control room pressure but also measure flow rates, calculate air changes per hour, change flow rates by controlling separate dampers and actuators, and interface with external devices such as thermostats. Pressure monitors and controls are typically equipped with audible and visual alarms, digital displays, and keypad programmability. (See, for example, PresSura monitors and controllers, TSI Inc., 500 Cardigan Road, Shoreview, MN 55126; 800-777-8356 or 651-490-2711; www.tsi.com/hvac/homepage/hvachome.htm#contact.)
Johnson Controls (P.O. Box 591, Milwaukee, WI 53201; 800-947-4677; www.johnsoncontrols.com) provides monitoring and room air pressurization especially for isolation room control. Their monitors offer optional control configurations for negative pressurization for isolation rooms, positive pressurization for protective isolation; and standby (flexible) operation for standard patient care. In addition to the monitor outside the door, the monitors can also provide visual alarms at nurses’ stations. These controllers can be linked to a Metasys® Facility Management System (an energy management system) to integrate pressurization with temperature and humidity control.
Dehumidification Systems
Relative humidity is linked not only to comfort but also to indoor air quality. It has been suggested that a relative humidity of between 40 to 60% is ideal to minimize the effects of bacteria, viruses, fungi, mites, respiratory infections, allergic rhinitis, and asthma (see ASHRAE Transaction, vol. 91, 1995; and “Indirect Health Effects of Relative Humidity in Indoor Environments,” Environmental Health Perspectives, Vol. 65, 1968). Fungal growth at humidities above 70% can have adverse health effects. Also, the effectiveness of air filters can be reduced at high humidity.
In areas of high humidity year round, dehumidification systems may be necessary to achieve indoor air quality objectives. Dehumidification technologies are also needed in zones where humidity control is important. Buildings with high outdoor makeup air, efficient thermal envelopes, and high occupant densities may also need dehumidification. Conventional dehumidification can account for a significant load on a space-conditioning system. Some energy-efficient alternatives are described below.
Single-path dehumidification splits the return air/outdoor air mixture, allowing one portion to go through the cooling coil while the other bypasses it, after which the two streams are then mixed and become supply air for the conditioned spaces. By varying 6-83 Processes and Opportunities in Healthcare Facilities the amount of bypass air, one can control space humidity and reduce reheat. In dual- path dehumidification, the outdoor air passes a primary cooling coil and the return air is split with one portion going through its own (secondary) cooling coil and the other is a bypass stream. The supply air is then a mixture of the cooled outside air, the cooled return air, and the bypass return air. Dual-path dehumidification combines humidity control with load-shifting to off-peak hours. EPRI, in conjunction with ClimateMaster® and Oklahoma Gas & Electric, has developed the ClimaDry system which combines a water-cooled direct expansion system for the ventilation path and a water-source heat pump for the recirculation path. The system provides direct control of ventilation and building zones, excellent humidity control, superior energy efficiency, and improved indoor air quality. R-407C refrigerant with zero ozone depletion potential is used in the ventilation system.
Another new dehumidification process uses a hybrid of desiccant wheel and heat pump technologies. With desiccant materials (such as the Engelhard Titanium Silicate), water is adsorbed at room temperature and removed from air; water can be regenerated from the desiccant at temperatures of 130 to 140 °F (54 to 60°C). The Southern Company has supported the development of a high-efficiency electric hybrid desiccant wheel/heat pump system with Engelhard/ICC. The system allows for independent control of humidity, high efficiency, control of mold and mildew, low operating cost, and improved indoor air quality.
Another new approach is the use of wrap-around heat pipes to control humidity. With the support of Florida Power, American Heat Pipes, Inc. (manufacturer’s representative: John D. Howell and Associates, 119 E. King St., P.O. Box 1673, Johnson City, TN 37605- 1673; 800-929-8548) has tested this technology at the St. Petersburg Surgery Center in St. Petersburg, Florida, adjacent to the Gulf of Mexico. St. Petersburg has three operating suites and a total of 6,200 sq ft (576 m2) of floor space. In general, heat pipes are tubes filled with measured amounts of refrigerants and permanently sealed. Heat applied to one end of the pipe causes refrigerant to vaporize, travel to the other end of the pipe where it condenses to release heat. The condensed liquid then flows back by gravity to the hot end to begin the cycle again. No external energy is consumed by the heat pipe for the transfer of heat. In this technology, a heat pipe is wrapped around the cooling coil of the air conditioner allowing the return air to be overcooled to remove excess moisture. The heat removed by the heat pipe is then delivered to the overcooled air to warm it back up to a comfortable temperature before it is distributed to the conditioned space. The heat pipe heat exchanger can increase moisture removal by 50 to 100% and works with direct expansion or chilled water systems.
As noted above, surgical suites require low room temperatures, generally between 62 to 68°F (17 to 20°C) which makes humidity control extremely difficult. In order to keep relative humidity low enough to prevent bacterial growth while maintaining low temperatures, Munters Corporation (16900 Jordan, Selma, TX 78154; 800-229-8557 or 210-651-5018, Fax 210-651-9085; http://38.208.237.2/dcweb.nsf) has developed the
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MedAire desiccant system which allows surgeons to control humidity and temperature in operating rooms at a level appropriate for each procedure. The system incorporates a desiccant wheel, filters, chilled water precooling, heat pipe post-cooling, and controls in an integrated rooftop package. A programmable controller is equipped with a modem for query and adjustment by phone lines. Relative humidities can be controlled to 45% or lower even at temperatures below 65°F (18°C).
Heat Pumps
A heat pump is a device that moves energy in the form of heat from a substance at a lower temperature (heat source) to another substance at a higher temperature (heat sink), in effect reversing the natural flow of heat, by means of a mechanical device such as a compressor. Physically resembling a conventional water-cooled chiller, a heat pump can serve for both heating or cooling. A description of different types of heat pumps can be found elsewhere (see, for example, EPRI’s Space-Conditioning System Selection Guide). In particular, hospitals can benefit from heat recovery heat pumps which boosts heat to serviceable temperatures for water heating. In a hospital that already has a chiller, the heat recovery heat pump can draw heat from the chiller’s condensed water or other waste heat source and deliver hot water between 120 to 220°F (49 to 104°C).
Case Study: East Jefferson General Hospital
East Jefferson General Hospital, Metairie, Louisiana: • 500-beds • 475,000 sq. feet (44,128 m2) • Air Handling Units: VAV Terminal Reheat, Multi-Zone
A McQuay THR-170D Templifier Heat Pump was installed with an operating maximum temperature of 140°F (60°C), design COP of 4.2, and operating COP of 5.5. The heat pump heats all of the hospital until the outside air dry bulb temperature is below 58°F (14°C). Heating hot water is reset from 120°F (49°C) at an outside air temperature of 55°F to 100°F (13 to 38°C) at an outside air temperature of 80°F (27°C). Annual electricity costs increase of $23,0335 was offset by total annual gas savings of $93,000.
(Source: Industrial Heat Pump presentation by Gregory Kurpiel and Shaun Hayes, Johnson Controls, Inc. (New Orlean, LA), EPRI Healthcare Initiative/Entergy Information Seminar, New Orleans, LA, February 23, 1995)
Hospitals and other healthcare facilities can benefit from heat pump water heaters (HPWHs). Commercial HPWHs are typically air-to-water heat pumps designed to heat water to about 140°F (60°C). The heat pump takes heat from the environment, thereby delivering space cooling and dehumidification, to raise water temperature for hot water use. The net result can be a decrease in energy costs for both water heating and air
6-85 Processes and Opportunities in Healthcare Facilities conditioning. A case study of an application of a heat pump water heater in a hospital kitchen is given in the section on Efficient Cooking and Other Kitchen Technologies.
EPRI in conjunction with ClimateMaster developed the RL Series Rooftop unitary air management product, an enhanced water source heat pump technology for air quality, temperature, and humidity control, with the option of using an alternative refrigerant. The system meets four requirements of hospitals, extended care facilities, and hospices: (1) control of cross-contamination between zones, (2) infusion of large quantities of make-up air according to zone requirements, (3) maintenance of tight temperature tolerances in each zone, and (4) delivery of hot water.
[The issue of CFCs in chillers and refrigerators as well as thermal energy storage are discussed in the separate sections that follow.]
Resources and References
David W. Bearg. “Demand Control Ventilation.” Engineered Systems, 1995; also presented by Bearg (AirXpert Systems, Inc., Lexington, MA) at the EPRI Healthcare Initiative/New England Electric Symposium, Providence, RI, July 13, 1995.
William R. Beckwith (Indoor Environment & Energy, Tampa, FL). “The Retrofit of Heat Pipes for Economical Humidity Control in a Surgery Center.” Presented at the EPRI Healthcare Initiative/Entergy Information Seminar, New Orleans, LA, February 23, 1995.
Commercial Heat Pump Water Heater Applications Handbook. Report CU-6666, Electric Power Research Institute, Palo Alto, CA, January 1990.
“Dual-Fuel Heat Pumps.” Brochure CU.2027R.4.92, Electric Power Research Institute, Palo Alto, CA, 1992.
“Ground-Source Heat Pumps.” Brochure BR-020270, Electric Power Research Institute, Palo Alto, CA, 1993.
“Heat Pump Reliability.” Brochure CU.3004R.5.92, Electric Power Research Institute, Palo Alto, CA, 1992.
“Heat Pump Water Heaters: An Efficient Alternative for Commercial Use.” Brochure CU.2020R.1.90, Electric Power Research Institute, Palo Alto, CA, 1990.
“Heat Recovery Heat Pumps: Low Cost Thermal Energy for Heating and Cooling.” Brochure BR-020250, Electric Power Research Institute, Palo Alto, CA, 1993.
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“Huntville Hospital Kitchen Employees ‘Beat the Heat’ With New Heat Pump Water Heaters.” The Energy Manager. 4 (1), Tennessee Valley Authority and Distributors of TVA Electric Power, 1989.
Mukesh Khattar (EPRI) and Michael J. Brandmeuhl (University of Colorado).”Total Building Air Management Using Dual Path System.” 1996.
Gregory Kurpiel and Shaun Hayes. “Industrial Heat Pump.” Presented at the EPRI Healthcare Initiative/Entergy Information Seminar, New Orleans, LA, February 23, 1995.
“The New High-Efficiency Water Loop Heat Pump.” Brochure CU.2047.01.92, Electric Power Research Institute, Palo Alto, CA, 1992.
Space-Conditioning System Selection Guide. TR-103329, Electric Power Research Institute, Palo Alto, CA, December 1993.
“Total Building Air Management With Unitary Air Control Water Source Heat Pump Systems.” Designer Challenge Series, ClimateMaster, Inc., Oklahoma City, OK, 1995.
“Water-Loop Heat Pump Systems.” Brochure BR-101133, Electric Power Research Institute, Palo Alto, CA, 1992.
Vendor literature.
Pradeep Vitta (The Southern Company) “Electric Hybrid Desiccant/Heat Pump.” Presented at the EPRI Healthcare Initiative/Southern Company Healthcare Workshop, Atlanta, GA, October 13, 1994.
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Issues and Opportunities in Facilities Engineering and Management: CFCs and Refrigeration
Background on CFCs
After the scientists Rowland and Molina first published their hypothesis in 1974, researchers worldwide have confirmed and refined their understanding of the serious long-term impacts of chlorofluorocarbons (CFCs) on the ozone layer in the stratosphere. CFC emissions have also been implicated in global warming. In 1987, representatives from some three dozen countries met in Montreal under the sponsorship of the United Nations Environment Program and established an international protocol restricting production of CFCs. Three years later, representatives from 93 nations met in London to revise the Montreal Protocol in light of new data on ozone depletion. The result was a rapid phaseout schedule for CFCs.
In response to the phaseout of CFCs, refrigerant substitutes such as hydrochlorofluorocarbons (HCFCs) and hydrofluorocarbons (HFCs) were developed. HCFCs have a lower ozone depleting potential than CFCs. A follow-up meeting in Copenhagen in 1992 further accelerated the phaseout schedule and introduced a phaseout program for HCFCs as well. The United States has ratified these schedules.
In addition to the phaseout schedule, the 1990 Clean Air Act Amendments require the recovery of all CFCs and HCFCs. The U.S. EPA has since launched an outreach effort to encourage owners of air-conditioning and refrigeration equipment to prepare for the phaseout schedules. The phaseout does not mean that CFCs and HCFCs will not be available. Used refrigerants will be available but prices are expected to rise.
Hospitals, medical centers, clinics, nursing homes, and other healthcare facilities are major users of refrigerant cooling equipment for space conditioning (including ventilation of critical areas), storage of temperature-sensitive drugs and other materials, food service, and other needs. Utilities can assist healthcare facilities by providing timely information and access to resources to assist them in dealing with the impact of CFC and HCFC phaseouts.
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Overview of the Regulations on Refrigerants
Phaseout Schedules
Table 6-12 U.S. Phaseout Schedule for CFCs and HCFCs in Refrigeration and Air-Conditioning Applications
Year Refrigerant Restriction
1996 CFC-11 • Phaseout of production CFC-12 • Phaseout of production
2010 HCFC-22 • Production and consumption frozen at baseline levels • Ban on use in new equipment
2015 HCFC-123 • Production and consumption frozen at baseline levels
2020 HCFC-22 • Ban on production and consumption HCFC-123 • Ban on use in new equipment
2030 HCFC-123 • Ban on production and consumption
The CFC and HCFC phaseout schedules adopted by the U.S. are shown in Table 6-12. CFCs have not been produced since January 1, 1996. Under the 1992 agreement, HCFC production will end by the year 2020.
CFC Excise Tax
In 1989 and 1992, the U.S. Congress imposed an excise tax on certain ozone-depleting chemicals and on imports of products made with or containing these chemicals. The tax was designed to penalize CFC consumers and bring the prices of CFCs closer to those for alternative refrigerants. The tax applies to new refrigerant and is calculated by multiplying the chemical’s ozone depleting potential by a base tax rate for a given year.
Recycling Requirements
The purpose for the recycling requirements under the 1990 Clean Air Act Amendments (CAAA) is to prepare users for the CFC and HCFC phaseouts which will make reclaimed or recycled refrigerants as the only refrigerant sources available. The following are some of the requirements under the CAAA:
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• Venting of CFCs and HCFCs to the atmosphere is prohibited; recovery and recycling of these refrigerants is required
• Owners of equipment with 50 lb (23 kg) or more of refrigerants must repair leaks within 30 days of discovery; the owner develops a plan to replace or retrofit equipment within one year—annual leaks must not exceed 15% for comfort cooling and other non-industrial applications
• Owners of equipment with 50 lb (23 kg) or more of refrigerants must keep records of the quantity of refrigerant added to their equipment during servicing and maintenance.
The EPA can impose fines of up to $25,000 per occurrence and offers a $10,000 reward for information leading to a conviction.
ASHRAE Standards
To guide the use of new refrigerants, the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) updated the safety standard for mechanical refrigeration 15-1994. The new standard, adopted by the Uniform Fire Code and other model codes, provide guidance for modifying local building codes.
UL Standards
Underwriters Laboratories (UL) has issued Standards for safety dealing with the conversion of cooling systems to non-CFC refrigerants. These standards cover construction and operation, insulating material and refrigerant compatibility, and procedures and methods.
Alternative Refrigerants
The following transitional refrigerants are used to substitute for existing refrigerants:
CFC-12 -----> HFC-134a commercial refrigeration some centrifugal chillers (medium pressure)
CFC-11 -----> HCFC-123 most centrifugal chillers (low pressure)
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For owners of unitary air conditioners, heat pumps, and other equipment using HCFC-22 (which will be available until the year 2020), the three most promising zeotropes or mixtures of refrigerant fluids are shown below:
HCFC-22 -----> possibly R-410a/R-410B, R-407C, or R-134a unitary HVACs commercial refrigeration positive displacement compressors centrifugal chillers (high pressure)
None of these alternatives are “drop-in” substitutes; they often require significant modifications of equipment and operation. Some require changes in the type of lubricant or sealant. Performance is also affected.
Another alternative is ammonia which has been used in large-scale food and warehousing industries. Ammonia can be used in a conventional vapor compression refrigeration cycle as well as in ammonia-water absorption refrigeration. Although ammonia has a coefficient of performance comparable to CFCs, it is flammable under certain conditions, reacts with copper, and is more toxic at lower concentrations than CFCs. Nevertheless, ammonia remains a viable alternative for high-capacity, low- temperature installations.
Options for Refrigeration Owners
As noted by one EPA official, “The worst action in refrigerant management is no action.” Chiller owners must act in response to the refrigerant phaseout and related regulations. Chiller operators should first develop refrigerant-use logs to document refrigerants and monitor leakage. They must then take immediate steps to mitigate refrigerant loss in old or new systems. These steps include:
• Replacing or repairing all leaky fittings and valves
• Adding isolation valves to allow refrigerant evacuation and storage before maintenance
• Using dual-relief valves to allow valve repairs during operation
• Using refrigerant valves with valve caps
• Using proper valve packings and seals
• Using back-seating valves
• Using a high-efficiency purge unit
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In addition, operators should use a refrigerant recovery device and provide a transfer- and-storage receiver system.
Having taken steps to minimize refrigerant loss, the owner of a chiller should then consider four basic options. Those options and their approximate costs (as a percentage of the cost of a replacement chiller) are:
1. Modifications for compatibility with a CFC substitute—20-30% of the cost of a new chiller
2. Optimized conversion of the chiller including changes in impeller, gearset, orifice, economizer, and heat exchange tubes -- 40-60% of a new chiller
3. Replacement of the compressor -- 60-80% of a new chiller
4. Replacement with a new chiller
The first three are retrofit options that result in changes in the efficiency and capacity of the chiller. Options #2 and 3 above can increase chiller efficiency to levels above that of the old equipment with the original CFC.
The decision on whether to retrofit or replace depends on chiller age, efficiency, service record, history of refrigerant use, and other factors affecting the equipment’s condition. The following is a common rule of thumb:
Chillers that are more than 20 years old --> replace Chillers that are less than 10 years old --> convert
“Resources and References” lists resources dealing with chiller selection or retrofit, as well as other information that could help a healthcare facility manager. These include comparisons of electric chillers vs. gas cooling systems, updates on the CFC phaseout, regulatory issues, etc.
Resources and References
Institutions
Commercial Building Air-Conditioning Center 150 E. Gilman Street, Suite 2200 Madison, WI 53703-1441 Phone: (800) 858-EPRI or (608) 262-8220 Fax: (608) 262-6209 Web: www.engr.wisc.edu/centers/tsarc/contact.htm
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EPRI’s HVAC&R Center provides toll-free phone support to member utilities seeking information on refrigerants and competitive cooling issues. The Commercial Building Air-Conditioning Center (CBAC) is EPRI’s on-line information resource for member utilities.
American Society of Heating, Refrigerating, and Air Conditioning Engineers 1791 Tullie Circle NE Atlanta, GA 30329-2305 Phone: (404) 636-8400 or (800) 527-4723 Fax: (404) 321-5478 Web: www.ashrae.org
The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) sponsors conferences and offers many resources materials including briefing papers, technical reports, guidelines, and conference proceedings. ASHRAE has issued the following useful material, among others: Standard 15-1994: Safety Code for Mechanical Refrigeration, Standard 34-1992: Number Designation and Safety Classification of the Refrigerants, Guideline 3-1990: Guideline for Reducing Emission of Fully Halogenated CFC Refrigerants, and The Refrigerant Recovery Book.
Air-Conditioning and Refrigeration Institute 4301 N. Fairfax Drive, Suite 425 Arlington, VA 22203 Phone: (703) 524-8800 Fax: (703) 528-3816 Web: www.ari.org
The Air-Conditioning and Refrigeration Institute (ARI) is a national trade association representing manufacturers of air-conditioning and refrigeration equipment. The Institute has available directories, policy recommendations, standards and guidelines. The Air-Conditioning and Refrigeration Technology Institute (ARTI) conducts research for ARI including evaluation of alternative refrigerants. ARI has released the following publications, among others: Directory of Certified Recovery and Recycling Equipment, Standard 700-93: Specifications for Fluorocarbon Refrigerants, and Standard 740-93: Performance of Refrigerant Recovery and Recycling Equipment.
Association of Energy Engineers 4025 Pleasantdale Rd., Suite 420 Atlanta, GA 30340 Phone: (770) 447-5083 Fax: (770) 446-3969 Web: www.aeecenter.org
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The Association of Energy Engineers (AEE) sponsors seminars and distributes printed material dealing with CFC and HCFC phaseout issues.
Refrigerating Engineers and Technicians Association 401 N. Michigan Avenue Chicago, IL 60611-4267 Phone: (312) 527-6763 Fax: (312) 527-6705 Web: www.reta.com
The Refrigerating Engineers and Technicians Association (RETA) sponsors meetings and offers refrigeration service certifications.
Refrigeration Service Engineers Society 1666 Rand Rd. Des Plaines, IL 60016-3552 Phone: (847) 297-6464 or (800) 809-0389 Fax: (847) 297-5038 Web: www.rses.org
The Refrigerating Engineers and Technicians Association (RSES) sponsors meetings and offers refrigeration service certifications.
The Alliance for Responsible Atmospheric Policy 2111 Wilson Boulevard, Suite 850 Arlington, VA 22201-3058 Phone: (703) 243-0344 Web: www.arap.com
The Alliance is a coalition of U.S. companies that produce CFCs, HCFCs, and HFCs, as well as products and processes that rely on these refrigerants. Its objectives relate to legislation and advocating the industry’s position.
Government Agencies
U.S. EPA Phone: (800) 296-1996 or (301) 614-3396 Web: www.epa.gov/spdpublc/mbr/mbrregs.html
The Environmental Protection Agency maintains a stratospheric ozone hotline to inform the public about refrigerant phaseout issues. The agency also distributes publications related to CFCs and HCFCs, including fact sheets, list of reclaimers, case histories, and rules. Among the materials in EPA’s publications list are: Final Rule Summary: Complying with the Refrigerant Recycling Rule, Short List of Alternative
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Refrigerants, Cooling and Refrigerating Without CFCs, and Resources: Air Conditioning and Refrigeration.
U.S. DOE Phone: (202) 586-5000 (general information) or (202) 586-9130 Web: www.doe.gov
The Department of Energy sponsors alternative refrigerant research and distributes reports and other printed information including Energy and Global Warming Impacts of CFC Alternative Refrigerants.
Selected Publications
“Case Study in Southern California Edison Territory: New and Rebuilt CFC-Free Chillers Provide Many Benefits.”SU-105401-R1. Commercial Cooling Update. Issue 2, Rev. 1, Electric Power Research Institute, Palo Alto, CA, April 1996.
“CFCs and Electric Chillers: Selection of Large Water Chillers in the 1990s.” TR-100537. Electric Power Research Institute, Palo Alto, CA, April 1992.
“Chiller Retrofit Issues.” SU-102513. CFC Update. Issue 6, Rev. 1, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, November 1995.
“Chiller Selection.” CFC Update. Issue 7, Rev. 2, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, February 1996.
“EPA Preparedness Campaign.” SU-102714. CFC Update. Issue 8, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, June 1993.
“Industrial Ammonia Refrigeration.” TechCommentary. 5 (1), Electric Power Research Institute, Palo Alto, CA, 1993.
“Information Resources.” SU-101267-R5. CFC Update. Issue 2, Rev. 5, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, March 1996. (Includes a list of refrigerant and chiller manufacturers, periodicals and newsletters, and seminars/meetings/proceedings)
“Refrigerant Recycling.” SU-101269-R4. CFC Update. Issue 4, Rev. 4, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, October 1997.
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“Refrigerant Regulatory Issues.” SU-101190-R5. Commercial Cooling Update. Issue 1, Rev. 5, Electric Power Research Institute, Palo Alto, CA, January 1996.
“Status of HCFC-22 Alternatives for Unitary HVAC.” Commercial Cooling Update. Issue 10, Rev. 2, Electric Power Research Institute, Palo Alto, CA, April 1997.
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Issues and Opportunities in Facilities Engineering and Management: Thermal Energy Storage
Thermal Energy Storage (TES) has applications in hospitals, nursing homes, and other healthcare facilities. TES is a technology for storing energy in a thermal storage mass for use as off-peak energy in low-cost space conditioning. TES systems are flexible and many systems are available. The thermal storage mass is usually inexpensive, involves no moving parts, and can last for 30 to 50 years with minor maintenance.
TES can meet the same cooling requirement with smaller, less expensive refrigeration equipment that has a lower electric demand during a utility’s peak demand periods while drawing most of its electric power and energy during off-peak periods. Many utilities offer time-of-use rates that include a significant reduction in electric energy prices during off-peak periods.
Some advantages of TES for space cooling include:
• Potential savings in cooling costs by 20-50%
• Savings in installed cost of refrigeration equipment
• Savings in kilowatt demand charges
• Possible savings due to off-peak energy use
• Enhanced performance of cold air distribution systems
• Possible use as backup cooling for critical cooling loads during power interruptions
In the construction of new buildings, TES systems used with cold air distribution allow for smaller ductwork. This means as much as 6 inches (152 mm) in floor-to-floor height reductions which may be significant in high-rise structures. The decrease in floor height could in turn provide savings in construction, plumbing, electrical and elevator costs.
Utilities benefit from TES systems because it allows utilities to reduce peak demand and fill load valleys, improve utilization of baseload generating equipment, reduce reliance on peaking units, and improve load factors. Cool storage also allows utilities to stem peak demand growth and defer capacity expansion costs.
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Principles of Cool Storage Operation
Cool storage relies on a storage medium with a high specific or latent heat to store cooling energy. Refrigeration is provided by conventional chillers or industrial-type ice- making units. Storage capacity is sized to shift all or part of a building’s demand for cooling to off-peak hours. Full storage supplies the building’s entire on-peak cooling needs. Partial storage supplies only part of the peak period cooling requirements and can be used to level off the building’s electrical demand for cooling over the whole 24-hour day or to reduce maximum demand to a predetermined level. The choice of strategy relative to full or partial cool storage is generally an economic decision.
TES systems for storing cooling energy typically use ice, chilled water, or eutectic salt as the storage mass. (Each of these is described below.)
Ice Storage
Ice-thermal energy storage (Ice-TES) allows for cool storage at 32°F (0°C). More than 1000 Ice-TES installations were in operation in the U.S. by the end of 1990. By making ice with electric refrigeration equipment during off-peak hours, the ice is allowed to melt to provide cooling, dehumidification, or refrigeration during the day. Actual ice storage systems require about 3 cubic feet (0.085 m3) of storage per ton-hour of cooling. An Ice-TES can be easily combined with a cold air distribution system. Alternately, industrial-grade ice-making units can be used to store energy in an ice/water mixture. These ice storage tanks are a third the size of chilled water-TES and can be stored in the central plant mechanical room, buried outside the building, or built into a basement or parking garage.
Case Study: Ralph H. Johnson Medical Center, Charleston, South Carolina
The Ralph H. Johnson Medical Center is a 300-bed VA hospital. Through the technical assistance of South Carolina Electric & Gas, the hospital phased out an old CFC-based chiller and replaced it with a 600-ton screw chiller using HCFC-22 along with a TES system comprised of 34 modular ice storage tanks. The hospital realized a 25% reduction in annual electrical costs while avoiding a 926 kW peak demand and shifting energy use during on-peak periods. The cold-air system provided greater comfort and increased productivity especially in surgical suites. Lower consumption and demand charges meant a savings of about $150,000 per year in electricity costs and expected simple payback of 5.5 years.
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Case Study: Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
The Dartmouth Hitchcock Medical Center is a 1.1 million sq. ft. (102,190 m2) facility that includes a 328-bed inpatient care hospital, a 160-physician clinic, medical research building, diagnostic and treatment facility, and separate energy plant. The central energy plant incorporates a 5,400 ton-hour ice storage system comprised on 36 ice tanks (150 ton-hours each); Calmac Manufacturing Corporation of Englewood, NJ) interconnected to a 520-ton ice-making chiller. Ice making during off- peak hours shifted an estimated 700 kW of demand.
The Medical Center realized approximately $35,000 in annual electrical demand savings plus $15,000 annual savings due to reduced utility off-peak kWh charges. Installation cost was about $310,000. With a utility rebate of $185,000, net payback is estimated at 2.5 years.
Case Study: Grossmont Hospital, La Mesa, California
Grossmont Hospital is a 490,000 sq. ft. (45,521 m2) medical facility in La Mesa, California. A study determined that the hospital had an additional design day cooling requirement of 740 tons. This requirement was met using a 320-ton chiller and 22 ice storage banks. San Diego Gas & Electric offered a cash incentive to install the ice-TES system by Calmac Manufacturing Corporation.
The new ice storage enabled the hospital to shift 232 kW off-peak and avoid a non-ratcheted $14.42 per kW time-of-use demand charge. Energy cost savings are estimated at $17,000 annually with a payback period of about three years.
Case Study: Deaconess Hospital, Oklahoma City, Oklahoma
The 210-bed Deaconess Hospital in Oklahoma installed a 120-ton air cooled chiller and eight ice banks to meet a need of 250 tons of additional air conditioning. Oklahoma Gas & Electric offered a cash incentive. The ice tanks were buried under the ground.
Ice storage not only cut the required chiller size in half, it also resulted in a shift of 250 kW off-peak thus saving the hospital a $9.15 per kW unratcheted utility time-of-use demand charge. Payback is estimated to be about five years.
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Case Study: St. Joseph’s Medical Center, South Bend, Indiana
St. Joseph’s Medical Center added new buildings to house medical offices, outpatient clinics, and an emergency center including surgical suites. With the assistance of American Electric Power, Ice-TES, high-efficiency chillers, and a variable air-volume cold-air distribution system were installed. Cooling energy to one building is provided by a 120-ton air-cooled reciprocating electric chiller and TES tanks with 900 ton-hours storage capacity. The emergency center is cooled by an air-cooled, screw-type chiller and ice TES tanks. The results were decreased operating costs and increased occupant comfort.
Chilled Water Storage
Another popular system uses chilled water to store cooling energy. Over 150 water-TES installations were operational in the U.S. at the end of 1990. During off-peak hours, water is chilled to between 40 to 46°F (4 to 8°C) by electric refrigeration equipment. During on-peak periods, the chilled water is circulated through cooling coils or heat exchangers to absorb heat and provide space cooling and dehumidification. In some facilities, fire protection water tanks may double as thermal storage. A cost analysis shows that water-TES should be considered whenever a cool storage capacity of 1000 ton-hours or more is needed. During summer months when the nighttime temperatures are 16 to 22°F (9 to 12°C) lower than daytime temperatures, an electric chiller operates efficiently with the cooler outside air and the water-TES system can take advantage of the lower temperatures. A cooling tower can be used to chill water at night.
Eutectic Salt Storage
Eutectic salts, also called phase change materials (PCMs), are also used as thermal storage. Over 80 PCM-TES installations existed in the U.S. at the end of 1990. Cooling energy is stored in PCM-TES systems in the same way as ice-TES. Eutectic salts are frozen or solidified during off-peak hours and allowed to melt to provide cooling and dehumidification during on-peak periods. A PCM-TES system consists of one or more plastic containers filled with a eutectic salt. Since these are passive units, these containers may be stacked in concrete storage units or buried under parking lots or lawns. Eutectic salts have been developed to undergo phase change while absorbing or releasing large amounts of energy. Two eutectic salts freezing at 41 or 47°F (5 or 8°C) are commercially available. PCM-TES can take advantage of cooler nighttime air temperatures. The salt can be solidified using a cooling tower at nighttime.
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Case Study: Saint Mary Medical Center, Long Beach, California
Saint Mary Medical Center received a $100,000 incentive payment from Southern California Edison to install a 2,500-ton-hour partial storage eutectic salt TES system in 1986. The PCM-TES system was used in lieu of a 400-ton chiller. The system shifted 500 kW of demand from on-peak to off-peak periods.
Cool Storage Control
Control technology for cool storage systems generally rely on preprogrammed, time- sequenced schedules for chiller and storage operation based on minimizing electrical costs for a design-day profile. Nondesign days, however, may occur 90% of the time so maximum cost savings may not be achieved.
EPRI commissioned Honeywell Inc. to develop software for optimal control of thermal storage systems. The Cool Storage Supervisory Controller (CSSC) is now available for use with energy management systems. The CSSC controller predicts temperature and load and selects an operating strategy for a given day. It then updates the ambient temperature and load profile throughout the day and adjusts its operating strategy on an hourly basis.
Cool Storage Economics
TES systems require an upfront incremental investment primarily for the storage tank and its auxiliaries. Unless there are space constraints, the determination of which storage strategy to employ is based on economic considerations involving the utility’s peak period, the differential rates between off-peak and peak rates, demand charges, and whether the building’s non-cooling load undergoes a large daily swing. In addition to storage costs, there are also refrigeration costs, potential savings in ductwork, pumps, fans, etc. Using a chilled water tank to double as a fire protection reservoir may lower insurance premiums.
The payback period for cool storage investments is usually two to six years, although paybacks of less than a year have been documented. TES can result in a 25% savings in total electric bill, or savings of 15 to 25¢ per sq. ft. ($1.60 to $2.70 per sq. m.)
Thermal Energy Storage for Space Heating
In a manner analogous to cooling storage, TES for space heating shifts the time of energy use for heating to off-peak hours. An energy storage medium is heated during nighttime hours and its heat is released on demand during the day. As in cooling
6-101 Processes and Opportunities in Healthcare Facilities storage, thermal storage for heating is flexible; systems can be sized to suit a room or an entire facility. A variety of storage media is used including special refractory brick, rock, cement/sand, or water.
Commercially packaged systems generally use brick or rock and are marketed in a range of sizes. Central forced-air and central hydronic units are designed for easy retrofit to conventional forced-air heating systems. In central forced-air units, the thermal storage furnace replaces an exiting oil or gas unit. In hydronic units, heat is stored in water stored in large vessels and the heated water is run through pipes in the baseboard or under the floor.
TES systems help provide uniform warmth. The technology is proven and reliable and requires little maintenance. Some utilities provide incentives to offset the equipment’s initial costs by offering rebates, special time-of-use rates, or off-peak rates. For a utility, TES can be part of a load management program of load shifting and increasing the use of higher efficiency baseload generating units.
Resources and References
List of Hospitals with Calmac TES
(Data provided by Calmac Manufacturing Corporation, Box 710, 101 West Sheffield Avenue, Englewood, NJ 07631; (201) 569-0420; Fax (201) 569-7593; www.calmac.com)
Grossmont Hospital, La Mesa, CA Tri-City Medical Center, Oceanside, CA Kaiser Permanente Hospital, San Diego, CA Largo Medical Center, Largo, FL L.W. Blake Memorial Hospital, Bradenton, FL Halifax Medical Center, Daytona Beach, FL Lutheran Medical Park, Fort Wayne, IN South Bend Medical Foundation, South Bend, IN South End Medical Clinic, Louisville, KY Dartmouth Hitchcock Medical Center, Lebanon, NH Kaseman Presbyterian Hospital, Albuquerque, NM Timkin Mercy Hospital, Canton, OH Deaconess Hospital, Oklahoma City, OK Children’s Hospital, Pittsburgh, PA Kent County Hospital, Warwick, RI Baylor Hospital, Dallas, TX Gallagher Road Medical and Surgical Building, Sherman, TX Riverside Hospital, Newport News, VA
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Printed Material, Slides, and Videos
“Cold Air Distribution Design Guide.” TR-105604. Electric Power Research Institute, Palo Alto, CA, 1995.
“Cold Air Distribution with Ice Storage.” CU.2038R.5.92. Electric Power Research Institute, Palo Alto, CA, 1992.
“Commercial Cool Storage Design Guide.” EM-3981. Electric Power Research Institute, Palo Alto, CA, 1985.
“Commercial Cool Storage Presentation Material.” 2 vols., EM-4405. Electric Power Research Institute, Palo Alto, CA, 1986.
“Commercial Cool Storage.” EU-3024. Electric Power Research Institute, Palo Alto, CA, 1993.
“Cool Storage Marketing Guidebook.” Slide presentation and handbook. EM-5841s. Electric Power Research Institute, Palo Alto, CA, 1988.
“Cool Storage Seminar.” Video lecture. EM85-03. Electric Power Research Institute, Palo Alto, CA, 1986.
“Cool Storage Supervisory Controller.” CU.2021.8.89. Electric Power Research Institute, Palo Alto, CA, 1989.
“Electric Thermal Storage Applications Guide and Product Directory.” CU-6741. Electric Power Research Institute, Palo Alto, CA, 1990.
“Electric Thermal Storage.” BR-100589. Electric Power Research Institute, Palo Alto, CA, 1992.
“Energy Efficient HVAC System Features Thermal Storage and Heat Recovery,” Eugene Bard of Bard, Rao + Athanas Consulting Engineers, Boston, MA, April 8, 1994.
“Eutectic Salts-Thermal Energy Storage.” BR-100691. Electric Power Research Institute, Palo Alto, CA, 1993.
“Ice-Thermal Energy Storage.” BR.100689. Electric Power Research Institute, Palo Alto, CA, 1992.
“Review of Heat Storage Materials.” EM-3353. Electric Power Research Institute, Palo Alto, CA, 1983.
“Rocks Around the Clock.” EPRI Journal. July/August 1987.
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“Stratified Chilled-Water Storage Design Guide.” EM-4852. Electric Power Research Institute, Palo Alto, CA, 1988.
“Thermal Energy Storage for a Hospital.” TechApplication. EPRI Community Environmental Center, Riverdale, NY, 1996.
“Thermal Energy Storage for Healthcare Facilities.” TechCommentary. EPRI Community Environmental Center, Riverdale, NY, 1996.
“Thermal Energy Storage With Cold Air Distribution in a Healthcare Facility.” TechApplication. EPRI Community Environmental Center, Riverdale, NY, 1996.
“Thermal Energy Storage.” BR-020252. Electric Power Research Institute, Palo Alto, CA, 1992.
“Water-Thermal Energy Storage.” BR.100690. Electric Power Research Institute, Palo Alto, CA, 1992.
Institutions
ITSAC Advisory (formerly ITSAC Newsletter) and Technical Bulletins, published with EPRI support by International Thermal Storage Advisory Council 3769 Eagle Street San Diego, CA 92103 Phone: (619) 295-6267
ITSAC bulletins keep customers abreast of product developments, applications, workshops, and utility marketing initiatives, as well as provide them with a directory of cool storage component and packaged system manufacturers.
Thermal Storage Application Research Center (TSARC) University of Wisconsin-Madison Phone: 608-262-8220 or 800-858-EPRI
The Thermal Storage Application Research Center (TSARC) is an EPRI-funded institution established to help utilities and their customers apply thermal storage technology.
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Issues and Opportunities in Facilities Engineering and Management: Water Disinfection and Purification
All water in a healthcare environment, except for sterilized water, can be a reservoir of infectious agents. The potential water reservoirs for nosocomial infections in a healthcare facility include:
• Water baths and basins
• Hospital sinks
• Faucet aerators and showers
• Immersions tubs
• Ice and ice machines
• Ice baths for thermodilution cardiac output
• Dialysis water
• Hospital toilets
• Tap water used for flowers
• Distilled water generators and containers
• Eye wash stations
• Potable water
• Cooling tower and boiler water
• Water distribution systems.
Even potable water that is not sterile but has acceptable levels of coliform bacteria (that is, less than 1 coliform bacterium per 100 ml) can harbor several kinds of noncoliform bacteria and nontuberculous mycobacteria. Certain types of water bacteria have the capability to survive in distilled, deionized, reverse osmosis, and softened water used to supply water for hemodialysis and other medical needs. A number of reports have demonstrated the presence of gram-negative bacteria in hospital sinks; some investigators have suggested that this bacteria can pass to patients by the hands of healthcare workers contaminated during washing.
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Cases of Water Contamination in Healthcare Facilities
Outbreaks linked to contaminated water in healthcare facilities have been documented in the literature:
• Legionella pneumophila cases were linked to contamination of hospital water supplies and water distribution systems
• Six patients in an intensive care unit were infected with Pseudomonas paucimobilis found in the ICU hot water line
• 19 patients acquired pulmonary disease due to Mycobacterium xenopi found in hot- water generators and water faucets in hospital wards in 1981
• Various outbreaks due to M. chelonae among patients have been reported: in one doctor’s office, it was due to contamination of tap water used to clean instruments; in a hospital, it was due to contamination in the hospital’s general water tanks; in a clinic, the outbreak came from the clinic’s water supply used in hemodialysis
• Serious outbreaks of infections with Pseudomonas and Acinetobacter were traced to contaminated bath water used to thaw or warm blood products
• Many skin infections (P. aeruginosa folliculitis) have been associated with tub immersions and contaminated whirlpool baths and hot tubs used in physical therapy and for cleaning burn wounds
• As far back as 1903, numerous cases of outbreaks have been documented as a result of contaminated ice and ice machines used in hospitals
• Multiple outbreaks in hemodialysis patients were due to contaminated water.
Many of these problems can be minimized by following careful disinfection procedures, use of sterile or properly disinfected water where necessary, and periodic inspection and cleaning of equipment. Distillation is used in some healthcare facilities but is energy intensive. For example, boiling a gallon of water consumes 20,000 more energy than the energy needed to disinfect the same amount of water using UV radiation (see below). Furthermore, distillation does not remove purgeable organic contaminants which are carried over into the distillate with the water vapor. Reverse osmosis is another method used especially in laboratories.
Chemical Treatment Methods
Chlorination is the standard water treatment method along with coagulation, sedimentation, and filtration. Chlorination can be accomplished through the addition of
6-106 Processes and Opportunities in Healthcare Facilities liquid chlorine, chlorine dioxide, or salts of hypochlorous acid (e.g., sodium hypochlorite or bleach). A new chlorination-based technology, developed by Los Alamos Technical Associates, is an electrotechnology which eliminates the need to handle dangerous chlorine gas. The MIOX technology produces aqueous hypochlorous acid solution by electrolysis of sodium chloride salt pellets and water. It is currently manufactured and sold by MIOX, Inc. (5500 Midway Park NE, Albuquerque, NM 87109; 888-MIOX-H2O or 505-343-0090; Fax 505-343-0093; www.miox.com). Although chlorination is an effective, inexpensive, and readily available technology, various health concerns have been raised in recent years. Any ammonia in the water reacts with residual chlorine to form chloramines which are toxic above certain concentrations. Recently, there has also been concern over chlorine reactions with organic matter in drinking water to form cancer-causing trihalomethanes. New technologies now exist as alternatives or supplements to chlorination.
Studies at the University of Arizona and Montana State University have shown that use of ionized copper and silver in conjunction with low levels of free chlorine can be effective in killing numerous species of harmful bacteria, especially Legionella pneumophila. This ionization process used in conjunction with reduced concentrations of chlorine and chloramines is an alternative for disinfecting potable hot water in healthcare facilities. The process can also be used for therapeutic baths and cooling towers. The Aqua Bio Control System (28870 U.S. 19 N, Suite 300, Clearwater, FL 33761; 813-669-5005; Fax 813-669-4701; http://aquabiotech.com/aqua/industries/poolsandspas.htm) is an advanced electrolytic process that controls and eliminates bacteria, viruses, algae, fungus, and yeast while reducing chemical usage by electrolytically generating copper and silver ions in the proper proportions for addition into water.
Iodine—another halogen like chlorine—has been used as a disinfectant for years and is effective on a wide variety of bacteria. Being less reactive than chlorine, iodine produces less halogenated organic compounds. The newer iodination processes involve resin- sequestered iodine systems which keep iodine attached to resin particles where pathogens are destroyed without releasing iodine into the disinfected water. However, iodine is more expensive than chlorine. The regenerable iodine system developed by UMPQUA research has been used in the Space Shuttle (NASA Tech Briefs, July 1994). Water flows through a Microbial Check Valve with an on-line iodinated ion exchange resin cartridge where microorganisms are destroyed. The new system allows for regeneration of iodine for longer-term use.
The TechniCat catalytic water treatment system, distributed by ARS Enterprises (12900 Lakeland Road, Sante Fe Springs, CA 90670; 800-735-9277 or 562-946-3505) operates catalytically to alter the minerals in water and reduce the ability of minerals to form scale. By transforming minerals in water to less ionically active forms, the TechniCat unit reduces scaling, improves the efficiency of heating and reverse osmosis devices, and may possibly decrease bacteriological activity. It can be used to treat water
6-107 Processes and Opportunities in Healthcare Facilities supplied to hospital sterilizers, reverse osmosis water treatment devices, ice machines, autoclaves, cooling towers, boilers, washer decontaminators, etc.
UV Disinfection
UV disinfection technology for destroying waterborne diseases is finding application especially in the developing world where the need is great but the technology may also be useful in healthcare and other facilities where water that is free of pathogens is critical in certain operations. In this technology, water is passed through a disinfection unit containing a lamp that generates UV-C light (so-called germicidal UV) to destroy bacteria, viruses, and other pathogens. UV disinfection is not effective in waters that are turbid or have high concentrations of suspended particles which can block UV radiation. UV destroys pathogens but is not effective on protozoan cysts such as those responsible for giardiasis which, however, can be removed by adding an appropriate filter. Other factors to consider in selecting UV disinfection are sedimentation, algae growth, and fouling, all of which can reduce the effectiveness of UV treatment. Unlike chlorination, iodination, or ionization, however, UV disinfection does not add anything to the water being treated and does not produce a taste or odor.
The Ohio Pure Water Company (P.O. Box 86, North Olmsted, OH 44070; 888-644-6329; Fax 888-OHIO-FAX; www ohiopurewaterco.com) distributes a range of UV water purification systems for use in hospitals, laboratories, veterinaries, and pharmaceutical industries. The system is designed to produce disinfected and ultrapure water for pathology labs, kidney dialysis, and post-disinfection rinses. The Sanitron UV water purifiers use between 10 to 110 watt lamps with a rated effective life of 10,000 hours. The purifiers provide a dosage in excess of 30,000 microwatt seconds per sq. cm. Water enters the stainless steel, cylindrical-shape purifier chamber and flows through an annular space between the quartz sleeve of the UV lamp and the chamber wall. Wiper segments induce turbulence to insure uniform exposure to UV radiation. The wiper assembly also facilitates periodic cleaning of the quartz sleeve without interrupting the operation. Depending on the model, the whole unit can consume between 14 to 1120 watts, with capacities from 2 to 333 gallons per minute (0.45 to 7.5 m3/h). Optional features include a UV radiation level monitor (to determine if UV dosage is sufficient), elapsed time indicator, and alarm.
The Center for Building Science’s Indoor Environment Program (Lawrence Berkeley National Laboratory, University of California, One Cyclotron Rd., Berkeley, CA 94720; 510-486-6155; www.lbl.gov) has developed a prototype UV Waterworks unit. UV Waterworks is an easy to use and inexpensive device with a life expectancy of 15 years; the 35-watt UV lamp inside a stainless steel chamber requires replacement every other year. A system, the size of a microwave oven, can disinfect four gallons per minute (0.9 m3/h).
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Ozonation
Ozone treatment has long been used as an oxidant and disinfectant for drinking water especially in Europe. Apprehensions over the health effects of chlorine by-products have prompted more interest in ozonation in the U.S. although the formation of bromate ion and possible aldehydes during ozonation have caused some concerns. Nevertheless, ozone treatment has the advantage of not only disinfecting various types of microorganisms, it also decomposes organic compounds, assists in the removal of suspended solids in water, removes odors and tastes, controls algae, removes dyes, and oxidizes certain metals and inorganic substances. As such, it has been used not only in potable water applications but also in treatment of sewage effluents, cooling tower water, beverage water, bottled water, hazardous waste, as well as applications in the pharmaceuticals industry, laundries, bleaching, and food processing. Although ozone has a short environmental life, one possible problem is the accumulation of ozone in an enclosed work space to an unacceptable concentration; hence, ozone monitoring in air is an important occupational safety precaution.
An ozonation system is composed of a power supply, feed gas preparation, ozone generator typically using corona discharge or UV energy, an ozone-water contacting device, and an off-gas treatment system. There are about three dozen ozone generator suppliers in North America manufacturing equipment that produce a wide range of sizes of ozone equipment. (For a list of vendors, the reader is referred to EPRI’s Ozone Reference Guide.) While many of the markets for ozonation are in large-scale municipal and industrial applications, compact small-scale ozonation systems also exist such as in medical device sterilization and in research laboratory applications. Ozonation for water purification in a healthcare facility would be a novel application.
Resources and References
“Aqua Bio Technologies, Inc. Electronic Water Treatment: Systems Operations Manual.” Brochure, Aqua Bio Technologies, Inc., 1996.
“ARS Enterprises.” Product Focus, Infection Control & Sterilization Technology. May 1996.
G.V. Colombo and D.R. Greenley. Advanced Microbial Check Valve Development. Final Report, NASA Contract NAS9-15854, June 1980.
Rip Rice. Ozone Reference Guide. EPRI Community Environmental Center, St. Louis, MO, April 1996.
R.J.B. Turpin. “Technicat Water Treatment in Industrial and Commercial Systems.” Pamphlet #2, Technicat, Inc., Santa Fe Springs, CA.
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David Weber and William A. Rutala. “Environmental Issues and Nosocomial Infections.” Chapter 25 in Prevention and Control of Nosocomial Infections. 3rd edition, edited by Richard P. Wenzel, Williams & Wilkins, Baltimore, Maryland, 1997.
Warren Weisman, Jr. and Mark J. Hammer. Water Supply and Pollution Control. 6th edition, Addison Wesley, Menlo Park, CA, 1998.
“UW Waterworks: Reliable, Inexpensive Water Disinfection for the World.” Center for Building Science News. Winter 1996 issue, Lawrence Berkeley National Laboratory, Berkeley, CA, 1996.
Vendor literature.
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Issues and Opportunities in Facilities Engineering and Management: Energy Management
An energy management system (EMS) provides the facility manager with information about and control over facility operations. The main benefit of an EMS is energy savings which can be achieved as lighting, space conditioning, and other operations are done more efficiently, and energy use is managed to take advantage of electric utility rate structures. There are additional benefits to an EMS such as improved occupant comfort, ability to spot impending equipment failures before they happen, more efficient maintenance scheduling, and better understanding of energy use patterns.
Some of the energy management strategies possible for a hospital with an EMS are:
• Adjustment of temperatures depending on time of day, day of the week, and season of the year
• Night purging to bring in cooler outside air during the night
• Reduction of air-conditioning energy depending on outside temperature; coordinating parameters of HVAC operation to function at highest efficiency
• Scheduled on-off controls, e.g., turning off lights and HVAC equipment in unoccupied areas; the EMS can also provide optimum start and stop strategies for different zones in the facility
• Resetting of boiler temperatures to reflect changing demand for steam use, hot water, and space heating
• Capability to optimize the use of thermal energy storage
• Controlling temperature, humidity, and other air quality parameters for patient and staff comfort; allowing for more local zone control in the healthcare facility; permitting occupant override
• Showing alarm conditions on potentially problematic equipment
• Monitoring operating performance for better diagnosis and maintenance scheduling
• Monitoring demand and cycle loads to avoid peak-demand periods
• Ability to shift energy use according to time-of-day rates, shedding loads when a demand limit is approached, etc.
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Distributed EMS for a Hospital
The EMS for a hospital is typically a distributed design, with the control logic distributed to many controllers communicating with each other and each providing some part of the overall energy management control. The system is comprised of timers and setback thermostats, local controllers, sensors (such as temperature, pressure, and occupancy sensors), actuators, and one or more operator terminals. The distributed EMS often has the capability to operate at reduced effectiveness in the event of a failure in one component. The controller usually has a preprogrammed logic that can provide standard functions including closed-loop control of HVAC equipment. The EMS allows communication not only between pieces of equipment, sensors, and controllers, but also with local area networks and external systems. An EMS can be monitored on site or remotely. Available software include graphical capabilities that show data in real time and in different levels of detail.
In procuring an EMS, several steps are important to ensure that the best system is obtained. Facility managers should involve energy consultants with experience in EMSs, conduct an energy audit to understand energy use patterns and identify energy savings opportunities, perform an economic analysis, develop specifications, and either solicit bids or obtain a performance contract (or guaranteed savings contract). The EPRI Healthcare Initiative has a network of consultants and EPRI staff who can assist in the acquisition of an EMS. Vital to the operation of an EMS are periodic evaluation of the data provided and ongoing maintenance of the EMS and associated equipment.
EPRI’s Commercial Building Energy Management System Handbook lists companies and EMS specifications and gives data on whether the EMS is appropriate for a hospital, extended care facility, or large hospital complex.
Case Study: St. Charles Medical Center, Bend, Oregon
St. Charles Medical Center: • General medical and surgical facility • 181-bed hospital • Serves 9,200 patients annually • 311,000 square feet (28,892 m2)
St. Charles signed an energy savings guaranteed contract (HealthLink™) with Johnson Controls (about $160,000 annually in utility cost savings guaranteed over a seven-year period). After an extensive audit, twelve energy conservation measures were identified. Bonneville Power Authority helped to fund the implementation of the energy management plan. Facility operations management were consolidated by installing a Metasys® Facility Management System. Metasys allows the operation of different systems and field equipment using one Metasys workstation, using existing controls of different manufacturers and providing a higher level of operational efficiency. In 1994, St. Charles Medical Center was named Energy Star Showcase Building by the Environmental Protection Agency.
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Real-Time Pricing (RTP) Controller
Real-time pricing is an hourly-based rate that reflects the time-varying cost of generating and transmitting electricity. These rates can be forecasted as little as an hour in advance. By providing healthcare customers with hourly-based pricing, customers can make optimal energy use decisions, reducing electricity usage during high RTP periods to realize savings. RTP control strategies include precooling, thermal energy storage, variable speed motors, stand-by generation, generalized load shedding, etc.
The full benefit of RTP can be achieved using an RTP controller. Honeywell’s RTP Controller automatically sheds and shifts electrical equipment usage in commercial facilities in response to RTP prices. The controller software can control up to 100 points on the building automation system. The RTP controller receives RTP rates directly from the utility and implements load shedding strategies to operate the facility in a cost- efficient way.
Example: Crawford Long Hospital, Atlanta, Georgia
An RTP controller has been installed at Emory University Crawford Long Hospital in Atlanta, GA with the support of Georgia Power and EPRI’s Information Systems and Telecommunications Business Unit.
EPRI has sponsored the development of a Customer Communications Gateway and Utility Master Station developed by Honeywell to facilitate two-way communication between utility and customer. The system provides general data, rate data, load data, and RTP data (projected and actual operating points). For the utility, the RTP controller reduces the need for peaking electric generation and provides a platform for new customer services. At the same time, the customer’s electric utility costs are reduced and operational efficiency is improved.
Resources and References
“Acquisition of Commercial Building Energy Management Systems.” BR-101640. Electric Power Research Institute, Palo Alto, CA, 1993.
“Benefits of Commercial Building Energy Management Systems.” BR-101639. Electric Power Research Institute, Palo Alto, CA, 1993.
“Commercial Building Energy Management Systems Handbook. TR-101638. Electric Power Research Institute, Palo Alto, CA, June 1993.
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“Honeywell Real-Time Pricing (RTP) Controller.” BR-105227. Electric Power Research Institute, Palo Alto, CA, 1995.
“Operation of Commercial Building Energy Management Systems.” BR-101641. Electric Power Research Institute, Palo Alto, CA, 1993.
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Issues and Opportunities in Food Services: Efficient Cooking and Other Kitchen Technologies
Electric Cooking Technologies
Cafeteria and kitchen services are found in hospitals, medical centers, nursing homes, and other healthcare institutions. Today, a whole range of electric cooking technologies as well as efficient ventilation and heat pump water heating are available for kitchen applications in the healthcare industry.
All-electric cooking equipment can provide the following benefits:
• Lower food costs
• Consistently higher food quality, better product consistency, and possible reduction in food shrinkage
• Lower ventilation and air conditioning requirements; as much as 20% lower hood ventilation costs; less heat in the kitchen
• Improved air quality: no combustion by-products nor risk of gas leakage
• More accurate temperature control
• Space savings due to compact designs
• Ease of operation; safe operation and elimination of open flames
• Energy efficiency and energy cost savings
• Generally lower capital cost for equipment compared to gas equipment
• Fewer moving parts than gas equipment; lower maintenance costs
• Faster pre-heating.
For example, the Frymaster electric fryer is an advanced technology sponsored by EPRI. It has a 50-pound (23 kg) capacity, single or dual open pot design, centerline thermostat, and boil-out mode. The solid state triac controls modulate the amount of energy to the electric elements with greater reliability and more precise temperature control. The insulation reduces standby energy consumption by about 10% over conventional electric fryers. The fryer has enhanced diagnostic features and a unique filtration system.
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Following are brief descriptions of specific electric cooking technologies supported by New England Electric. A demonstration of these technologies is available at the Culinary Arts Foodservice Exposition (CAFE) of Johnson & Wales University in Providence, Rhode Island. (The university has the largest college of culinary arts in the world operating in five campuses: Providence, RI; Norfolk, VA; North Miami, FL; Charleston, SC; and Vail, CO. The CAFE is a state-of-the-art commercial cooking center showcasing the leading electrotechnologies in cooking.)
Flashbake Unit: The unit uses intense light in the visible range to cook from the inside out, and infrared to brown and crisp. It uses only 20% of the energy of a conventional oven. A pizza is cooked in 50 seconds, New York Strip steak in 2 minutes, grilled shrimp in 20 seconds, and Angel Food cake in 4 minutes.
Induction Cooktop Range: The cooktop range provides instant and variable heat without flames. Just the pan gets hot and only when it is on the cooking surface. An electric current is induced in the pan causing it to get hot; a piece of paper placed underneath the pan will not burn. The ceramic top remains cool to the touch and is wiped clean easily. The induction cooktop range cooks faster than gas and 20% faster than current electric ranges. It takes 30 seconds to boil one pint of cold water.
Electric Fryer: With a high cooking efficiency, the electric fryer produces more french fries per hour than equivalent gas models. The heat is radiated only in the oil so no energy is lost up the flue and kitchens stay cooler. Since these fryers ensure that oil never overheats, cooking oil lasts longer. They are easier to clean and require less downtime for cleaning. Solid-state electronics have increased reliability. Streamlined designs eliminate small areas where food particles can collect and carbonize, thereby improving food taste. Electric fryers save money.
Electric Griddle: Compared to conventional griddles heated by a gas burner underneath, the electric griddle is heated by resistance heaters clamped to or embedded into the plate. Heat is transferred more efficiently to the griddle plate and less heat is lost to the kitchen air, reducing overall energy consumption by about 30%. Chrome griddles retain heat in the griddle plate: one cannot feel much heat six inches (152 mm) above its heating surface at 400°F (204°C).
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Emissions for gas burning and concerns for gas leaks are eliminated. Cleaning times for chrome-plated electric griddles are reduced by 44% over steel-surface gas models. No flavor is transferred. Electric griddles eliminate uneven “hot spots” in the heating surface.
Combo-Oven: The combo-oven combines conventional cooking with steaming capabilities. It can roast, bake, poach, vapor grill, etc. No flavor is transferred.
Conduction Cooking: This is cooking with direct heat by conduction and using no fans. Hot fluid is locked into the shelves. Cooking time is reduced. It can be used for cooking great quantities of food.
Rapid Chiller: The rapid chiller uses cold fluid inside the shelving system to rapidly chill food items. It is quicker than blast freezers.
Pulper: The pulper reduces bulk waste by 80% and allows the waste stream to be reused, therefore reducing waste haulage and labor costs. The pulper also improves sanitation.
Kitchen Exhaust Ventilation
A large kitchen’s total energy costs are linked to heating, ventilation and air conditioning, and as much as 75% of this load may be attributable to operation of the kitchen’s exhaust ventilation system. Therefore, a well-designed ventilation system with Underwriters Laboratory certification would be worth the higher initial cost because of lower operating costs in the long run. A well-designed, UL-listed ventilation system offers the following benefits:
• Lower energy costs…lower CFMs can reduce exhaust volumes by 10 to 40%
• Safer operation…many new models offer automatic fire suppression by connecting water lines to ventilator hoods; grease can be collected in troughs for regular emptying to prevent hazardous accumulation
• Lower maintenance…many new models have self-cleaning features.
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Heat Pump Application in Hospital Kitchens
Use of heat pump water heaters are also possible in kitchens. The heat pumps reduce water heating costs while providing cool air in kitchens. A case study is provided below.
Case Study: Huntsville Hospital Kitchen
Five 4-ton heat pump water heaters were installed in the late 1980s in the kitchen area at Huntsville Hospital, a 578-bed hospital in Alabama. In addition to providing hot water, the heat pumps helped to “spot cool” the 85 kitchen employees thus improving the working environment.
Two heat pumps were placed above the refrigeration area and one above the steam unit. The heat pumps dropped the average temperature from about 95° to 76° (35° to 24°C) during meal preparation and reduced relative humidity to around 40%. The heat pump above the dishwasher not only helped cool the area but also reduced condensation by acting as a dehumidifier.
The installation cost about $55,000 with a $20,000 grant from the State of Alabama, but the facility estimated an annual savings of some $14,000. Payback was actually realized in only two years because of the added benefit of heat pump water heaters: air conditioning of the kitchen space.
Resources and References
Bulletin No. 818-0122, Frymaster® Welbilt™, The Frymaster Corporation, 8700 Line Avenue, P.O. Box 51000, Shreveport, LA 71135-1000; 800-221-4583, or 318-865-1711; Fax 318-868-5987; www.frymaster.com.
“Cooking with Electricity: Electric Griddles Can Take A Grilling.” ElectroTechnologies- Powerful New Ideas, New England Electric.
“Foodservice Sourcebook: A Quick-Reference Guide to Industry Information and Sources.” EM-6135. Electric Power Research Institute, Palo Alto, CA, 1990.
EPRI’s Foodservice Sourcebook contains a directory of major distributors and manufacturers of electric ovens, fryers, broilers, griddles, ranges, cookers, kettles, skillets, steamers, coolers, refrigerators, freezers, dishwashers, hot water heaters, ventilation, and exhaust equipment.
“Frying with Electricity: Electric Frying Redefines Fast Food.” ElectroTechnologies- Powerful New Ideas, New England Electric.
“Huntville Hospital Kitchen Employees ‘Beat the Heat’ With New Heat Pump Water Heaters.” The Energy Manager. 4 (1), Tennessee Valley Authority and Distributors of TVA Electric Power, 1989.
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“Juicy Techniques for Cutting Costs With Electric Cooking Equipment.” Environmental Solutions: Products & Services, Southern California Edison, Edison International Company.
“Optimizing Kitchen Ventilation: UL-Approved Ventilation Systems Offer Refreshing Savings.” ElectroTechnologies-Powerful New Ideas, New England Electric.
“The C.A.F.E.” ElectroTechnologies—Powerful New Ideas, New England Electric.
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Issues and Opportunities in Lodging Services: Ozone Laundry
Ozone-Based Laundry Operations
Hospitals and nursing homes often operate their own laundry services to clean lightly soiled materials such as sheets, towels, pillowcases, bedspreads, blankets, patient gowns, and diapers. A typical 350-bed hospital with 100,000 patient-days per year may generate about one million kilograms of laundry annually; an estimated 2 billion kilograms are generated in U.S. hospitals per year. Laboratories and free-standing clinics may contract out to a traditional, commercial laundry service for the cleaning of laboratory gowns, sheets, wash cloths, etc. An ozone-based laundry system is an innovative, cost-effective, environmentally friendly alternative for healthcare facilities.
One obstacle to the use of ozone-based systems is that recommended guidelines used by hospitals for washing linens are based on the traditional method of immersing laundry in water at 160°F (88°C) for 20 minutes to ensure disinfection. These guidelines date back to the 1930s and assume the use of detergent and alkali. They were necessary for isolation room and operating room linens, most of which are now in the form of disposable (non-reusable) textiles.
Ozone-based laundry systems are appropriate for the bulk of a hospital’s laundry such as beddings, blankets, gowns, towels, etc. An existing laundry washing equipment can be retrofitted for the closed-loop ozone-based laundry system (described below). Ozone-based laundry systems are also available for lease. In comparison to traditional laundry services, ozone-based systems offer several key advantages:
• Shorter cleaning cycle times…therefore ozone systems save time and increase productivity
• Operation at low temperatures…therefore water heating requirements are drastically reduced or eliminated
• Reduced amount of chemicals and detergents…therefore effluent concentrations of residual chemicals are lower and environmental impact is lessened
• Recycling of water (for closed loop systems)…therefore use of water and amount of sewerage are significantly reduced
• Lower cost per pound of load compared to traditional laundry systems…therefore significant cost savings are achieved.
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There are also several important “fringe benefits” with the use of ozone-based systems:
• Longer textile life, since the major causes of fiber degeneration (hot water, alkali and sour, bleaches, long exposure to mechanical action) are reduced
• Removal of odors
• Disinfection
• Production of hypoallergenic garments, since residual detergents and alkali imbedded in fiber from traditional systems (which are a contributing cause of skin irritation and may contribute to bed sores in bed-ridden patients) are reduced.
• Reduced wear and tear of washing machine equipment in part due to reduced machine run time
Some of the disadvantages of ozone-based systems are explained below:
• Depending on the amount of ozone generated and the location of the ozone-based system, an air quality monitoring system may be needed to detect the level of accumulated ozone in the workplace.
• Ozone will not completely clean heavy and hard-to-remove stains such as heavy food grease, mascara, inks, certain food dyes, and certain medicines. Varying amounts of a low temperature enzyme detergent may have to be added with ozone.
• While there are about 100 ozone-based laundering systems operating in the United States (especially in hotels, correctional institutions, and commercial laundry facilities), there is little experience in ozone laundering in healthcare facilities.
The Occupational Safety and Health Administration (OSHA) guidelines for ozone levels in the work environment show a permissible exposure level of 0.1 ppm averaged during an 8-hour period. (The distinct smell of ozone can be detected by humans at concentrations as low as 0.02 ppm.) In the event of high ozone concentrations in the air, shutting off the ozone generator instantaneously cuts off production of ozone and ozone levels rapidly dissipates as ozone breaks down to its more stable form, oxygen.
Principles of Operation
Washing is a function of five processes: mechanical action, temperature, time, dilution, and chemistry. The chemical processes in conventional washing and soil removal include oxidation, emulsification, lubrication, flocculation, neutralization, and saponifacation. Adding ozone to the wash formula changes the wash process so much
6-121 Processes and Opportunities in Healthcare Facilities so that less chemicals, fewer water operations, shorter wash times, and lower temperatures are needed.
Ozone is a powerful oxidizer. When used with water in cleaning laundry, ozone oxidizes fatty oils and grease that bind dirt to cloth. As dirt is removed from clothing by mechanical action of a washing machine, ozone assists in the flocculation and coagulation of dirt, making it easier to filter out of water. As an oxidizer, ozone can also break down many organic contaminants including compounds responsible for odors. Hence, ozone destroys laundry odors and eliminates the need to add scents. Using ozone with small amounts of low temperature enzyme detergents and peroxide bleaches (instead of chlorine bleaches) can result in a synergistic effect, making detergent chemicals more effective and providing good bleaching with less color degradation. Ozone also acts as an effective disinfectant by destroying bacteria and viruses in the laundry.
There are basically two types of ozone-based laundry systems that may be used: closed- loop or recycling system; and open-loop or non-recycling (also called a flow-through) system.
Closed-Loop Ozone Laundry System
Whenever water in the washing machine is drained, the dirty water is collected in a sump and pumped through a screen or coarse bag filter to remove larger particles and lint from the water. The coarsely filtered water is collected in a holding tank. Upon activation of a second-level switch, the water is pumped through a second filter which removes particles down to 20 microns in size. The filtered water then flows into a storage tank.
Ozone gas is injected into a venturi mixer to form microscopic bubbles which then enter the storage tank through the bottom. As the tiny ozone bubbles rise to the surface, they oxidize odor molecules and residual chemicals, and destroy bacteria and viruses. They also carry with them smaller remaining particles, as well as any oil and grease molecules, forming a film at the surface of the water. When the storage tank fills, the film overflows through an outlet and into the sewer. Additional “make-up” water from the regular water supply line is added to the storage tank as needed. (If well water or very hard water is used, a water softener may be required.)
Clean water from the storage tank is pumped into a charging or contact tank upon demand. In cases where high quality textiles are processed, a 5-micron polishing filter may be used between the two tanks to remove even smaller particles. In the charging tank, more ozone gas is bubbled through the bottom of the tank to create a residual of ozone in the water. This ozone-laden water is used whenever the washing machine calls for more water during its different cycles.
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Ozone is produced by an ozone generator and an air preparation system which concentrates oxygen in the atmosphere as it is supplied to the generator. An air compressor is needed.
The system is controlled by a control panel which interfaces between the washing machine and the various pumps and level switches. The panel is also a diagnostic center to isolate problems in a system and to accelerate maintenance and repair. The system is completely automated and does not require specialized skills or training.
Open-Loop Ozone Laundry System
An open-loop system uses one contact tank which is filled by the local water supply line. (A water softener may or may not be required.) As in the case of the closed-loop system, the ozone generator delivers ozone gas to the bottom of the contact tank via a venturi mixer. The ozone-laden water is pumped into the washing machine on demand. Small amounts of similar additives as those used in the closed-loop system are introduced into the washer when needed, as in the case of heavily soiled linens. Dirty water is simply flushed into the drain. (Any residual ozone molecules in the dirty water would eventually break down into oxygen.) While the open-loop laundry system has the same benefits as the closed-loop system, the closed-loop system has the added advantage of a 40-50% savings in water and sewerage.
The Steiner Corporation, a prominent commercial laundry chain, released the following results (Table 6-13) from its independent study of a CyclO3PSS ozone-based laundry installation at the laundry chain’s Milwaukee facility:
Table 6-13 Comparison for a Commercial Laundry Chain
(Milwaukee Facility, The Steiner Corporation)
Before Ozone After Ozone Percent Change Installation Installation
Pounds Processed Per Employee Hour 825 lb 1101 lb +33.5 (374 kg) (499 kg) Wash Room Person Hours 637 499 -27.7 Water Consumption per pound 2.19 gallons 1.77 gallons -23.7 (8.29 L) (6.7 L) Washing Labor Costs * * -46 Chemical Costs * * -35 Wastewater Results 148 ppm FOG 94.2 ppm FOG -36
* proprietary information; FOG = fats, oils, and greases
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Resources, References, and Vendors
IES, Inc. (International EcoScience) 5862 Bolsa Avenue, Suite 102 Huntington Beach, CA 92649 Phone: (714) 799-3123 Fax: (714) 799-3013 Malcom McLean, President Wess Illing, Chief Engineer
IES conducts engineering research and development on ozone systems and provides service to government and commercial facilities. They also offer an open and closed loop laundry system.
CyclO3PSS Corporation 3646 West 2100 South Salt Lake City, UT 84120 Phone: (800) 972-9091 or (801) 972-9090 Fax: (801) 972-9092 www.cyclopss.com/index.htm
™ CyclO3PSS recently introduced its OzO3-Clean System 200, an improved and enhanced version of its CyclO3PSS ozone washing system. Its CyclO3PSS technology has been installed in over a dozen installations in the largest of laundry facilities. The company has also developed a smaller, portable, ozone washing system called CyclO3PSS Textiles POWER System designed to demonstrate the effectiveness of ozone-based systems to commercial and industrial facilities. CyclO3PSS sees its POWER system as a step towards expanding ozone-based laundry systems in institutions including hospitals.
GuestCare, Inc. 3030 LBJ Freeway, Suite 1460 Dallas, TX 75234 Phone: (800) 218-7494 or (214) 243-3035 Fax: (214) 243-0706 Web: www.etven.com/guestcare/index.html
GuestCare is a major distributor of ozone laundry systems to the hospitality industry in the United States. Their GuestCare NT-800 Ozone Laundry System can handle up to one million pounds (453,600 kg) annually, uses PLC-based controls, includes ozone air monitoring, and only requires a 2’ x 5’ x 6’ (high) (0.6 × 1.5 × 1.8 m) space. Ozonation is done by vacuum injection and every system is customized to meet specific needs. They offer a one-year parts and service warranty on all components. The company installs in- line water meters for “before and after” proof of savings due to ozone; they expect annual savings of 3-12% on laundry labor, 45-65% on laundry water and sewer, 50-75%
6-124 Processes and Opportunities in Healthcare Facilities on chemicals, and 75-95% on natural gas for hot water. GuestCare has several dozen ozone laundry installations in lodging facilities as well as in hospitals, correctional institutions, and nuclear power stations.
E. Katzenelson, B. Kletter, and H.I. Shuval. “Inactivation Kinetics of Viruses and Bacteria in Water by Use of Ozone.” AWWA Journal. December 1974.
Michael Martin. “Nosocomial Infections Related to Patient Care Support.” Chapter 31, Prevention and Control of Nosocomial Infections. 3rd edition, edited by Richard P. Wenzel, Williams & Wilkins, Baltimore, MD, 1997.
“Ozone Cold Water Laundry.” TU E Technologies Update. TU Electric, January 1995.
Jack Reiff. “Ozone Puts the Washroom On A Diet.” Textile Rental. Magazine of the Textile Rental Services Association of America, June 1995.
Vendor literature
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Issues and Opportunities in Information Systems and Telecommunications: Telemedicine
Modernization of Hospital Data Processing Systems
The healthcare industry is 5 to 10 years behind most industries in data processing. Healthcare providers have been spending only 1-2% of their operating budgets on information technology. Several factors are compelling more hospitals to overhaul their computer systems:
• Pressure to cut costs
• Demand for increased efficiency and productivity
• Requirement to submit medicare claims electronically
• Availability of powerful, low-cost computers with high-tech data processing and networking capabilities
Moreover, as Ode Keil, formerly of the Joint Commission on Accreditation of Healthcare Organizations pointed out, “Most of the medical records of this country constitute a fire hazard.”
Currently, 10% of hospitals are undergoing major data processing overhauls. Analysts anticipate that hospital spending on information systems will increase to $13 billion by 1998 (compared to less than $4 billion in 1988). Increased computerization will mean that power quality issues will become more significant in coming years.
Growth of Telecommunications and Telemedicine
Developments in the information superhighway, compressed interactive video, high- speed transmission cables, satellite link-ups, and other information and telecommunications technologies have created new opportunities for the healthcare industry in four major areas:
1. Administrative teleconferencing
2. Continuing medical education
3. Telemedicine
4. Community health information networking
6-126 Processes and Opportunities in Healthcare Facilities
With mergers, acquisitions, and increasing affiliation among hospitals, the use of interactive compressed videoconferencing provides a means of enhancing management. According to VTEL, a compressed video systems manufacturer, as of 1998 the bulk of their customers adopt the technology for administrative uses. Over 1,500 VTEL systems are installed in healthcare accounts worldwide. Nationally, 37 states have VTEL systems.
Continuing medical education account for about 30% of compressed video applications. One example is the Baylor Health Care System in Texas. Clinicians at the Baylor Medical Center at Garland participate in weekly one-hour continuing education programs with their colleagues at the parent facility in Dallas. The system also allows them to “attend” whole-day clinical education programs without being away from their patients. In addition, the hospital saves on travel expenses and the cost of staff replacement for that period of time.
Telemedicine refers to a two-way audio and video communications network that allows hospitals and physicians access to medical and technological resources via telephone lines and satellite link-ups. Telemedicine dates back to 1959 when two-way, closed- circuit television was used. However, compressed video and other new technologies are gaining acceptance among clinicians. In a pilot study by VHA Inc. (Irving, Texas), physicians were provided compressed video technology during a six-month project. 83% said they would use the technology for diagnostic purposes, 94% said they were comfortable using it for consultations, and 100% would use it for education.
Rural hospitals and physicians were among the first to utilize the new technology. Telemedicine can assist rural healthcare providers stay in touch with other professionals, stay current with medical developments, improve retention of physicians in rural areas, and possibly improve patient outcomes. Another potential benefit is improved preventive healthcare.
Rural areas, however, pose major challenges: lack of telephone line capacity and reliability; lack of computerization; inability of long-distance transmission lines to meet telecommunications demands; lack of local resources for training in telecommunications technology and software; and lack of local consultants to assist in assessment and design of networks.
Congress mandated the “Telecommunications Act of 1996” to ensure that effective delivery and affordable access to telecommunication services is available to schools, libraries and rural health care providers at comparable rates charged to urban areas. The Federal Communications Commission (FCC) has adopted rules to implement this requirement. There are an estimated 12,000 eligible non-profit rural health care providers including: post secondary educational facilities offering health care instruction, community health centers, and other public or non-profit facilities, including hospitals. Rural areas, as defined by the Federal Office of Rural Health Policy
6-127 Processes and Opportunities in Healthcare Facilities
(ORHP) are those areas not located in a Metropolitan Statistical Area as defined by the Federal Office of Management and Budget (OMB). This universal service support provides discounts only for telecommunications services, Internet access, and internal connections. All telecommunications carriers that provide interstate telecommunications services are required to contribute to universal support mechanisms.
For further details on the Universal Service Funds to decrease costs to eligible rural health care providers, and to obtain an application, contact the Rural Health Care Division of the Universal Service Administration Company (a non-profit subsidiary created by the FCC to administer the rural health care program) at (800) 229-5476 or www.rhc.universalservice.org. The FCC is another source of information at (888) CALL-FCC, (202) 418-7393 Kim Parker, or www.fcc.gov/healthnet.
Several telemedicine bills were introduced to Congress in 1997 and 1998. “The Comprehensive Telehealth Act of 1997 (S.385)” and its companion bill “The Improved Access for Telehealth Act of 1997 (H.R.966)” provide reimbursement under the Medicare program for telehealth services. “The Medicare Telemedicine and Medical Informatics Demonstration Act of 1997 (H.R.1101)” provides for a project to demonstrate the application of telemedicine and medical informatics to improving the quality and cost-effectiveness of health care services under Medicare and other health programs. “The Rural Demonstration Act of 1997” directs the Health and Human Services Secretary to expand and strengthen the demonstration project known as the Medical Telemedicine Demonstration Program. “The Promoting Health in Rural Areas Act of 1998 (S.2603)” was another bill introduced to recognize telemedicine as a promising tool for providing medical expertise to rural communities, technical expertise to rural health professionals and facilitating interaction with peers. Although none of these bills were reported out of their respective committees, this issue is expected to continue to receive attention from Congress as it addresses health care reform in the coming session.
In January 1997 the ORHP released the first major survey of rural telemedicine. “The Exploratory Evaluation of Rural Applications of Telemedicine”, conducted by Abt Associates, Inc., includes information about the extend to which telemedicine is used in rural areas, by whom, for what purposes and the costs. In early 1997, nearly 30% of the 159 hospitals surveyed in the winter of 1996 were expected to be using some sort of telemedicine to deliver patient care. Of these, 68% were expected to offer only teleradiology. More than 40% of the telemedicine programs surveyed had been providing teleconsults for one year or less. Radiology and cardiology were the most common clinical applications reported, followed by orthopedics, dermatology and psychiatry (see Figure 6-9). Telemedicine systems were also used for non-clinical applications such as continuing education for health professionals. 58% of the sample had used their equipment for four or more different non-clinical uses (see Figure 6-10). Despite growth and expansion, the cost of telemedicine remained high. Federal and
6-128 Processes and Opportunities in Healthcare Facilities state grants were common sources of direct funding for telemedicine programs, and the majority of sites also received hospital financial support. Third-party reimbursement for telemedicine was elusive; fewer than 25% of hub facilities had successfully negotiated payment with insurance carriers and many had not yet undertaken such negotiations (see Figure 6-11). The most common transmission technologies involved copper telephone lines (78% of telemedicine facilities and 83% of teleradiology only facilities), and dedicated telecommunication services such as T1 (76% and 29% of telemedicine and teleradiology only facilities respectively). Fiber optic lines were also commonly reported (52% of telemedicine facilities) as were switched services such as switched 56Kbps and ISDN. Satellite or microwave transmission were each mentioned by less than 10% of respondents. 38% reported availability of not only a dedicated service, but also a switched service. Utilization was low in the first years of most rural telemedicine programs. Only 17% used their system more than once each day. 60% of facilities that had been operating between one and two years had a narrow range of clinical applications whereas those operating for two or more years were more likely to have a broader set of applications (62%).
(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm)
Figure 6-9 Most Commonly Reported Clinical Applications
6-129 Processes and Opportunities in Healthcare Facilities
(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm)
Figure 6-10 Non-Clinical Applications
(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm)
Figure 6-11 Funding Sources
6-130 Processes and Opportunities in Healthcare Facilities
Utilities have long recognized the importance of information systems and telecommunications in reducing costs and providing value-added services to their customers. With this wealth of resources and experience at their disposal, utilities could assist the healthcare industry in adopting information and telecommunication-based tools and in partnering with healthcare providers to offer innovative services based on information systems and telecommunications technologies.
Resources and References
Rhonda Bergman. “From the Mountains to the Prairies: Country Docs Get Set to Take a Spin on the Information Superhighway.” Hospitals & Health Networks. December 5, 1994.
“The FCC’s Universal Service Support Mechanisms” and “Frequently Asked Questions On Universal Service For Rural Health Care Providers.” Federal Communications Commission (National Call Center 1-888-225-5322).
Roger Guard and Mary M. Langman. “Legislative Priorities for Medical Libraries.” MLA News. (#301):22, Nov/Dec. 1997.
“Health Care Hospitals, Drugs and Cosmetics: Current Analysis.” Standard & Poor’s Industry Survey, April 1994.
Marianne Puckett and Mary M. Langman. “Legislative Update - Part 2.” MLA News. (#313):7, Feb. 1999.
“REA Address Highlights.” Rural Telecommunications. 12 (3) May/June 1993.
“Rural Facilities Tap Telemedicine.” Modern Healthcare. 24 (6), February 7, 1994.
Kathryn Taylor. “We’re (Almost) All Connected: Providers’ Booming Interest in Telemedicine May Spur More Development.” Hospitals & Health Networks. September 20, 1994.
Telecommunications Act.” Health Factor, 5 (3), August 1997, quarterly newsletter of the Dept. of Family Medicine, University of South Dakota School of Medicine.
“Telemedicine Report to Congress.” Jan. 31, 1997, Office of Rural Health Policy, www.ntia.doc.gov/reports/telemed/evaluate.htm.
6-131 Processes and Opportunities in Healthcare Facilities
Issues and Opportunities: Resources of the EPRI Healthcare Initiative
The EPRI Healthcare Initiative (HCI) is a collaborative effort with member utilities. Its purpose is to assist the healthcare industry to meet the ever-changing demands of the industry through education and the use of electrotechnology solutions that will reduce risk and liability, meet regulatory compliance demands, and ultimately provide the highest level of quality patient care.
Some of the issues in the healthcare industry not discussed in this report or only mentioned in passing are:
• Construction and renovation issues
• Facility safety management
• Security and security systems for healthcare facilities
• Environment of care management
• Healthcare quality assurance
• Safety database management
• Benchmarking for the healthcare industry.
A comprehensive list of publications, services, and training programs, along with a description of the Healthcare Initiative can be found in “EPRI Healthcare Initiative Products and Services Catalog” (BR-107072-R2) and subsequent editions.
Resources are available from:
EPRI Healthcare Initiative 50 Main Street, Suite 1260 White Plains, NY 10606 914-644-8358 or 800-424-EPRI Fax: 914-644-8761
6-132 7 HEALTHCARE PROVIDERS AS ELECTRIC UTILITY CUSTOMERS
As the healthcare sector is a large and complex customer segment, it offers an important marketing opportunity for electric utilities that can understand and respond to the needs of the institutions it comprises, especially hospitals, clinics, and nursing homes.
A recent study by RKS Research and Consulting in North Salem, New York, found that 68% of hospital and healthcare executives surveyed (representing 1,000 separate facilities nationwide) are willing to pay 13% more than the commodity price of electricity for additional reliability, convenience, and tailored services (Healthcare Facilities Management, May 1996). Less than half—45%—would switch suppliers for a price reduction of 5%, while half expressed interest in working out a deal with the local provider. Among the services sought after by hospital and healthcare executives are simplified electric rates, energy audits, backup power, and an empowered utility account executive as a single point of contact to meet their specific needs.
Interestingly, a survey by the American Hospital Association, sponsored by EPRI in 1994, revealed that electric utilities were not considered as sources of information or value-added service by the majority of hospital contacts (hospital engineers, facility managers, safety professionals, environmental managers, planning directors, etc.). The results of three focus groups showed that respondents did not see utilities as a resource on alternative treatment alternatives, energy-related and environmental regulation, lighting, indoor air quality, HVAC, TB engineering controls, water heating, cooking, design and remodeling, or energy-related advocacy. There was a general lack of knowledge or understanding of alternative treatment technologies. A small percentage of respondents noted having used utility services for facility energy audits, power quality audits, or performance contracting.
An effective utility program for the healthcare sector could be based on the following five basic concepts:
• Be a low-cost provider – The healthcare sector is increasingly cost conscious and electric utility programs should be sensitive to this.
7-1 Healthcare Providers as Electric Utility Customers
• Provide value-added services – As shown by the RKS survey, in addition to reduced energy costs, value-added service is sought after by healthcare executives. While healthcare facilities use large amounts of electricity, they have other related needs which open up a marketing opportunity for utilities. Many of these are electrotechnology or service opportunities as described in this report: medical waste treatment, sterilization of instruments, power quality service, efficient lighting, thermal energy storage, indoor air quality, ozonation for cooling towers, ozone- based laundry, emergency power, water purification, electric cooking, etc. However, as the AHA survey pointed out, many facility engineers, environmental managers, safety officers, etc. are not aware of these resources that utilities can provide. Therefore, it is important for a utility representative to let it be known to the customer that the utility can provide a broad menu of services. Recognizing the challenges facing the healthcare industry, as described in this report, utilities can make a proactive, customer-focused commitment to help the industry by providing assistance and expertise in many areas. In this way, the utility becomes a valued resource for cost-effective products and services vital to the survival and competitiveness of the facility.
• Create partnerships with the customers – Healthcare institutions are changing rapidly, not just by choice but by a need to survive in an increasingly competitive environment. This climate of change creates opportunities for utilities to form new relationships with their healthcare customers. Again, as revealed by the RKS survey, many healthcare executives are interested in working out deals with suppliers. New partnerships could involve arrangements in financial as well as traditional technical areas. Technically-oriented partnerships could involve endeavors such as demonstrating a new medical waste treatment technology or ozone-based laundry. Partnerships could involve the local hospital association as well. Financially- oriented partnerships might be helping to finance infrastructure improvements such as telecommunication. In addition to EPRI tailored collaboration projects, utilities could also assist in the purchase of a new technology under a shared savings arrangement with EPRI. The possible partnership arrangements are many and depend on the specific needs and culture of each institution. Partnerships set the stage for customer retention.
• Establish a local team to coordinate with the EPRI Healthcare Initiative – the Healthcare Initiative is constantly identifying and developing ways for utilities to better serve and support the healthcare industry. To make the most effective use of this resource, utilities could establish a local team to work with the Healthcare Initiative, involving utility representatives who specialize in environmental issues, power quality, building performance, etc. This team would implement programs from the Healthcare Initiative that are appropriate to the healthcare customers in the service territory.
7-2 Healthcare Providers as Electric Utility Customers
Other ideas for maximizing the resources of the Healthcare Initiative include: inviting healthcare customers to attend HCI meetings and conferences; providing customers with HCI publications and resources reprinted with your company’s logo; organizing workshops and seminars on selected topics of interest to healthcare customers in your service territory through the HCI; using tailored collaboration funds to subsidize services or help purchase electrotechnologies for your major customers; offering a demonstration project or a shared cost-savings arrangement to a customer in conjunction with an electrotechnology vendor and EPRI; sponsoring a prominent member of the healthcare industry in your area to participate in the advisory committee of the HCI; and serving in one or more of the committees of the Healthcare Initiative.
Include on the utility team a person from the healthcare industry – Having a person on the utility team with a substantial experience in the healthcare sector will add credibility. Such a person would understand the issues and dynamics of the industry, speak the “language” and provide insights on how to best approach organizations within this customer group. Such a person could identify the key players, such as the CEO, an executive vice president, director of facilities engineering, department head, or chief financial officer in a hospital, who may be the best person(s) to approach for a particular project or proposal. This is the concept that developed into the EPRI Regional Healthcare Marketing Network. In this program the national HCI database, products and services are customized for the utilities current market segment or projected customer targets.
Each utility will address the market in different ways, but an effective program has as its foundation a knowledge of the customer and a commitment to provide innovative products and services at a competitive price.
7-3 blank page A GLOSSARY OF COMMON TERMS
Accreditation with commendation—Accreditation granted to an organization by the JCAHO if the survey of all required components of the organization is completed, an accreditation decision grid score of 90 or higher is attained with no individual grid element scores of 4 or 5, and no type I recommendations are given.
Ambulatory care—Medical services provided on an out-patient basis.
Aspergillus—An allergen fungal spore found in the atmosphere and in indoor air capable of causing Aspergillosis, an infection in the tissues or mucous surface in the lungs and capable of spreading to other organs.
Autoclave—Sterilizer for sterilizing medical and surgical instruments by exposure to steam at 121° to 132°C in a sterilizing chamber.
Biohazardous waste—See Infectious waste.
Bloodborne pathogen rule—An OSHA rule based on the assumption that blood and certain body fluids (amniotic, pericardial, peritoneal, synovial, cerebrospinal, semen, and vaginal fluids) of all patients are potentially infectious for human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens, and healthcare workers are required to take precautions to avoid exposure to these fluids.
Capitation—A method of reimbursement under some managed care plans in which providers receive a fixed fee per person in the covered (enrolled) population, regardless of the amount and cost of services used by that population.
Central services—That department in a hospital that collects and receives used patient- care items and equipment, and packages, processes, stores, maintains, and dispenses these articles to the rest of the hospital; also called Sterile Supply.
Chemotherapeutic waste—Waste contaminated with antineoplastic or cytotoxic agents used in the treatment of cancer and other diseases.
Chlorination—The addition of liquid chlorine, chlorine dioxide, or hypochlorite to water or medical waste for the purpose of disinfection.
A-1 Glossary of Common Terms
Cleaning—The removal of foreign material, such as soil, from medical instruments and generally precedes sterilization or disinfection.
Community hospitals—As defined by the AHA, are “all non-federal short-term general and other special hospitals whose facilities are open to the public. (Other special hospitals include obstetrics and gynecology; eye, ear, nose and throat; rehabilitation; orthopedic; and other individually described specialty services.)” In contrast, non community hospitals, according to the AHA, include federal hospitals, long-term hospitals, psychiatric hospitals, alcoholism and chemical dependency facilities, and hospital units of institutions. Community hospitals are the most common type, with 90% of total hospital beds.
Conditional accreditation—Accreditation granted by the JCAHO to an organization not found to be in substantial compliance with the standards but believed to be capable of remedying the deficiencies within six months.
Conditioned space—Parts of a building that are heated and/or cooled to provide comfort to the occupants.
Continuing care retirement communities (CCRCs)—Institutions which provide housing and healthcare in a campus-style setting with convenient services such as house- keeping and meals. The levels of care range from assisted living to skilled nursing. Additional healthcare services include emergency response, health clinics, wellness programs, hospice, primary and specialty physician care, dental care, pharmacy, and physical therapy. These facilities are often very expensive and not covered by Medicare.
Cooling Tower—A device that removes heat absorbed by cooling water through the process of evaporation so that the water can be reused.
Custodial care facilities—Institutions which provide nursing and health-related care to patients who do not require the degree of care and treatment of a skilled or intermediate care facility. Examples of custodial care facilities include convalescent homes with healthcare and homes for the mentally retarded, with healthcare.
Demand control ventilation (DCV)—Ventilation wherein the amount of air provided to a conditioned space is modified in response to changes in occupant distribution.
Dessicant—A sorbent material that removes water or water vapor.
Diagnostic Related Groups (DRGs)—A system by which the federal government reimburses hospitals on a fixed-fee basis for Medicare patients.
A-2 Glossary of Common Terms
Disinfection—The elimination of many or all pathogens but not necessarily the destruction of all living organisms such as resistant bacterial or fungal spores; different processes can achieve varying levels of disinfection.
Drift—Water in the form of droplets and water vapor that rise and escape from the top of a cooling tower.
Electromagnetic interference (EMI)—An incompatibility of a device and its electromagnetic environment resulting in an adverse effect on the performance of the device.
Electron beam irradiation—The treatment of materials, such as medical waste or medical instruments, for the purpose of sterilization or disinfection by exposure to ionizing radiation generally consisting of high energy electrons.
Emergency power supply system (EPSS)—The system used to provide an alternative, emergency source of power; it consists of one or more transfer switches and generators.
Environment of Care (EC) - Plant, technology, and safety management standard of the JCAHO which includes safety, security, control of hazardous materials, emergency preparedness, life safety, medical equipment, and utility systems.
Ethylene oxide (ETO) sterilizer—Sterilizer to sterilize medical and surgical instruments by exposure to ethylene oxide gas in a sealed chamber; ethylene oxide is a highly toxic, flammable, and explosive gas, and is a probable carcinogen.
Eutectic material—Salts that undergo a phase change when absorbing and releasing energy in thermal energy storage systems.
Fee for service—A payment arrangement under which patients and other payer groups pay providers (doctors, hospitals, etc.) separately for each service performed.
Harmonic distortion—A change in the sinusoidal wave shape of voltage or current caused by nonlinear loads that draw nonsinusoidal currents from a system.
Health maintenance organization (HMO)—A health insurance plan through which subscribers receive comprehensive medical services from affiliated providers for a preset, prepaid annual fee.
Heat pump—A device that moves energy in the form of heat from a substance at lower temperature to another substance at a higher temperature by means of a mechanical device such as a compressor which operates off an outside power source.
A-3 Glossary of Common Terms
HEPA filter—A high-efficiency particulate air filter having a particle collection efficiency of 99.7% or greater for particles up to 0.3 microns.
Home healthcare—A method of delivering medical services to patients in their homes rather than in medical facilities.
Independent practice association (IPA)—An organization contracting with a managed care plan to deliver services at a single capitation rate. The IPA in turn contracts with individual providers to deliver services, either on a capitation basis or fee-for-service basis.
Independent practitioner organization (IPO)—An organization of providers, usually physicians, contracting with a variety of health plans for a variety of services, such as health care. The primary differences between an IPO and an IPA is that most IPAs contract with a single HMO, while an IPO may contract with multiple types of plans, and IPOs generally do not assume financial risk.
Indoor air quality (IAQ), acceptable—Air in which there are no known contaminants at harmful concentrations and to which a substantial majority of persons exposed do not express dissatisfaction.
Infectious waste—Waste materials that are considered to be a potential health hazard due to possible contamination with pathogenic agents; also referred to as red bag waste because of the color of plastic bags commonly used in hospitals to segregate infectious waste; sometimes referred to as biohazardous waste and marked with the international biohazard symbol; see also Regulated medical waste.
Intermediate care facilities—Institutions which provide continuous nursing and rehabilitative services but not on a continuous basis as do skilled nursing facilities. Personnel are on duty continuously but licensed nurses are required only part of each day. The line between skilled and intermediate nursing facilities is sometimes blurry, and various organizations account for the categories differently.
Investigational device exemption—An exemption given to manufacturers of medical devices intended solely for investigational use, thereby allowing manufacturers and researchers to gather safety and effectiveness data using human subjects.
Legionella—The bacterial strain (in particular, Legionella pneumophila) that can cause a pneumonia-like illness known as Legionnaires’ Disease or Legionellosis; the bacteria thrives in warm, damp, and stagnant conditions, as in cooling tower water, humidifiers, etc., and has the potential of contaminating air.
Lumen—The inner open space of any tubular-shaped device as one finds in an endoscope or other medical device; lumened instruments are difficult to sterilize.
A-4 Glossary of Common Terms
Managed care—A supervised system of financing and providing healthcare services for a defined population group. Health maintenance organizations are a common form of managed care.
Managed competition—A proposed government-sponsored healthcare system which is designed to stimulate competition in the healthcare industry by aggregating healthcare purchasers into cooperatives to negotiate provision of healthcare services more cost- effectively than in the current system.
Medicaid—A joint federal-state program providing medical or nursing home services to persons with a low-income.
Medical device report (MDR)—A report to the FDA of incidents that reasonably suggest that a medical device has caused or contributed to a death or serious injury.
Medical waste—Solid or liquid waste generated from a healthcare facility or health- related institution; see also Infectious waste and Regulated medical waste.
Medicare—A federally-funded national health insurance program for persons over 65, and for the disabled.
Micron—One-millionth of a meter.
Microwave drying—The use of microwave energy generated by magnetron tubes to dry linens, clothes, and other fabrics.
Municipal solid waste—Solid waste (not including infectious, hazardous, or radioactive wastes) generally collected in hospital trash bins or dumpsters and removed for disposal in a municipal landfill.
Nosocomial infections—Infections not present or incubating in a patient at the time of hospital admission but subsequently acquired as a result of hospitalization.
Outdoor air—Air from outside a facility not previously circulated through the ventilation system.
Ozone—An unstable form of molecular oxygen (O3) usually formed by an electrical discharge in air; ozone is a powerful oxidizing and disinfecting agent.
Pathogens—Microorganisms that can cause diseases.
Pathological waste—Tissues, organs, and other body parts removed during surgery, autopsy, or other medical procedures and subsequently discarded.
A-5 Glossary of Common Terms
Peak clipping—The reduction of peak electric load by direct load control.
Permissible exposure limit (PEL)—An allowable exposure level to chemicals in the workplace as determined by OSHA and generally expressed as an average exposure concentration over an 8-hour shift.
Plasma—A physical state of matter obtained by adding sufficient energy to a gas so that atoms and molecules form free electrons and ions.
Power quality (PQ) problem—Any voltage, current, or frequency deviation that results in the failure or misoperation of equipment.
Preferred provider organization (PPO)—A healthcare plan which contracts with independent providers (physicians and hospitals) at a discount for services. A PPO may be risk bearing, like an insurance company, or may be non-risk-bearing. An example of the latter is a physician-sponsored PPO which markets itself to insurance companies or self-insured companies via an access fee.
Premarket notification—A notification submitted by manufacturers (at least 90 days before marketing a device for the first time) to the FDA showing that the device is substantially equivalent to an existing, legally marketed product; also known as a 510(k) notification or submission.
Provisional accreditation—Accreditation granted by the JCAHO to an organization that elects to use the Early Survey Policy and meets the initial standards requirement.
Pyrolysis—A process involving chemical and physical changes as a result of intense heat, generally in the absence of oxygen or air.
Real-time pricing (RTP)—An hourly-based pricing rate that reflects the time-varying cost of generating and transmitting electricity.
Recycling—The use, reuse, or reclamation of materials from a waste stream; one of the components of waste minimization.
Red bag waste—See Infectious waste.
Regulated medical waste—A classification of medical waste used for regulatory purposes generally consisting of the following classes: cultures and stocks, pathological waste, blood and blood products, used sharps, animal waste, isolation wastes, and unused sharps; sometimes included are discarded medical equipment contaminated with infectious material, surgery waste, laboratory waste, and dialysis wastes.
A-6 Glossary of Common Terms
Return air—Air returned from a conditioned space to be recirculated or expelled through the exhaust.
Skilled nursing facilities—Institutions which provide inpatient and rehabilitative service to patients requiring continuous healthcare, but not hospital services. Care is ordered by and under direction of physicians, and staff includes licensed nurses continuously on duty. Skilled nursing facilities are the most common type of nursing home.
Source reduction—Any activity that reduces or eliminates the generation of waste at the source, usually within a process; one of the components of waste minimization.
Sterile supply—That department in a hospital that collects and receives used patient- care items and equipment, and packages, processes, stores, maintains, and dispenses these articles to the rest of the hospital; also called Central Services.
Sterilization—The inactivation of all forms of microbial life.
Subacute care facilities—Institutions which generally provide more intensive care than a traditional nursing facility but less than acute care provided by a hospital. Subacute care facilities charge less than acute care hospitals for similar care and services. As a result, some managed care organizations are moving hospital patients to subacute care facilities before discharge. Subacute care facilities are a new area of nursing home care.
Telemedicine—The practice of medicine involving the use of two-way audio and video communication networks thereby allowing healthcare facilities and providers access to medical and technological resources via telephone lines and satellite link-ups.
Thermal energy storage (TES)—A system involving the storage of energy in a thermal mass for use in cooling or heating during off-peak periods in conjunction with space conditioning.
Transfer Switch—A device that allows the transition from a normal power source to an alternative emergency generator and back again.
Transient—A high-voltage pulse that is extremely short and fast; also called a spike.
Tuberculosis—An infection primarily of the lungs caused by inhalation of a sufficient number of droplets containing Mycobacterium tuberculosis or related species.
Ultraviolet germicidal irradiation (UVGI)—An air disinfection technology whereby an air stream is exposed to ultraviolet radiation (specifically at 253.7 nm wavelength, also known as germicidal UV or UV-C) for the purpose of destroying germs.
A-7 Glossary of Common Terms
Uninterruptible power supply (UPS)—A type of battery back-up system designed to provide continuous power to critical loads.
Universal precautions—A set of precautions issued by the CDC designed to prevent the transmission of bloodborne pathogens and which became the basis for OSHA’s Bloodborne Pathogen Rule.
Valley filling—The building of off-peak electric loads .
Voltage sag—A period of lower than normal voltage usually lasting from a half cycle to a few seconds.
Voltage surge—A period of higher than normal voltage.
Waste minimization—The reduction, to the extent feasible, of waste generated at a facility as well as waste subsequently treated, stored, or discarded.
[The definition of terms used in analyses of the healthcare industry are taken from several sources including Dun & Bradstreet, American Hospital Association, and the US Department of Commerce.]
A-8 B SUMMARY OF SELECTED STATE REGULATORY AGENCIES AND REGULATIONS ON MEDICAL WASTE
[NOTE: This section provides a simplified summary of state regulations and is not a comprehensive, complete, or precise description of the laws and regulations. It is not intended for the purpose of compliance, legal advise, or legal analysis. Some of the rules and regulations may have been revised since the time of this writing. The reader should contact the appropriate state agency or agencies for the complete text of regulations and any revisions.]
Alabama
Alabama Department of Environmental Management Land Division Solid Waste Branch 1751 Cong. W.L. Dickinson Drive Montgomery, AL 36109-2608 (334) 271-7730 (334) 279-3050 (Fax) www.adem.state.al.us
The agency that deals with medical waste is the Solid Waste Branch, Land Division, of the Department of Environmental Management. The regulations, found in Chapter 335-13-7 (Division 13) of the Solid Waste Program, set requirements for the following: generators; collection, storage, and transport of treated and untreated waste; treatment measures; and disposal of treated and untreated waste. Some exemptions are provided for generators producing or transporting less than 220 pounds (110 kg) of medical waste per month.
Medical waste is defined as: animal waste, blood and body fluids, microbiological waste, pathological waste, renal dialysis waste, sharps, and surgical waste. Generators who produce these wastes are required to prepare and update written plans to ensure proper management of medical waste. The regulations specify, among others, packaging and labeling requirements, permits for storage and transport of untreated waste, and storage, transport and disposal requirements. Approved treatment methods are incineration, steam sterilization, chemical disinfection-encapsulation, and “other B-1 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste treatment methods” if approved by the Department. An alternative method must demonstrate that it provides protection to the public and environment equal to incineration and steam sterilization. Wastes—particularly sharps, dialysis, pathological and animal wastes—must be rendered unrecognizable prior to final disposal.
Alaska
Alaska Department of Environmental Conservation Air and Solid Waste Management Section 410 Willoughby Avenue, Suite 105 Juneau, AK 99801 (907) 465-5162 (907) 465-5164 (Fax) www.state.ak.us/local/akpages/ENV.CONSERV/home.htm
Pathologic or infectious wastes are regulated by the Department of Environmental Conservation under the Solid Waste Management Regulations. Infectious waste is a “special waste” defined as: laboratory, surgical, and hospital waste; surgical specimens; specimens in contact with persons who have a suspected or diagnosed communicable disease; substances in contact with pathogenic organisms; disposable material from outpatient areas and emergency rooms; and equipment such as syringes and needles.
The regulations require that pathological or infectious waste must first be disinfected or sterilized and then packaged for disposal, or must be incinerated in a pathological waste incinerator before disposal.
Arizona
Arizona Department of Environmental Quality Waste Programs Division Solid Waste Unit 3033 North Central Avenue Phoenix, AZ 85012 (800) 234-5677 or (602) 207-2300 www.adeq.state.az.us
Medical waste is defined as “any solid waste which is generated in the diagnosis, treatment, or immunization of a human being or animal or in any research relating to that diagnosis, treatment, or immunization, or in the production or testing of biologicals, but not including hazardous waste…” (Arizona Revised Statutes, section 49-701.6)
The authority to regulate disposal of medical waste is the Arizona Department of Health Services which gives licenses to facilities such as hospitals, clinical laboratories,
B-2 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste and nursing homes. There are no specific waste disposal regulations for doctors, dentists, clinics, veterinarians, and funeral homes. The Department of Environmental Quality has been authorized to write rules for off-site treatment, storage, transport, and disposal of medical waste from all facilities. Until the rules are finalized, the Department recommends treatment by incineration, steam sterilization, chemical disinfection, encapsulation, microwave treatment, or sewer disposal (for liquid waste). Promulgation of new rules is expected in 1999.
Arkansas
Arkansas Department of Health Medical Waste Disposal Program 5800 West Tenth Street, Suite 401 Little Rock, AR 72204 (501) 661-2920 or (501) 661-2893 (501) 280-4706 (Fax) http://health.state.ar.us
The state’s rules and regulations are described in the booklet “The Management of Medical Waste From Generators and Health Care Related Facilities” (March 7, 1995) by the Arkansas Department of Health. The regulations define medical waste and promulgate requirements for: identification, segregation, packaging, labeling, storage, transport, treatment, and disposal of medical waste. Specific requirements are provided for commercial transporters and commercial facilities that treat and dispose of waste.
Medical waste is defined as waste from a generator or healthcare facility which, if improperly treated, handled or disposed of may transmit an infectious disease. The following are listed as specific examples of medical waste: pathological waste, liquid and semi-liquid blood, contaminated items, microbiological waste, and contaminated sharps.
In particular, the regulations apply to hospitals, long-term care facilities, laboratories, professional offices, clinics, as well as blood banks, funeral homes, abortion clinics, birthing centers, health maintenance organizations, pharmacies, etc. Medical waste generated at home is exempted.
The rules require that medical waste be segregated from other waste at the point of generation. The approved treatment methods are: incineration; sterilization by steam, dry heat, chemical vapor, or ethylene oxide; and disinfection by thermal inactivation (using microwave or dielectric energy) or by a chemical agent. Other alternative technologies have to be evaluated and approved by the Department. Among the criteria for evaluation are environmental impact, worker safety, and level of microbial inactivation. Treated waste that is rendered unrecognizable need not have special packaging and labeling when transported or disposed. Transporters, mobile treatment
B-3 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste systems, and commercial facilities that treat, store and/or dispose of medical waste are required to have a permit. The Department also requires a verbal and written report of all incidents involving the release of medical waste to the environment.
California
California Department of Health Services Medical Waste Program 107 S. Broadway, Room 3028 Los Angeles, CA 90012-4405 (213) 897-7570 (213) 897-7370 (Fax) www.dhs.cahwnet.gov/ps/ddwem
California’s Medical Waste Management Act (Chapter 6.1, Division 20, Health and Safety Code) regulates storage, treatment, and transport of medical waste. It is enforced by the state’s Department of Health Services and any local agency (usually county health departments) who choose to enforce the requirements. The Act specifies the types of generators and requirements for each type of generator with regards to storage and registration, requirements for haulers, permits for treatment facilities, containment and storage, and treatment methods.
Medical waste is waste generated as a result of diagnosis, treatment, or immunization of humans or animals; medical research; and production or testing of biologicals. Medical waste includes sharps and biohazardous waste (which means laboratory waste, waste containing microbiological specimens, surgery specimens or tissues, animal parts or carcasses, waste containing blood or blood products, isolation waste, surgical waste fixed with formaldehyde or other fixatives, and chemotherapeutic waste). Excluded from the definition are microbiological cultures used in food processing and biotechnology, body fluids unless they contain blood, non-biohazardous waste (such as paper towels or paper products), hazardous waste, radioactive waste, household waste, and waste from normal veterinarian, agricultural, or animal livestock management on a ranch or farm.
A generator that produces less than 200 pounds (91 kg) per month is called a “small quantity generator.” If the small quantity generator treats its waste on-site, it must register with the state, maintain records, and be subject to biennial inspections. It must obtain a permit if it utilizes a common storage facility. A “large quantity generator” (producing more than 200 pounds (91 kg) per month) is required to register, maintain tracking records, and be subject to annual inspections. Transporters must be registered, and all off-site treatment facilities and transfer stations must be permitted and inspected.
B-4 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste may be treated by: incineration in a method approved by the department (e.g., controlled air, multi-chamber incinerator); sewage discharge of liquid and semi- liquid lab waste and microbiological specimens; steam sterilization in accordance with a specified procedure; and alternative methods. Sharps must be decontaminated by incineration, steam sterilization, or disinfection by an alternative method. As of 1994, the approved alternatives not requiring a permit are: mail disposal services for sharps; Needlelyzer; Saf-Gard Suction Sanitation System for suction canisters; and Isolyser Liquid Treatment System and Sharps Management System. The approved methods requiring a permit or registration are: BioMedical Waste Systems; Disposal Science Inc. Sharps Disposal; DOCC Demolizer; Sanitec Microwave; MedMark International MedAway-1; Medical SafeTEC; Mediclean Technology; Medifor-X Dispoz-All-2000; Nutek Electron Beam (no longer available); Plasma Energy Applied Technology; Spintech TAPS; Stericycle; Synthetica; Thermokill; and Winfield Condor.
Colorado
Colorado Department of Public Health and Environment 4300 Cherry Creek Drive So. Denver, CO 80246-1530 (303) 692-1000 www.state.co.us/gov_dir/cdphe_dir
Colorado House Bill 89-1328 (CRS 25-15-401 et seq.) applies to all generators of infectious waste and sets minimum requirements for generators on handling their infectious waste. Infectious waste is defined as waste capable of producing an infectious disease; for waste to be infectious, it must contain pathogens with sufficient virulence and quantity such that exposure by a susceptible host could result in disease. The law takes the U.S. EPA’s categories of infectious waste, developed in 1986, in designating infectious waste: isolation waste, blood, blood products, body fluids, pathological/anatomical waste, contaminated sharps, and contaminated laboratory or research waste.
Responsibility for regulating facilities that store and treat infectious waste is jointly shared between the Colorado Department of Health and the local county or municipality. Under the law, generators must develop an on-site infectious waste management plan which specifies handling, labeling and packaging, contingencies for spills, staff training, designation of person responsible for implementation, and provisions for treatment and disposal. The plan must be available to haulers, licensing agencies, and regulators. The law also includes sections on liability and penalties. Treatment following written procedures must be documented. Colorado accepts incineration, autoclaving, chemical disinfection, as well as discharge of liquid/semi- solid waste to a sewage treatment system, as appropriate treatment methods. Other methods may be approved by the Department of Health. Recognizable body parts must be disposed by incineration or interment.
B-5 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Connecticut
Connecticut Department of Environmental Protection Solid Waste 79 Elm Street, 4th Floor Hartford, CT 06106-5127 (203) 424-3316 http://dep.state.ct.us
State regulations are found under Biomedical Waste Management, section 22a-209-15 of the Regulations of Connecticut State Agencies. Biomedical waste is first defined as untreated solid waste (or a container that has not been decontaminated) generated during the administration of medical care or medical research, excluding hazardous waste, home healthcare waste, discarded personal hygiene material, medical equipment used by farmers for livestock, and collected samples taken for enforcement purposes. A small quantity generator is defined as a biomedical waste generator producing or transporting less than 50 pounds (23 kg) per month. (Some exemptions are allowed for the small generator.)
The generators of biomedical waste are required to segregate biomedical waste to the extent practicable and prepare a written biomedical waste management plan. The regulations also specify packaging, storage, transport, personal protection, decontamination, spill response, recordkeeping, and tracking requirements. With regards to treatment and disposal, chemotherapy waste must be incinerated, and pathological waste incinerated or interred. Infectious waste must be incinerated or discharged into a sanitary sewer if in liquid or semi-solid form. The regulations allow use of a steam sterilizer to decontaminate biomedical waste but must be in accordance with specific operating, testing, and recordkeeping requirements. (A recent amendment includes specific requirements for gravity flow and vacuum sterilizers.) The regulations require sharps to be rendered unrecognizable. Alternative methods must be at least equivalent to incineration in protecting public health and the environment, and must be approved in writing by the state. Written procedures for using an approved method must be incorporated in the management plan.
Delaware
Delaware Department of Natural Resources and Environmental Control Solid Waste Management Branch 89 Kings Highway P.O. Box 1401 Dover, DE 19903 (302) 739-3689 or (302) 739-3820 www.dnrec.state.de.us/solid.htm
B-6 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Infectious waste regulations are found in Section 11 (Special Wastes Management) of Regulations Governing Solid Waste, adopted on November 1989. Infectious waste is defined as “solid wastes which may cause human disease and may reasonably be suspected of harboring human pathogenic organisms, or may pose a substantial present or potential hazard to human health or the environment” when improperly managed. Categories include biological wastes (e.g., blood and blood products, pathological waste, cultures, stocks, laboratory waste, animal waste, dialysis waste), sharps, discarded biologicals, isolation wastes, and contaminated residues resulting from cleanup of spills.
The regulations require permits for any generator treating, storing, or disposing of infectious waste. Small quantity generators, defined as producing less than 50 pounds (23 kg) per month, are not required to obtain a permit for storage. As part of the permit requirements, the generator submits a plan for the management of the waste. Regulations on packaging, labeling, storage, spill containment and cleanup, recordkeeping and reporting, transportation, and manifest tracking are provided. Restrictions are imposed on the siting of infectious waste treatment facilities. There are also provisions dealing with the closure of a facility. The regulations require that waste cannot be compacted or ground until after the waste has been rendered noninfectious. Anatomical parts must be incinerated or interred. The approved treatment methods are steam sterilization, incineration, or other methods that render the waste non-infectious. The regulations provide performance standards for steam sterilization. For other treatment methods, an initial efficacy test must be conducted to demonstrate that a specified reduction or kill of test microorganisms is achieved; afterwards, periodic verification tests on test or indicator microorganisms are required at least quarterly. Records must be retained for at least three years.
Florida
Florida Department of Environmental Protection Biomedical Management Waste Program Bureau of Solid and Hazardous Waste Twin Towers Office Building 2600 Blair Stone Road Tallahassee, Florida 32399-2400 (904) 488-0300 or (904) 487-0004 (904) 921-8061 (Fax) www2.dep.state.fl.us
Regulations are found in Chapter 62-712 (Biomedical and Biological Waste Management) of the DEP regulations (1994), available from the Bureau of Solid & Hazardous Waste, Solid Waste Section, Mail Station 4565, Department of Environmental Protection (address above). Biomedical waste (also called biohazardous waste) is defined as any solid or liquid waste that may present a threat to humans, and
B-7 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste includes non-liquid tissue and body parts from humans and other primates, lab and veterinary waste, discarded sharps, blood, blood products, and body fluids. The definition also includes used adsorbents and disposable devices saturated with blood. The regulations cover transport, registration, storage, treatment, disposal, recordkeeping, and preparation of contingency plans.
All biomedical waste transporters must be registered with the department and the waste must be properly segregated, packaged, and labeled. Specific requirements are given for packaging and labeling, with references to U.S. DOT regulations. Off-site biomedical waste storage requires a general permit. Biomedical waste must be treated within 30 days of collection from a generator using one of the following: incineration, microwaving and shredding, chemical disinfection, and sterilization in a steam sterilizer following specific operating requirements. Biomedical waste may also be disposed in a sewage treatment system. Alternative treatment methods have to have approvals from the Department. Approval must be requested in writing for a specific facility and treatment method and a demonstration of effectiveness and safety of the technology must be made.
Georgia
Georgia Department of Natural Resources Environmental Protection Division Commercial and Industrial Solid Waste Program 4244 International Parkway, Suite 114 Atlanta, GA 30354 (404) 362-2671 www.ganet.org/dnr
Regulations are found in the following sections of the Rules of Solid Waste Management, Chapter 391 (Solid Waste Management) of the Department: 391-3-4-.04 (General); 391-3-4-.06 (permit by rule for collection, transportation, processing, and disposal); 391-3-4-.08 (solid waste thermal treatment operations); and 391-3-4-.15 (biomedical waste). The regulations apply to all facilities generating biomedical waste including hospitals, blood banks, clinics, dental offices, funeral homes, HMOs, labs, physicians offices, veterinaries, nursing homes, research facilities, home healthcare organizations, etc. Partial exemptions are given to facilities generating less than 100 pounds (45 kg) a month.
In the regulations, biomedical waste is defined as any solid waste which contains pathological waste, biological waste, cultures and stocks of infectious agents and associated biologicals, contaminated animal carcasses, chemotherapy waste, and contaminated discarded medical equipment and parts not including supplies and materials.
B-8 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The permit by rule allows collection, transfer station, inert waste landfill, waste treatment, and sludge disposal operators to operate as long as certain conditions are met, including notification of the Department director. On-site thermal treatment (combustion) operators must treat no less than 75% of their own waste, routinely sample bottom and fly ash, meet air quality standards, provide fire protection, and supervision. Lead batteries, radwaste, or regulated amounts of hazardous waste must be kept out of the biomedical waste stream. Specific storage, containment, and transport provisions are given. The following are the accepted methods of treatment: incineration in a thermal treatment facility, autoclave (except for chemotherapy waste), and methods specifically granted approval by the director. Fluids and semisolid waste may be discharged to a sewage facility. Recognizable body parts may not be buried in a landfill.
Hawaii
Hawaii Department of Health Office of Hawaiian Health P.O. Box 3378 Honolulu, HI 96801 (808) 586-4080, or (808) 586-4410 www.hawaii.gov/doh
The Hawaii Rules for Management and Disposal of Infectious Waste are found in Title 11, Chapter 104 of the Hawaii Administrative Rules under the authority of section 321-21, Hawaii Revised Statutes. Infectious waste is defined as any waste containing pathogens capable of causing infectious disease including infectious isolation waste, cultures and stocks, blood, blood products, body fluids, pathological waste, contaminated sharps, and contaminated animal waste.
The rules refer to CDC, EPA, and other federal agencies for proper handling and treatment of infectious waste. Regulations for transportation within and without the generating facility as well as storage are provided. Generators and transporters must develop a written infectious waste management plan including provision for contingencies. Depending on the type of wastes, they may be treated by incineration, autoclaving, wastewater disposal (blood and body fluids), and chemical disinfection. Infectious waste that has not been properly treated can be disposed in permitted or authorized disposal sites. Recognizable body parts must be incinerated or disposed according to other applicable laws. Treated non-incinerated waste must be clearly marked as noninfectious. Violators of any provisions of the regulations are subject to administrative penalties not exceeding $1000 per separate offense. The regulations include provisions related to liability.
B-9 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Idaho
Idaho Department of Health and Welfare 450 W. State Street Boise, ID 83720-0036 (208) 334-5500 (208) 373-0502 (Division of Environmental Quality) www2.state.id.us/dwh
Medical waste had been regulated under solid waste but legislation for specific regulation of infectious waste has been proposed. The administrative rules and standards are available from the Office of Administrative Rules (208) 334-3577.
Illinois
Illinois Environmental Protection Agency 2200 Churchill Road, P.O. Box 19276 Springfield, IL 62794-9276 (217) 524-3300 (217) 524-3289 (PIMW Coordinator) (217) 782-3397 (general information) www.epa.state.il.us
Regulations for potentially infectious medical waste (PIMW), adopted by the Illinois Pollution Control Board, are found in Title 35, Subtitle M of the Illinois Administrative Code under the authority of Title XV of the Illinois Environmental Protection Act. The term potentially infectious medical waste or PIMW is categorized under “special waste” and refers to waste generated in connection with diagnosis, treatment, or immunization of humans or animals, and waste in relation to medical research or production/testing of biologicals. PIMW wastes include: cultures and stocks, pathological waste, blood and blood products, used sharps, animal waste, isolation waste, and unused sharps, but exclude household waste, treated waste (except sharps), and decontaminated sharps rendered unrecognizable.
The regulations require the segregation of PIMW into sharps, oversized PIMW, and all other PIMW. Packaging, labeling, transport, and storage requirements are provided, and in general off-site operations require a permit. With regards to treatment, the State requires that any treatment process must demonstrate its ability to eliminate the infectious potential through an Initial Efficacy Test (IET) and Periodic Verification Tests (PVT) which are described in detail in Sections 1422.124 and 125 of the Code. Autoclaves, incinerators, and ethylene oxide units installed and operated before June 21, 1993 are not required to perform the IET. Compaction and rupture of containers are not allowed prior to treatment unless these are integral parts of the treatment process. Quality assurance programs are also required including a written plan to describe
B-10 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste operating parameters and designate responsible personnel. Disposal of residues from PIMW treatment are also regulated; incinerator ash is considered an industrial process waste and must be managed as a special waste. In addition, if more than 50 pounds (23 kg) of PIMW per month are generated, an annual report specifying quantities and disposition of treated waste must be submitted to the agency. Untreated PIMW is banned from all landfills. Decontaminated sharps must also be rendered unrecognizable or placed in a proper package prior to disposal.
Indiana
Indiana State Department of Health Communicable Disease Division 2 North Meridian Street Indianapolis, IN 46206 (317) 233-7665 www.isdh.state.in.us/doh
Regulations on medical waste are found in Rule 3 (Infectious Waste) codified in 410 IAC 1-3-1 through 1-3-29. Infectious waste is defined as waste that epidemiologic evidence indicates is capable of transmitting a dangerous communicable disease. Included are contaminated sharps; infectious cultures and stocks; pathological waste; blood and blood products; carcasses, body parts, blood and body fluids, and bedding of laboratory animals; and other intermingled wastes.
The rule requires a written policy and procedures to address specific requirements. General and, at times, specific requirements on containment, storage, and transport are given in the rules. Approved treatment technologies are: incineration, steam sterilization, chemical disinfection, thermal inactivation, irradiation, or discharge in a sanitary sewer or septic system.
The subsequent section, Rule 4 (Universal Precautions), deals with training, equipment, personnel policy, and precautions to prevent contamination of employees of healthcare facilities with blood or other body fluids.
Iowa
Iowa Department of Natural Resources Wallace State Office Building 502 E. 9th Street Des Moines, IA 50319-0034 (515) 281-8941 or (515) 281-8934 www.state.ia.us/government/dnr/organiza/epd/index.htm
B-11 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste treatment and disposal regulations were covered broadly in Chapters 102 and 104, Title VIII (Waste Management and Disposal) of the Iowa Code. Under the present regulations, infectious waste was designated a special waste and could be placed with regular municipal solid waste if rendered nonpathological, did not contain free liquids, and sharps were incinerated or mechanically destroyed. Generators had to notify the hauler and landfill regarding the infectious waste.
Kansas
Kansas Department of Health and Environment Bureau of Waste Management Forbes Field, Building 740 Topeka, KS 66620-0001 (785) 296-1600 (785) 296-1592 (Fax) www.kdhe.state.ks.us/waste
Regulations regarding medical services waste are found in K.A.R. 28-29-27. “Medical services waste” is defined as waste materials potentially capable of causing disease or injury and generated in connection with human and animal care though inpatient and outpatient services. Not included are hazardous and radioactive wastes.
The regulations require segregation of medical services waste from other solid wastes at the point of origin. There are also requirements for storage, collection, and transportation. Medical services waste must be disposed at an authorized facility on the same day as they are collected. Processing of the waste must be done in such as way as to prevent dispersal of aerosols and liquids. Where feasible, medical services waste should be processed before transportation off-site. Processes include sterilization by autoclave or chemical treatment; grinding, melting, or pulverizing sharps; discharge of liquids into a sanitary sewer; incineration; or disposal in a hazardous waste disposal facility or a sanitary landfill. Disposal in a sanitary landfill requires an industrial solid waste disposal authorization which must be obtained from the Solid Waste Section of the Bureau of Waste Management at (913) 296-1121 or (913) 296-1167.
Kentucky
Kentucky Department of Environmental Protection Resource Conservation and Local Assistance Branch Division of Waste Management 14 Reilly Road Frankfort, KY 40601 (502) 564-6716 www.nr.state.ky.us/nrepc/dep/waste/dwmhome.htm
B-12 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The Natural Resources and Environmental Protection Cabinet’s Department of Environmental Protection does not have requirements specific to transport, storage, collection, and disposal of medical waste. Nevertheless, the Department created the Infectious Waste Task Force in 1988 to develop recommendation for handling. These recommendations are in effect and serve as a basis for regulatory actions. The Department’s Division of Air Quality (502-564-3382) deals with permitting of medical waste incinerators. The Transportation Cabinet registers vehicles of haulers of municipal solid waste, which includes infectious waste haulers.
Under the Infectious Waste Task Force recommendations, the major categories of infectious waste are: microbiologicals (infectious cultures and stocks), blood and blood products, all discarded sharps, pathologicals (tissues, organs, body parts), animal waste, miscellaneous biomedical waste (such as bandages, dressings, etc.), and isolation waste. The Task Force recommends segregation and labeling of infectious waste at the point of generation. General recommendations are made on storage and transport. Recommendations are also made dealing with public education, enforcement and penalties, waste minimization, and other issues.
Treatment of infectious waste must result in non-hazardous, non-infectious, and unrecognizable waste. The accepted treatment methods are incineration, autoclaving, and sanitary sewer disposal (in keeping with applicable sewerage regulations). Alternative treatment technologies must obtain prior review and approval by both the Cabinet for Human Resources (502-564-7398) and the Natural Resources and Environmental Protection Cabinet.
Louisiana
Louisiana Department of Environmental Quality Office of Solid and Hazardous Waste Solid Waste Division P.O. Box 82178 Baton Rouge, LA 70884-2178 (225) 765-0355 (225) 765-0617 (Fax) www.deq.state.la.us/oshw/hw/hw.htm
Louisiana Department of Health and Hospitals Office of Public Health 325 Loyola Avenue New Orleans, LA 70112 (504) 568-5051 (504) 568-2609 (Fax) www.dhh.state.la.us/oph/ophmain.htm
B-13 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Office of Public Health Division of Environmental Health Services 6867 Bluebonnet Baton Rouge, LA 70811 (504) 568-5181 (infectious waste)
Office of Public Health Assistant Secretary 1201 Capital Access Road Box 3214 Baton Rouge, LA 70802-3214 (225) 342-8903
Medical waste disposal is subject to various regulations by the Louisiana Department of Health and Hospitals (DHH) and the Louisiana Department of Environmental Quality (DEQ). These agencies also follow rules from the federal Occupational Safety and Health Administration regarding packaging and labeling of certain types of waste such as sharps. Under a memorandum of understanding between the two state agencies in 1993, both agencies would share authority over transportation and treatment of medical waste. DHH, however, would regulate packaging, labeling, storage, and the approval of alternative technologies and DEQ would handle permitting and approval of commercial (off-site) treatment facilities, transportation, and treatment in relation to landfilling. The regulations governing packaging, labeling, storage, transport, and treatment of medical waste are in Chapter XXVII of the Louisiana Sanitary Code under the Department of Health and Hospitals. There are also brief sections regarding the landfilling of medical waste in Chapter 13, Part VII, Title 33 of the Louisiana Administrative Code under Solid Waste Regulations of the Department of Environmental Quality. DEQ has been authorized to draft new regulations for transportation, incineration, and disposal of medical waste. The Department of Health and Hospitals defines several terms—medical waste, infectious biomedical waste, and potentially infectious biomedical waste—of which the latter is used most extensively. Potentially infectious biomedical waste includes cultures and stocks; pathological waste; blood and blood products; sharps; bandages, diapers and other disposable material used for infected wounds or by isolation room patients; and commingled waste.
Small healthcare and medical facility generators are defined as those producing less than 25 kg (55 pounds) of potentially infectious biomedical waste a month (not including sharps) or less than 5 kg (11 pounds) of sharps a month. Large generators that treat their waste at an off-site facility must follow packaging, labeling and transport requirements. Generators that treat their waste on site must prepare an annually updated contingency plan on how they expect to manage their medical waste should their on-site treatment system become inoperative.
B-14 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Acceptable treatment methods are: incineration, steam sterilization (under specified conditions), disposal of liquids in a sanitary sewer following Sanitary Code requirements; thermal inactivation (under specified conditions), chemical disinfection (using approved chemical agents), and irradiation (only with written approval of the State Health Officer). Body parts must be buried, cremated, or disposed by means authorized by law. Sharps may be incinerated, or encased in plaster or in other substances (approved by the State Health Officer) within a tightly closed container, or treated in a way that renders them unrecognizable and precludes their release if compacted. Treated waste may be disposed of in a permitted landfill. Still recognizable medical waste must carry a supplemental label specifying the treatment method and date and the name/initial of the person responsible for treatment.
Maine
Maine Department of Environmental Protection State House Station 17 Augusta, ME 04333 (207) 287-7688 or (800) 452-1942 www.state.me.us/dep/mdephome.htm
The Biomedical Waste Management Rules, under the authority of 38 MRSA Section 1319-0, are found in 06-096 CMR Chapter 900. In general, wastes of a biological origin are covered under this rule, whereas those of a chemical origin would fall under the Hazardous Waste Management Rules. The definition of biomedical waste includes discarded blood/blood products/body fluids or waste saturated with them, pathological waste, sharps, cultures and stocks, carcasses and other waste from animal research, and cytotoxic drugs/chemotherapy waste not regulated as hazardous waste. The rule prohibits mixing biomedical waste with other hazardous or radioactive wastes. Facilities generating less than 50 pounds (23 kg) of biomedical waste per month are exempted from most of the rules.
For generators, the rules require registration and development of a written management plan, and define standards for packaging, labeling, handling, storage and recordkeeping. There are specific rules and licensing requirements for transporters, transfer facilities, and treatment/disposal facilities. With regards to treatment methods, pathological waste must be incinerated or interred and blood/blood products/body fluids can be incinerated or discharged through a sewer or septic system. All other biomedical waste must be incinerated in a licensed incinerator (incineration is considered a method of treatment and not of disposal). However, a petition can be submitted to the Board of Environmental Protection for approval of an alternative technology; demonstration of effectiveness and safety equivalent to incineration must be made. Application for licensing of a treatment and disposal facility is made to both the Bureau of Oil & Hazardous Materials Control (for a biomedical waste treatment facility license) and to the Bureau of Air Quality Control (for an air emission license).
B-15 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Maryland
Maryland Department of the Environment 2500 Broening Highway Baltimore, MD 21224 (410) 631-3000 or (800) 633-6101 www.mde.state.md.us/reference/index.htm
Medical waste regulations are found in Chapters 11-13 under Subtitle 13 of Title 26, Department of Environment regulations, under the authority of §§7-201 et seq., 9-252, 9-314 of the Annotated Code of Maryland. “Special medical waste” is defined as composed of anatomical material, blood, blood-soiled articles, contaminated material, microbiological laboratory waste, and sharps. They are considered controlled hazardous substances and subject to other provisions. Excluded are household waste, waste generated in handling animals (unless the animal has a transmittable disease), ash or by-products from incineration, etc. A person generating less than 50 pounds (23 kg) per month is exempted from the regulation.
The regulations promulgate standards applicable to generators which include manifest, packaging, labeling, recordkeeping, and international shipment requirements. Generators who treat, store, dispose or transport special medical waste are required to obtain a Maryland Identification Number. There are specific transporter regulations. Sharps cannot be disposed in a solid waste landfill unless first incinerated and mechanically destroyed.
Massachusetts
Massachusetts Department of Public Health Division of Community Sanitation 305 South Street, 1st Floor Jamaica Plain, MA 02130 (617) 983-6761 (617) 983-6770 (Fax) www.magnet.state.ms.us/dph/csanskel.htm
105 CMR 480.001 to 480.7000, Chapter VIII of the State Sanitary Code, Department of Public Health, set forth the requirements for storage and disposal of infectious waste or physically dangerous medical or biological waste. The term “infectious or physically dangerous medical or biological waste” includes blood and blood products, pathological waste, cultures and stocks, contaminated animal carcasses/body parts/bedding, sharps, and biotechnological by-product effluents.
The regulations define storage, labeling, recordkeeping, and manifest requirement, as well as administrative and enforcement procedures. A medical waste tracking form is
B-16 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste provided by the Department. The approved methods of treatment are steam sterilization, gas sterilization, chemical disinfection, incineration at an approved facility, and other approved methods. Specifically, under the regulations, blood and blood products may be disposed of in the municipal sewerage or septic system or may be incinerated or sterilized using gas, chemical or steam prior to disposal in an approved sanitary landfill. Sharps shall be contained in puncture-resistant containers and disposed of by incineration or by rendering noninfectious and physical destruction. Blood-saturated materials, cultures and stocks, dialysis waste, and laboratory waste may be incinerated or rendered noninfectious by steam, incineration, thermal inactivation, or chemical disinfection and disposed of in an approved sanitary landfill. Biotechnology by-product effluents may be processed by steam sterilization, chemical disinfection, incineration at an approved facility, or other approved methods with additional requirements. Pathological waste and animal carcasses must be incinerated or interred. Other treatment methods may be approved under the condition that scientific studies validating the process are accepted by the Department.
Michigan
Michigan Department of Public Health 3423 N. Logan/Martin Luther King Jr. Boulevard P.O. Box 30195 Lansing, MI 48909 (517) 335-8024 or (800) 444-6472 www.mdch.state.mi.us
Medical waste regulations are found in Part 138 (Medical Waste) of the Public Health Code, Sections 333.13801 through 333.13831. Medical waste is defined as cultures and stocks, liquid human and animal waste, pathological waste, sharps, and contaminated wastes from animals, except any of these that may be generated from a household, agricultural business, home for the aged, or home health care agency.
The regulations specify requirements for storage as well as containment depending on whether the waste is incinerated on-site or not. Approved methods for decontamination of waste are specified according to the type of waste. These methods include autoclaving, incineration, and flushing down a sanitary sewer. Some types of waste can be disposed in a sanitary landfill. Alternative methods are accepted for some types of waste but only after approval by the department.
Facilities that generate, store, decontaminate, or incinerate medical waste (referred to as “producing facilities”) must register and submit a written medical waste management plan which contain certain required information. The plans are reviewed by the department. In addition, the regulations specify packaging, procedures for the investigation of reports and violations, the creation of an interdepartmental medical
B-17 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste waste advisory council and a medical waste emergency response fund, and training requirements.
Minnesota
Minnesota Pollution Control Agency Solid Waste Section Ground Water and Solid Waste Division 520 Lafayette Road St. Paul, MN 55155-4194 (800) 657-3864 or (612) 296-6300 www.pca.state.mn.us/netscape.shtml
The permanent rules relating to infectious waste management are in Minnesota Rules Chapter 7035 adopted by the Pollution Control Agency under the authority of the Infectious Waste Control Act. Infectious waste is define as laboratory waste, blood, regulated body fluids, sharps, and research animal wastes that have not been decontaminated.
All untreated infectious waste must be segregated and may not be compacted prior to incineration or disposal. There are requirements for labeling, containment, disposal, storage, transportation, the preparation and certification of management plans, and financial assurance. Sharps must be placed in puncture-resistant containers. Incineration requires an air emission permit and must operate in compliance with other regulations. In addition to incineration, the other accepted methods are autoclaving under specific conditions, as well as other methods (grinding, microwaving, etc.) that require approval by the commissioner of the agency.
Mississippi
Mississippi State Department of Health 2423 North State Street P.O. Box 1700 Jackson, MS 39215-1700 (601) 576-7960 (601) 576-7505 (Fax) www.msdh.state.ms.us/msdhhome.htm
Mississippi Department of Environmental Quality Office of Pollution Control P.O. Box 10385 Jackson, MS 39289-0385 (601) 961-5171 www.deq.state.ms.us
B-18 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The State Department of Health has “Adopted Standards for the Regulation of Medical Waste” governing the handling and treatment of infectious waste on site. They are also responsible for alternative technologies treated in house. Under their regulations, “infectious medical waste” includes wastes from care of patients and animals with specific transmittable diseases, cultures and stocks, blood and blood products, pathological waste, contaminated carcasses/body parts/bedding of animals, discarded sharps, and other wastes classified by the department. The term “medical waste” is defined as all other waste generated in patient care, diagnostic or research areas, that is non-infectious but aesthetically repugnant. The Department of Environmental Quality addresses infectious waste disposal through specific conditions in solid waste management permits that generally prohibit acceptance of waste not rendered non- infectious. They also regulate transport (not requiring licensing) and off-site management (requires an operating permit) of infectious waste through the Nonhazardous Solid Waste Management Regulations.
Under the Department of Health regulations, all generators must have a waste management plan to include storage, containment, labeling, and treatment. Infectious medical waste must be segregated at the point of origin. Compaction or grinding shall not be used to process infectious medical waste unless the waste is rendered non- infectious. The acceptable methods are incineration in an approved incinerator, sterilization by heating in a steam sterilizer under specified conditions, discharge of liquid or semi-liquid waste in an approved sewerage system, interment or incineration of recognizable anatomical remains, and chemical sterilization using sterilants recognized by U.S. EPA.
Missouri
Missouri Department of Natural Resources Solid Waste Management Program P.O. Box 176 Jefferson City, MO 65102 (800) 334-6946 or (573) 751-5401 www.dnr.state.mo.us/deq/swmp/homeswmp.htm
Infectious waste is covered under Chapter 260, Section 203 and 204, of the Missouri Solid Waste Management Law, and the regulations are found in Title 10, Division 80, Chapter 7 (Infectious Waste Management) of the Code of State Regulations. Infectious waste includes isolation waste; contaminated surgical, dialysis and laboratory wastes; cultures and stocks, blood and blood products; pathology waste; and sharps. Regulations exist also for small quantity generators producing 100 kilograms or less of infectious waste per month. Hospitals can accept infectious waste for treatment from small quantity generators and other hospitals as defined in the regulations, but the hospital treating the waste needs to submit a notice of intent to the department.
B-19 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The regulations include provisions on packaging, tracking, and transportation of infectious waste. Sharps, whether generated at a hospital or individual residence, must be packaged in rigid, leakproof, puncture-resistant containers. Requirements are set forth for infectious waste processing facilities which can use any of two approved methods: incineration or steam sterilization; other methods may be approved by the department on a case-by-case basis. Hospitals may treat infectious waste by autoclaving, incineration, chemical disinfection, or other methods approved by the department. Once treated, the waste must be certified as having been treated prior to disposal in a landfill.
Montana
Montana Department of Environmental Quality Waste Management Division Solid Waste Program 2209 Phoenix Avenue P.O. Box 200901 Helena, MT 59620-0901 (406) 444-2544 www.deq.state.mt.us
The Infectious Waste Management Act (75-10-1001 to 1006) is enforced by the Department of Environmental Quality, formerly the Department of Health and Environmental Sciences. Infectious waste includes cultures and stocks, human pathological waste, free-flowing human blood or blood products, and sharps.
The regulations require segregation of infectious waste at the point of origin. There are also provisions for storage, transportation, treatment, and disposal, as well as licensing and regulation. Employees handling or managing infectious waste must receive training. Generators and transporters must develop contingency plans. Compaction or other mechanical manipulation of infectious waste is prohibited. The treatment methods are incineration, steam sterilization, chemical sterilization using approved techniques, sewer discharge for liquid or semisolid infectious waste, and incineration or interment for body parts.
Nebraska
Nebraska Department of Environmental Quality Integrated Waste Management Section P.O. Box 98922 Lincoln, NE 68509-8922 (402) 471-2186 (402) 471-2909 (Fax) www.deq.state.ne.us
B-20 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste regulations are found under Special Wastes in Chapter 12 of Title 132 (Integrated Solid Waste Management Regulations) with definitions given in Chapter 1. Infectious waste includes blood, blood products, body fluids, infectious sharps, laboratory waste, contaminated animal parts, and other wastes identified by infectious waste generators.
Infectious waste cannot be disposed of at a solid waste disposal area unless first rendered non-infectious by incineration, autoclaving, or other treatment method approved by the department. Other requirements applicable to special wastes must also be met.
Nevada
Nevada Department of Conservation and Natural Resources Division of Environmental Protection Bureau of Waste Management Solid Waste Branch 333 W. Nye Lane Carson City, NV 89706 (702) 687-4670 or (702) 687-5872 (general information) (702) 687-6396 (Fax) www.epa.gov/swerust1/states/nevadaul.htm
Medical/infectious waste regulations are found in Sections 444.589, 444.646 and 444.662 of the Nevada Administrative Code. The definition of “medical waste” makes reference to Appendix G of 49 CFR 173, U.S. Department of Transportation regulations, and includes cultures and stocks, pathological wastes, human blood and blood products, sharps, animals waste, isolation waste, and unused sharps.
Medical waste can be deposited at approved sites under specified conditions. Storage and transport requirements are also provided.
New Hampshire
New Hampshire Department of Environmental Services Waste Management Division 6 Hazen Drive Concord, NH 03301-6509 (603) 271-2900 (603) 271-2925 (infectious waste) (603) 271-2456 (Fax) www.state.nh.us/des/biowmd.htm
B-21 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Infectious Waste regulations are found in Part Env-Wm 2604.01 to 2604.05 as well as Part Env-Wm 2207.02 of the Solid Waste Rules. Infectious waste includes cultures and stocks; pathological wastes; blood and blood products; sharps; contaminated animal carcasses, body parts, or bedding; waste from human or animal patient care, surgery, or autopsy; laboratory wastes; dialysis wastes; discarded medical equipment and parts in contact with infectious agents; biological waste and discarded materials contaminated with blood and other secretions from humans or animals in isolation; discarded preparations from genetically altered living organisms and their products; and other waste materials determined by the director to pose a threat to human health or the environment.
The regulations include requirements for storage, transportation, treatment, and disposal of infectious waste, as well as treatment and disposal exemptions. There are limited permit standards for infectious waste processing or treatment facilities. The regulations require treatment that achieves high-level disinfection, specifically, a four Log reduction of Bacillus subtilis, by incineration, steam sterilization, chemical disinfection, or gas disinfection. Pathological incineration is the preferred treatment method. Recognizable body parts must be incinerated or interred. Non-infectious liquid blood or body fluids may be disposed in a sanitary sewer. Sharps infectious waste require incineration.
New Jersey
New Jersey Department of Environmental Protection and Energy Division of Solid Waste Management P.O. Box 414 401 E. State Street Trenton, NJ 08625 (609) 984-6880 (609) 984-6874 (Fax) www.state.nj.us/dep/dshw/hwr
New Jersey Department of Health and Senior Services Division of Environmental and Occupational Health Consumer and Environmental Health Services P.O. Box 369 Trenton, NJ 08625 (609) 984-2193 or (609)-588-2577 (general information) www.state.nj.us/health
The regulations for regulated medical waste are found in Subchapter 3A of 7:26 New Jersey Administrative Code. Regulated medical waste includes cultures and stocks, pathological wastes, blood and blood products, sharps, animal waste, isolation wastes,
B-22 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste and unused sharps. The state requires registration of generators, transporters, intermediate handlers, and destination facilities.
Prior to transport off-site, wastes must be segregated to the extent practicable, separating sharps, fluids greater than 20 cc, and other medical waste. There are also packaging, storage, decontamination, labeling, marking (identification), tracking, recordkeeping, and reporting requirements. Specific requirements for transporters and operators of a regulated medical waste incinerator. Treatment methods are incineration, steam sterilization, chemical disinfection, irradiation, thermal inactivation, or any other effective method approved by the Department of Health. The Department of Health has developed efficacy standards such that a minimum 4 Log reduction in certain bacteria and viruses is achieved.
New Mexico
New Mexico Environment Department Solid Waste Bureau Harrold Runnels Building 1190 St. Francis Drive P.O. Box 26110 Santa Fe, NM 87502-6110 (505) 827-2775 www.nmenv.state.nm.us
Infectious waste requirements are found under Special Waste in Section 706, Part VII, of the Environmental Improvement Board/Solid Waste Management Regulations. The rules apply not only to hospital and clinics but also to intermediate care facilities, HMOs, health agencies, laboratories, medical buildings, physicians and dentists offices, veterinarians, funeral homes, etc. Infectious waste includes microbiological laboratory wastes, pathological wastes, disposal equipment and materials requiring special precautions, blood and blood products, used sharps, and contaminated animal carcasses, body parts, and bedding.
Anyone treating infectious waste must certify in writing that the waste has been rendered noninfectious, and such certification must be provided to transporters or disposal facilities. The regulations include provisions for storage, containment, treatment, and disposal. Compaction, grinding, or similar devices are not allowed before the waste has been rendered noninfectious or unless approved by the department. Body parts must be disposed of by incineration or interment. Otherwise, the acceptable methods of treatment, in accordance with certain provisions, are incineration, steam sterilization, and sewer discharge for liquid or semi-solid waste. Other methods may be approved by the secretary if efficacy can be demonstrated (namely, a 4 Log reduction for B. stearothermophilus or B. subtilis, and a 6 Log reduction in specified vegetative bacteria, fungi, parasites, viruses, and microbacteria).
B-23 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
New York
New York State Department of Environmental Conservation Division of Solid Waste 50 Wolf Road Albany, NY 12233-1011 (518) 485-8940 or (800) 342-9296 (800) 312-9296 (hazardous waste) (518) 457-7744 (Fax) www.dec.state.ny.us/website/dshm/sldwaste/index.htm
New York State Department of Health Regulated Medical Waste Program Wadsworth Center P.O. Box 509 Empire State Plaza Albany, NY 12201-0509 (518) 458-6483 or (518) 485-5378
The original regulations on regulated medical waste were mainly in Subparts 360-10 and 360-17 of Part 360, Title 6 of the New York Codes, Rules, and Regulations (NYCRR) under the statutory authority of the Environmental Conservation Law. The definition of regulated medical waste, found in 6 NYCRR 364.9, was any medical waste that was a solid waste (as defined elsewhere) generated in the diagnosis, treatment, or immunization of human beings or animals, in medical research, or in production of biologicals. It included cultures and stocks of infectious agents, associated biologicals; human pathological wastes; liquid human blood, blood products, items saturated with blood; sharps; contaminated animal carcasses, body parts, and bedding of animals exposed to infectious agents; surgery or autopsy waste in contact with infectious agents; laboratory waste in contact with infectious agents; dialysis wastes in contact with blood; biological waste and discarded materials contaminated with blood and other fluids from humans who were isolated to protect others; and unused sharps. Excluded were hazardous and household wastes, incinerator ash, treatment residues, human remains intended for interment or cremation, and samples transported off-site by EPA or State designated enforcement personnel. Different regulations or exemptions applied depending on whether a generator produces or transports off-site 50 pounds (23 kg) of less per month.
The regulations have since been amended by Section 1389 aa-gg under Chapter 438 of the Public Health Law of 1993. A pamphlet “Managing Regulated Medical Waste” by the NY Department of Health provides interpretive guidelines for implementing revisions to the Public Health Law. Among the changes are the definition of medical waste which reduces the number of subcategories to the following: cultures and stocks, human pathological waste, human blood and blood products, sharps, animal waste,
B-24 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste and any specific items designated by the Commissioner of Health. One notable change is that IV bags and associated tubing are no longer considered regulated medical waste. (It should be noted that the federal EPA has adopted New York’s definition for some rulemaking.)
Under the original regulations, New York requires segregation to the extent practicable of sharps, fluids greater than 20 cc, and other regulated medical waste. Facilities involved with storage, transfer, and disposal of regulated medical waste must comply with permit requirements to construct and operate, as well as operational requirements. Sharps must be treated and destroyed before landfilling. Recognizable body parts and animal carcasses must be disposed of by interment or incineration. Treated regulated medical waste or treated and destroyed medical waste (TDMW) may be disposed of only in landfills or approved incinerators. The approved treatment methods for regulated medical waste are (see Section 360-17.5 for specific operating conditions): incineration, autoclaving, sewerage system discharge for liquid or semi-liquid waste, and other treatment methods approved by the commissioner of the New York State Department of Health. Approval as an alternative treatment requires a written application which includes testing and supporting documentation to be able to determine efficacy. Each treatment unit is required to successfully complete an approved validation testing program.
The revised regulations requires hospitals and nursing homes to establish procedures for accepting sharps waste from private residences effective July 1, 1996. As before, all alternative treatment alternatives must be approved. Evaluation is conducted by the Regulated Medical Waste Program (RMWP) of the Department of Health. A list of approved technologies can be obtained from the RMWP.
North Carolina
North Carolina Department of Environment, Health, and Natural Resources Division of Solid Waste Management P.O. Box 27687 Raleigh, NC 27611-7867 (919) 733-4984 (919) 761-2390 (West NC) (919) 486-1191 (East NC) www.ehnr.state.nc.us/EHNR
The Medical Waste Management rules are mainly found in 15A NCAC 13B, Sections 1200 et seq. of the North Carolina Administrative Code. Medical waste is comprised of general waste (no special requirements), sharps and blood or body fluids less than 20 cc (requiring packaging), and regulated medical waste which requires treatment. Regulated medical waste means blood and body fluids in volumes greater than 20 cc, microbiological waste (cultures, stocks, etc.), and pathological waste (including animal
B-25 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste carcasses and body parts exposed to pathogens). North Carolina does not require registration of generators.
The regulations provide requirements for packaging, storage, transportation, treatment, and disposal. Some exemptions from packaging, labeling, storage, and recordkeeping requirements are allowed depending on whether the generator or treatment facility is an integrated medical facility (i.e., one of more healthcare facilities located in one county or two contiguous countries, affiliated with a university or under common ownership or control, and serving a single service area) or not. Labeling requirements differ from those of OSHA. Sharps must be packaged in rigid, leak-proof, and puncture resistant containers and can be disposed of with general solid waste. Facilities treating regulated medical waste generated off-site require a permit by the Solid Waste Section. The acceptable methods of treatment are incineration or sanitary sewerage disposal for blood and body fluids; incineration, steam sterilization, microwave treatment, or chemical treatment for microbiological waste; and incineration for pathological waste. Other methods require approval by the Division.
North Dakota
North Dakota Department of Health and Consolidated Laboratories Division of Waste Management 1200 Missouri Avenue P.O. Box 5520 Bismark, ND 58506-5520 (701) 328-5150 (701) 328-5200 (Fax) www.health.state.nd.us/ndhd/environ
The Regulated Infectious Waste rules are found in Chapter 33-20-12 of the Department regulations. Under the regulation, regulated infectious waste refers to cultures and stocks, pathological waste, blood and blood products, sharps, animal waste, isolation waste, and unused sharps.
North Dakota requires segregation of regulated infectious waste from other waste, and segregation of sharps at the point of origin. All regulated infectious waste must be incinerated or disinfected; sharps not incinerated must be rendered nonsharp. Blood and blood products can be discarded through the municipal sewage system. Other requirements for containment and handling are included in the management standards for regulated infectious waste.
B-26 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Ohio
Ohio Environmental Protection Agency Division of Solid and Infectious Waste Management P.O. Box 1049 Columbus, OH 43216-1049 (614) 728-3778 (614) 728-3898 (Fax) www.epa.ohio.gov/new/divs.htm
The Division of Solid and Infectious Waste Management of Ohio EPA regulates infectious waste and the regulations are found mainly in OAC-3745-27 of the Ohio Administrative Code. In addition, the Division of Air Pollution Control (614-644-2270) regulates infectious waste incinerators. Infectious wastes include cultures and stocks, laboratory waste, pathological wastes, isolation wastes, human and animal blood and blood products, contaminated animal wastes, sharps, and other materials determined by the public health council as infectious waste. There are separate generator standards depending on whether a facility generated less than 50 pounds (23 kg) per month (small generator) or not. Siting criteria and permitting requirements for an infectious waste treatment facility are specified in OAC 3745-27-37, -50, and -51.
The regulations promulgate standards for generators, transporters, operators of infectious waste treatment facilities, as well as packaging, storage, and registration requirements. Small generators are required to segregate at the point of generation, place sharps in specified containers, and maintain records, among other requirements. Facilities generating 50 pounds (23 kg) per month or more also need to segregate waste at the point of generation, place sharps in containers specified in the rule, and treat waste on site or at an off-site facility, employ only registered transporters, provide information if required, record spills or accidents, and develop spill containment and clean-up procedures. Untreated liquid or semi-liquid infectious waste may be discharged in a disposal system. Under Ohio regulations, incineration, autoclaving, limited chemical submersion of cultures, sharps encapsulations (by Disposal Science, Inc.), and Sanitec microwave (on a site-specific basis) are the approved treatment technologies. OAC rule 3745-27-38 governs alternative treatment technology approvals. The rule states specific efficacy requirements and detailed microbial testing protocols. Persons seeking approval of their technology must submit test results and other documentation.
B-27 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Oklahoma
Oklahoma Department of Environmental Quality Waste Management Division Solid Waste Compliance Unit P.O Box 1677 Oklahoma City, OK 73101-1677 (405) 702-6100 (405) 702-6225 (Fax) www.deq.state.ok.us
The Department of Environmental Quality regulates handling, storage, transport, tracking, treatment, and disposal of medical waste. The relevant regulations are contained in Oklahoma Administrative Code 252:500 Subchapter 15 (Biomedical Waste). Incinerator air emissions are under the Air Quality Service of the department, and waste management practices of nursing homes are part of the licensing program of the Oklahoma State Department of Health (405-271-5600).
Subchapter 15 applies to hospitals and other facilities that do not have on-site incineration or cremation. Biomedical waste is defined as materials which are to be discarded and which are infectious, i.e., any substance that may cause injury or disease to humans and the environment but are not regulated as waste. The specific list of infectious waste follows the EPA categories (cultures and stocks; blood and blood products; pathological waste; contaminated sharps; contaminated animal wastes; wastes from surgery, autopsy, etc.; laboratory waste; dialysis waste; isolation waste; and contaminated medical equipment). In addition, Oklahoma recognizes chemical wastes such as pharmaceutical waste, laboratory reagents, cytotoxic/antineoplastic agents, and other chemicals contaminated with infectious agents.
Biomedical waste generators that treat off site are required to follow labeling, packaging, safe handling, and storage requirements. Once packaged, compaction of untreated infectious waste is prohibited. There are standards provided for commercial (off-site) waste processing facilities including specific standards for biomedical waste incinerators. The approved treatment methods are: incineration in an approved incinerator, stream sterilization, chemical disinfection, and any other method approved by the department. Oklahoma specifies incineration in an approved incinerator as the preferred method. Approval of commercial alternative methods are done on a case-by- case basis. Specifically designed incinerators are the only accepted way of treating antineoplastics and cytotoxic drugs.
B-28 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Oregon
Oregon Health Division Center for Disease Prevention and Epidemiology CD Program 800 NE Oregon Street, #21 Portland, OR 97232 (503) 731-4023 www.ohd.hr.state.or.us/cdpe/welcome.htm
Oregon Department of Environmental Quality Waste Management and Cleanup Division Solid Waste Policy and Programs 811 SW Sixth Avenue Portland, OR 97204-1390 (503) 229-5913 or (800) 452-4011 (503) 229-6922 (infectious waste) www.deq.state.or.us/wmc/cleanup/clean.htm
Oregon Public Utilities Commission Transportation Safety Division 550 Capital Street NE Salem, OR 97310-1380 (503) 378-5915 www.odot.state.or.us
The various portions of the infectious waste disposal regulations are regulated by the Health Division (dealing with alternative treatment technologies), Department of Environmental Quality (dealing with incineration and landfills), and Public Utilities Commission (dealing with transportation of infectious waste). The rules dealing with infectious waste disposal are in ORS 459.386 through 459.405, and in Oregon Administrative Rules 333-18-040 through 333-18-070. The regulations define four basic kinds of infectious waste: pathological waste, biological waste, cultures and stocks, and sharps.
The regulations require all generators, including diabetics in private residences and doctors offices, to segregate infectious waste from other wastes. Generators producing less than 50 pounds (23 kg) a month are exempted from specific portions of the law. There are certification and recordkeeping requirements for transporters. Storage requirements are also provided. Pathological waste must be incinerated or treated in the same manner as cultures and stocks if the Department of Environmental Quality determines that incineration is not reasonably available. Cultures and stocks must be incinerated or sterilized by steam sterilization or other means prescribed by the Health Division. Other treatment methods must be approved by the National Sanitation B-29 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Foundation or other nationally recognized third parties. Liquid or soluble semi-solid biological wastes may be discharged into the sewage treatment system that provides secondary treatment. Body parts must be incinerated or disposed of in a manner similar to cultures and stocks. Uncompacted sharps not incinerated or autoclaved may be sent to a landfill if kept in its special container. The Environmental Quality Commission may approve other methods of treatment and disposal by rule.
Pennsylvania
Pennsylvania Department of Environmental Resources Bureau of Waste Management P.O. Box 8471 Harrisburg, PA 17105-8471 (717) 783-2388 www.dep.state.pa.us/dep/deputate/airwaste/wm/default.htm
Hazardous Waste: www.dep.state.pa.us/dep/deputate/airwaste/wm/hw/hw.htm
The regulations for infectious and chemotherapeutic waste are found in Chapters 271 to 285 (Municipal Waste Regulations) of Title 25 of the Pennsylvania Code. Infectious waste is defined as municipal and residual waste generated in the diagnosis, treatment, immunization, autopsy, or preparation for interment or cremation of humans or animals, including waste from related research or production/testing of biologicals. Several exceptions are made including wastes from individual residences. Chemotherapeutic waste is defined as that resulting from production or use of antineoplastic agents but not including waste that would be classified as hazardous waste under other regulations.
The following sections deal specifically on infectious and chemotherapeutic waste: 271.101 to 271.102 – general provisions for permits; 271.711 to 271.744 – general permit requirements relative to infectious and chemotherapeutic waste; 273.401, 273.411, 273.511, 273.512 – additional requirements for disposal of processed infectious and chemotherapeutic waste; 283.302 – additional requirements for processing of infectious and chemotherapeutic waste; 283.402 - infectious waste monitoring; 285.131 to 285.148 – storage and marking requirements; and 285.222 to 285.434 – transportation and transporter requirements (including provisions related to discharges and spills).
Under the regulations, a facility processing infectious and chemotherapeutic waste on- site shall be considered to have a waste processing permit if it uses an autoclave and renders the waste unrecognizable, or an incinerator that burns at least 50% of its own waste and accepts other waste only from small quantity generators (those that generate less than 220 pounds (100 kg) per month). Specific requirements are provided for small quantity generators. No permits are needed for temporary storage (24 hours or less).
B-30 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Commercial processing facilities must apply and obtain a permit from the Department of Environmental Resources. Under specific circumstances, the Department may issue general permits on a regional or statewide basis for a category of infectious and chemotherapeutic waste processing facility (excluding commercial facilities).
The regulations require segregation of the infectious and chemotherapeutic waste stream at the point of generation. There are provisions for the storage of infectious and chemotherapeutic waste as well as residues of processed waste. For example, infectious and chemotherapeutic waste must be stored using refrigeration for up to 30 days (up to 90 days if frozen) and contained in such as way as to prevent leakage and odors. The regulations specify that disinfection of infectious waste must be monitored and, in general, the waste must be rendered unrecognizable. This entails microbiological analysis of the residue or of microbiological indicators and at different frequencies, depending on the method of disinfection used. Compaction and grinding are not allowed prior to disinfection, and the processed waste can only be disposed of in approved landfills. Landfill operators must comply with specific requirements to dispose of processed infectious and chemotherapeutic waste. Anatomical remains must be incinerated and sharps must be rendered unusable prior to disposal. Body fluids may be disposed by discharge into a permitted sewage system with secondary treatment.
Although the regulations do not specifically mention alternative technologies, they require that disinfection processes “other than thermal processing or incineration” must ensure the total destruction of specified indicator organisms in 95% of samples tested during disinfection. The microbiological analysis of indicators must be conducted every 40 hours during the operational life of the facility and the results made available to the Department upon request.
Rhode Island
Rhode Island Department of Environmental Management Office of Waste Management 235 Promenade Street Providence, RI 02908-5767 (401) 277-2797 (401) 222-3812 (Fax) http://webster.doa.state.ri.us:8888/dem_wastemgt
The rules and regulations governing the generation, transport, storage, treatment, management, and disposal of regulated medical waste is found in Regulation DEM-DAH-MW-01-92 under the authority of Chapter 23-19.12 of the General Laws. Regulated medical waste is defined to include cultures and stocks, pathological wastes, blood, blood products, body fluids, sharps, animal waste, isolation waste, unused sharps, spill/cleanup material, and mixtures. Hazardous and household wastes,
B-31 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste incinerator ash, human remains, etiologic agents being transported, and enforcement samples are excluded. In general, generators must register and obtain a registration number.
The regulations require segregation of regulated medical waste to the maximum extent practicable. Packaging and containment, storage, decontamination, on-site transport, labeling and marking, on-site treatment/destruction, and reporting requirements are provided. Recordkeeping requirements for on-site incineration, steam sterilization, or other treatment or destruction methods are specified. There are also transportation requirements including permitting, EPA notification, tracking, etc. With regards to acceptable treatment methods, liquid regulated medical wastes must be incinerated or discharged into a sanitary sewer system with approval; pathological wastes must be incinerated; sharps and unused sharps must be incinerated, chemically disinfected, or steam sterilized followed by grinding/shredding; other regulated medical waste such as cultures and stocks must be incinerated, chemically disinfected, or steam sterilized followed by grinding/shredding. The director can approve alternative technologies if they are proven through tests to meet a specified efficacy standard.
South Carolina
South Carolina Department of Health and Environmental Control Bureau of Solid and Hazardous Waste Management 2600 Bull Street Columbia, SC 29201 (803) 734-5360 www.state.sc.us/dhec/eqchome.htm
The Infectious Waste Management Regulations are found in regulations R.61-105 under the authority of the South Carolina Infectious Waste Management Act. Under the regulations, infectious waste includes sharps, microbiologicals, blood and blood products, pathological waste, isolation waste, and contaminated animal waste. All generators of waste have to register (except for private residences).
Under the regulations, only small quantity generators (producing less than 50 pounds (23 kg) per month) can transport their own waste. The regulations require segregation of infectious waste from solid waste as close to the point of generation as practical. Other requirements include packaging, labeling, storage, manifesting, disinfection of containers, along with specific regulations for transporters and permitted treatment facilities. Liquid or semi-liquid waste may be discharged into an approved wastewater treatment disposal system, and recognizable body parts my be interred or donated for research. The accepted treatment methods prior to disposal in a sanitary landfill are: incineration, steam sterilization, chemical disinfection, and other approved methods. A “Guide to the South Carolina Infectious Waste Management Regulations R.61-105” by the Department (December 1994) provides a listing of the current treatment techniques:
B-32 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste chemical disinfection by hydrogen peroxide, chemical encapsulation, electron beam irradiation, electropyrolysis, gas sterilization using ethylene oxide, incineration, laser treatment, mechanical/chemical disinfection, microwave disinfection, plasma pyrolysis, steam sterilization, and thermal inactivation or dry heat sterilization.
South Dakota
South Dakota Department of Environment and Natural Resources Joe Foss Building 523 East Capitol Avenue Pierre, SD 57501-3181 (605) 773-3152 www.state.sd.us/state/executive/denr/denr.htm
The Medical Waste regulations are in Title 74, Article 35 of the Department regulations. Regulated medical waste is defined to include cultures and stocks, pathological waste, blood and blood products, sharps, animal waste, isolation waste, and unused sharps.
The regulations include recordkeeping, standards for incinerator emissions, container requirements, storage, labeling, decontamination, and identification requirements. Other incinerator requirements are specified. The accepted disposal methods are incineration in accordance with conditions specified in the regulations, steam sterilization, chemical disinfection, or an equally effective treatment method upon approval by the department.
Tennessee
Tennessee Department of Health Division of Health Care Facilities 425 5th Avenue North Nashville, TN 37247-0508 (615) 741-7221 (615) 741-7051 (Fax) www.state.tn.us/health/hcf
Tennessee Department of Environment and Conservation Division of Solid Waste Management 5th Floor L & C Tower 401 Church Street Nashville, TN 37243-1535 615-532-0780 www.state.tn.us/environment/swm/index.htm
B-33 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Tennessee’s infectious waste management program is managed between three divisions: Division of Health Care Facilities which regulates handling and treatment of infectious waste, Division of Solid Waste Management which approves disposal of these wastes in sanitary landfills, and the Division of Air Pollution control (615-532-0554) which sets standards for infectious waste incinerators. Regulations are found in Hospital Rules and Regulations (Chapter 1200-8.2.02(e)), Solid Waste Processing and Disposal (rule 1200-1-7), and Infectious Waste Incineration Rules and Regulations (Chapter 1200-3-25).
Infectious waste is defined as solid or liquid wastes containing pathogens with sufficient virulence and quantity such that exposure by a susceptible host could result in disease. Waste categories include isolation wastes, cultures and stocks, blood and blood products, pathological wastes, all discarded sharps, animal wastes, and other wastes. The regulations require that infectious waste be segregated from other wastes at the point of origin. Packaging, storage requirements, and incinerator permitting are also specified.
Wastes can be treated by incineration, steam sterilization, or some other process that renders it non-infectious. Liquid or semi-liquid infectious wastes may be discharged in a sewer system. All remains, except those cremated or buried, must be incinerated or discharged to the sewer after grinding. Some categories of infectious waste may not be disposed of in a sanitary landfill, or may be disposed of only after being treated and packaged in a specified way.
Texas
Texas Natural Resource Conservation Commission P.O. Box 13087, MC-124 Austin, TX 78711-3087 (512) 239-1000 www.tnrcc.state.tx.us/homepgs/direct.html
Texas Department of Health 1100 West 49th Street Austin, TX 78756 (512) 458-7541 (512) 458-7686 (Fax)
New rules on medical waste management, adopted in 1995, are found in Chapter 30 of the Texas Administrative Code, in particular, 30 TAC 330.1001-330.1010. Medical wastes are considered “special wastes from health care related facilities” identified by the Board of Health as requiring special handling to protect human health or the environment. Such waste includes blood and other body fluids, microbiological waste such as cultures and stocks, pathological waste including body parts, sharps, and
B-34 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste animal waste such as carcasses exposed to pathogens. There are also regulations governing medical waste found in Chapter 25 TAC §§1.31 et seq. under by the Texas Department of Health. Separate regulations dealing with low-level radioactive waste disposal are found in Chapter 31 of the Texas Administrative Code under the Texas Low-Level Radioactive Waste Disposal Authority.
Except for homes and lodging establishments, all generators of medical waste are required to segregate those wastes from ordinary trash and to treat them using an approved treatment method. The approved methods are: chemical disinfection, incineration, encapsulation (for sharps only), steam disinfection, thermal inactivation, chlorine disinfection/maceration, and moist heat disinfection (such as microwave disinfection). The rules specify which of these approved methods can be used for each major type of waste and that an “approved alternate treatment process” can also be employed. Depending on the type of waste, the treated residues may be deposited in a sanitary landfill, into a sanitary sewer system, or interred. Some types of waste must be rendered unrecognizable or must be labeled as treated waste before final disposal.
The level of documentation of treatment depends on the amount of medical waste generated. Entities generating 50 pounds (23 kg) or less per month must keep minimal information on the treatment as specified in the rules. Facilities generating more than 50 pounds (23 kg) a month must, in addition, keep a record of written procedures for operation and testing of equipment or for preparation of chemicals used. Depending on the amount generated, testing must be conducted once a month or more frequently (e.g., weekly for those generating greater than 200 pounds (91 kg) a month) to demonstrate a 4 Log reduction of appropriate biological indicators. Routine parameter monitoring (for example, temperature, pressure, pH, etc.) may be substituted for biological monitoring for cases where the manufacturer has documented compliance based on those specific parameters.
The rules specify requirements for transporters of untreated medical waste. These requirements include registration, vehicle requirements, labeling, insurance, recordkeeping, etc. Requirements are also provided for medical waste collection stations, storage, and treatment using mobile systems.
Utah
Utah Department of Environmental Quality Division of Solid and Hazardous Waste 288 North 1460 West Salt Lake City, UT 84114-4880 (801) 538-6170 (801) 538-6715 (Fax) www.eq.state.ut.us/eqshw/dshw-1.htm
B-35 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The infectious waste requirements are in section R315-316 of the Utah Administrative Code promulgated by the Solid and Hazardous Waste Control Board. The standards apply to any health facility, transporter, storage/treatment/disposal facility, but exempt health facilities generating 200 pounds (91 kg) or less of infectious waste per month.
The regulations specify general operational, storage, containment, transportation, treatment, and disposal requirements. Facilities are required to prepare and maintain a management plan which includes segregation procedures. Infectious waste may be incinerated, sterilized in a steam sterilizer, discharged to a sewage treatment system with secondary treatment if liquid or semi-solid and approved by the sewage treatment operator, or disposed in a permitted Class I, II or V landfill. Specific conditions are provided for each treatment process mentioned. Recognizable body parts must be incinerated or interred. Other treatment or disposal methods may be used upon approval of the executive secretary.
Vermont
Vermont Agency of Natural Resources Department of Environmental Conservation Solid Waste Management Division 103 South Main Street, West Building Waterbury, VT 05671-0404 (802) 241-3444 or (802) 241-3888 (802) 241-3296 (Fax) www.anr.state.vt.us/dec/wmd.htm
The Solid Waste Management Division regulates general solid waste, conditionally exempt small quantity generator (ESQG) hazardous waste, and infectious waste. Other wastes from a hospital or other healthcare facility may fall under the category of hazardous waste or radioactive waste. Hazardous waste is regulated by the Hazardous Materials Management Division. Infectious waste is defined as including isolation wastes, cultures and stocks, blood and blood products, pathological waste, contaminated laboratory waste, sharps, dialysis waste, experimental animal carcasses and body parts, experimental animal bedding and other animal wastes, contaminated food products, and contaminated equipment. Under the Hazardous Waste Management Regulations, infectious wastes from hospitals, clinics, doctors offices, mortuaries, laboratories, etc. are considered “Listed Waste” and designated VT 07.
Section 6-802(b) of the Solid Waste Management Rules requires that infectious waste be made non-infectious by disinfection, sterilization, or incineration prior to disposal in a certified landfill. After treatment, the waste must still be handled separately from general solid waste. They must be labeled as infectious waste that have been treated in the manner prescribed and must be disposed in an isolated area.
B-36 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Virginia
Virginia Department of Environmental Quality Waste Management Board P.O. Box 10009 Richmond, VA 23240-0009 (804) 698-4000 or (800) 592-5482 www.deq.state.va.us/info/direct.htm
Medical waste regulations adopted by the Virginia Waste Management Board are found in VR 672-40-01:1. Regulated medical waste is defined as meeting either of two criteria: (1) any solid waste that is suspected by the health care professional in charge of being capable of producing an infectious disease in humans, or (2) any solid waste that belong to one the following categories: cultures and stocks, blood and blood products, tissues and other anatomical wastes, sharps, animal wastes, residues from clean-up of spills, and any waste contaminated by or mixed with regulated medical waste. Some exemptions are made, such as sewage sludge, hazardous waste, etc.
The regulations provide general requirements for packaging, labeling, spill management, closure, recordkeeping, and other issues. The general requirements for treatment and disposal state that the waste must be incinerated, steam sterilized, or treated by an alternative method. Special requirements apply to incineration and steam sterilization. Special requirements are also provided for the accepted alternative technologies, namely, dry heat treatment, microwave treatment, and chlorination. Other technologies must petition for review by submitting a “Petition for Evaluation and Approval of Regulated Medical Waste Treatment Technology”; as with other treatment methods, a permit is required to operate an alternative technology. Alternative methods must comply with other requirements pertaining to operation controls and records.
The regulations also state that the treated waste, except incinerated waste, must be shredded or ground (except for small processes treating no more than five pounds (2 kg) per day average). Untreated waste cannot be disposed of in a solid waste landfill. The regulations note that radioactive material must be managed under regulations by the U.S. Nuclear Regulatory Commission and the Virginia Department of Health. Special requirements are given for storage facilities and transportation of regulated medical waste. Other provisions relate to permit applications, issuance procedures, and variances.
B-37 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Washington
Washington Department of Ecology Northeast Regional Office 3190 160th Avenue SE Bellevue, WA 98008-5452 (425) 649-7000 www.wa.gov.ecology
- or -
Washington Department of Ecology M.S. PV-11 Olympia, WA 98504-8711 (206) 407-6000
Requirements for biomedical waste management are found in Chapter 70.95K RCW (which provides a statewide definition but does not prescribe a statewide management program), Chapter 175 Laws of 1994 (for residential sharps disposal), biomedical waste transportation rules by the Washington Utilities and Transportation Commission, Department of Ecology rules on incinerators, and various local infectious waste management programs, among others.
Biomedical waste is limited to animal waste, biosafety level 4 disease waste, cultures and stocks, human blood and blood products, pathological waste, and sharps. Residential sharps collections including the use of pharmacy return programs as drop- off sites, are provided in the regulations. In addition to incineration, other waste treatment technologies may be evaluated by the department of health in consultation with the department of ecology and local health department.
West Virginia
West Virginia Department of Health and Human Resources Office of Environmental Health Services 815 Quarrier Street, Suite 418 Charleston, WV 25301 (304) 558-2981 (304) 558-1291 (Fax) www.wvdhhr.org
Regulations dealing with infectious medical waste are found in Sections 64-56-1 through 64-56-20 of the West Virginia Administrative Rules (Title 64, Series 56). Infectious medical waste is defined as capable of producing an infectious disease if it has been, or is likely to have been, contaminated by a pathogen not routinely and freely B-38 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste available in the community, and if the pathogen is in sufficient quantity and virulence to transmit disease. Infectious medical waste specifically includes: cultures and stocks, blood and blood products, sharps, animal wastes, isolation wastes, clean-up residues, and waste mixed or contaminated by infectious waste. Excluded are remains and body parts being used for medical purposes, remains lawfully interred or cremated, personal products, etc.
The regulations describe the general permit application and approval procedures, as well as packaging and labeling, spill management, storage, transportation, manifesting, recordkeeping, and reporting requirements. There are also provisions for fees, inspections, enforcement orders, hearings, and penalties. All infectious medical waste management facilities must submit an infectious medical waste management plan.
The acceptable methods of treatment are: incineration, steam treatment, discharge to a sanitary sewer, and “any other alternative method approved in writing and permitted by the secretary” (of the Department of Health and Human Resources). Specific requirements are given for each. To apply for approval as an alternative method, the results of an efficacy test must be submitted along with other documentation. The secretary may issue provisional approval until an appropriate trial period can validate performance.
Wisconsin
Wisconsin Department of Natural Resources Bureau of Waste Management Medical Waste Coordinator WA/3 P.O. Box 7921 Madison, WI 53707-7921 (608) 266-2111 or (608) 266-0061 (608) 267-2768 (Fax) www.dnr.state.wi.us/org/aw/wm
The medical waste rules that apply directly to generators and transporters include Chapter NR 526 and Section NR 520.04, Table I of the Wisconsin Administrative Code. The rules consist of three parts: general provisions, infectious waste management, and medical waste reduction requirements for hospital, clinics, and nursing homes. Infectious waste include contaminated or unused or disinfected sharps, bulk blood and body fluids, microbiological laboratory waste including cultures, human tissue, as well as tissue, bulk blood, or body fluids from animals carrying an infectious agent transmittable to humans. Medical waste means infectious waste and other waste that contains or may be mixed with infectious waste.
B-39 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The safety requirements for infectious waste management cover segregation, handling, storing, transporting and shipping, treatment and disposal. Sharps must be incinerated, disinfected, or otherwise treated to render them non-infectious, broken, and non- reusable. The accepted treatment methods are: incineration, steam disinfection, chemical disinfection, mechanical grinding with chemical disinfection, mechanical grinding with heat disinfection, gas disinfection, and other methods that render the waste non-infectious. However, certain types of waste must be treated only by prescribed methods. There are minimum requirements for all treatment facilities. The regulations also require medical waste reduction if they generate more than 50 pounds (23 kg) per month. This involves adoption of a policy that commits to an audit of waste management practices, setting waste reduction goals, examining alternatives to disposable items, etc. Generators producing more than 500 pounds (227 kg) per month had to implement their reduction plans by November 1, 1995; those producing between 200 to 500 pounds (91 to 227 kg) per month, by November 1, 1996; and those between 50 to 200 pounds (23 to 91 kg) per month, by November 1, 1997.
Wyoming
Wyoming Department of Environmental Quality Solid and Hazardous Waste Division Herschler Building 122 West 25th Street Cheyenne, WY 82002 (307) 777-7758 (307) 777-7682 (Fax) www.deq.state.wy.us
Wyoming Department of Health Preventive Medicine Division 117 Hathaway Building 4th Floor Cheyenne, WY 82002 (307) 777-7657 (307) 777-7439 (Fax) http://wdhfs.state.wy.us/WDH/default.htm
Wyoming has no specific rules or guidelines for the handling, treatment, storage, transport, or disposal of infectious waste. However, a facility that commercially treats quantities of infectious waste is required to obtain a solid waste treatment permit and requirements as described in Chapter 1 (general provisions), Chapter 6 (transfer, treatment, and storage), and Chapter 7 (financial assurance) of the solid waste rules and regulations. Moreover, the Wyoming Department of Health has published standards requiring institutions such as hospitals and other healthcare facilities to follow acceptable plans controlling handling, segregation, treatment and disposal of infectious
B-40 Summary of Selected State Regulatory Agencies and Regulations on Medical Waste waste. With regard to treatment methods, the Department of Environmental Quality agrees with the recommendation of EPA’s Guide for Infectious Waste Management (May 1986) which includes incineration, steam sterilization, etc.
B-41 blank page C ALTERNATIVE MEDICAL WASTE TREATMENT TEHCNOLOGIES: VENDOR ADDRESSES AND PHONE NUMBERS
[N.B.: Neither EPRI, members of EPRI, nor any persons acting on behalf of them (a) makes any warranty, expressed or implied, with respect to the use of any apparatus or process in this report, or (b) assumes any liabilities with respect to the use of, or for damages resulting from the use of, any apparatus or process in this report.]
Aegis Bio-Systems, LLC (JYD-1500) 3324 French Park Drive, Suite A Edmond, OK 73034 (888) 993-1500 or (405) 341-0190 (405) 844-9364 or (405) 341-4667 (Fax) www.JYD-1500.com
American Immuno Tech LLC 320 Kalmus Drive Costa Mesa, CA 92626 (888) 543-8991 (714) 241-8435 (Fax) [email protected]
American Delphi, Inc. (Environmental Disposal System ) 7110 Fenwick Lane Westminster, CA 92684 (800) 854-6464 (714) 894-0515 www.americandelphi.com
C-1 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Antaeus Group (SSM-150) 10626 York Road, Suite D Hunt Valley, MD 21030 (410) 666-6160 (410) 666-6110 (Fax) www.antaeusgroup.com
Bio-Oxidation Services, Inc. (Bio-Oxidizer) 613 Third Street 120 E. Grant Street Annapolis, MD 21403 (410) 990-9430 or (888) 463-3927 (410) 990-9431 (Fax) www.bioxidation.com
BioSterile Technology, Inc. (Biosiris) 4104 Merchant Road Fort Wayne, IN 46818 (219) 489-2962 or (888) 710-3792 (219) 489-3654 (Fax) www.biosterile.com
Brincell (Ster-O-Lizer) P.O. Box 27488 Salt Lake City, UT 84127 (801) 973-6400 or (877) 973-6400
Circle Medical Products 3950 Culligan Avenue, Suite D Indianapolis, IN 46218 (317) 357-8080 (317) 357-8349 (Fax)
CMB Maschinenbau und Handels Gmb H. (Sintion) A-805 Graz Plabutscherstrasse 115 Austria 43-316-685515 43-316-685515-10 (Fax) www.sintion.at www.nmwrc.com/sintion1.html
C-2 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Daystar/Prometron Technics Corp. c/o M. Funai Masuda, Funai, Eifert & Mitchell, Ltd. One East Wacker Drive Chicago, IL 60601 (312) 245-7500 (312) 245-7467 (Fax)
Delphi Research, Inc. (MEDETOX) 701 Haines Avenue NW Albuquerque, NM 87102 (505) 292-9315
DOCC, Inc. (Demolizer) 240 East 76th Street New York, NY 10021
Donlee Technologies, Inc. 693 North Hills Road York, PA 17402-2211 (717) 755-1081 (717) 755-0020 (Fax)
Ecolotec, Inc. 100 Springdale Road, A-3, Suite 290 Cherry Hill, NJ 08003 (609) 346-2447 (609) 346-1779 (Fax)
Electro-Pyrolysis, Inc. (EPI/Svedala DC Arc Furnace) 996 Old Eagle School Road Wayne, PA 19087 (610) 687-9070 (610) 964-8570 (Fax)
Enertech Environmental (SlurryCarb) 739 Trabert Avenue NW Atlanta, GA 30318 (404) 355-3390 (404) 355-3292 www.enertech.com
C-3 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
HI Disposal Systems, LLC (Plasma-Based Pyrolysis-Vitrification) National City Center 115 West Washington Street, Suite 1265 Indianapolis, IN 46204 (800) 995-1265 or (317) 693-1265 (800) 973-1265 (Fax) www.hawkinsindustries.com
Industrial Microwave Company, Inc. (MWD 20) 545 Brandywine Drive Colorado Springs, CO 80906 (719) 540-0823 (719) 540-0835 (Fax)
Integrated Environmental Systems (Plasma Enhanced Melter – PEM) 1535 Butler Loop Richland, WA 99352 (509) 946-1901 www.cenet.org/evtec/eval/iet.htm
Isolyser Company, Inc. (Isolyser LST and SMS) 4320 International Blvd. Norcross, GA 30093 (770) 806-9898 www.orex.com
KC Mediwaste, L.C. 4219 University Blvd. Dallas, TX 75205 (214) 528-8900 (214) 528-0467 (Fax)
Leslie Industries P.O. Box 13405 Tallahassee, FL 32317 (805) 422-0099
Lynntech, Inc. 7610 Eastmark Drive College Station, TX 77840 (409) 693-0017 (409) 764-7479 (Fax) www.lynntech.com
C-4 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Mark-Costello Company 1145 Dominguez Street Carson, CA 90746 (310) 637-1851 (310) 762-2330 (Fax) www.mark-costello.com
Med-Compliance (Encore) 5307 El Paso Drive El Paso, TX 79905 (800) 274-4627 (915) 778-8359 (Fax)
Medzam/SAFETEC 1055 East Delavan Avenue Buffalo, NY 14215 (800) 456-7077 www.saftec.com
MSE Technology Applications, Inc. Eastern Region 9104 Forest Shadow Way Fairfax Station, VA 22039-3344 (703) 690-9317 (703) 690-0259 www.mse-ta.com
NCE Concepts, Ltd. (TurboClean Thermal Processor) 2150 Chennault Carrollton, TX 75006 (214) 991-4090 (214) 991-9334 (Fax)
Plasma Pyrolysis Systems, Inc. Box 158 Stuyvesant Falls, NY 12174 (518) 828-4684 (518) 822-0132 (Fax)
PMA Services (MedClean-M) 22347 La Palma Avenue, Suite 106 Yorba Linda, CA 92687 (714) 692-8533 (714) 692-5478 (Fax)
C-5 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Positive Impact Waste Solutions, Inc. (MMT 3000) 4110 Rice Dryer Boulevard Pearland, TX 77581 (281) 412-9991
Premier Medical Technology, Inc. 9800 Northwest Freeway, Suite 302 Houston, TX 77092 (713) 680-8833 (713) 683-8820 (Fax)
Roatan Medical Technologies (Redloc Microwave) P.O. Box 227377 Dallas, TX 75222-7377 (972) 647-4033 (972) 647-4454 (Fax)
Safety Disposal System, Inc. (EnviroSafe) 3890 NW 132nd Street Opa Locka, FL 33054 (800) 828-0692 www.medwaste.net
San-I-Pak, Inc. P.O. Box 1183 Tracy, CA 95378-1183 (209) 836-2310 (209) 836-2336 www.sanipak.com
Sanitec, Inc. 26 Fairfield Place West Caldwell, NJ 07470 (800) 551-9897 or (978) 227-8855 (617) 942-7114 (Fax) www.etven.com/sanitec/index.html
SciCan, Inc. (TAPS Processor) 2002 Smallman Street Pittsburgh, PA 15222 (800) 572-1221 www.sciscan.com
C-6 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Sierra Industries, Inc./RE Baker 1021 South Linwood Avenue Santa Ana, CA 92705 (800) 437-9763 or (714) 560-9333 (714) 560-9339 (Fax) www.sierraindustries.com
SPS Medical Equipment Corporation (Needle-Eater) 450 West First Avenue Roselle, NJ 07203 (800) 978-8006
Startech Environmental Corporation 79 Old Ridgefield Road Wilton, CT 06897 (203) 762-2499 (203) 761-0839 (Fax)
Sterile Technology Industries, Inc. (Chem-Clav) 1155 Phoenixville Park, Unit 105 West Chester, PA 19380 (610) 436-9980 (610) 436-9986 (Fax)
SteriLogic Waste Systems, Inc. (Hydroclave) P.O. Box 84 Kempton, PA 19529 (610) 756-3003 (610) 756-3004 (Fax)
STERIS Corporation (EcoCycle 10) 5960 Heisley Road Mentor, OH 44060 (800) 548-4873 (440) 639-4450 (Fax) www.steris.com
Svedala Industries, Inc. 350 Railroad Street Danville, PA 17821-2046 (570) 275-3050 (570) 275-6789 (Fax)
C-7 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Tempico, Inc. (Rotoclave) P.O. Box 428, 251 Hwy 21 N Madisonville, LA 70447-0428 (800) 728-9006 or (504) 845-0800 (504) 845-4411 (Fax) www.tempico.com
ToxGon Corporation 631 S. 96th Street Seattle, WA 98108 (206) 762-5583 (206) 763-9331 (Fax)
Tuttnauer USA Co., Ltd. 33 Comac Loop, Equi-Park Ronkonkoma, NY 11779 (800) 624-5836 or (516) 737-4850 (516) 737-0720 (Fax) www.tuttnauer.com
Unitel Technologies 411 Business Center Drive, Suite 111 Mt. Prospect, IL 60056 (847) 297-2265
University of Miami E-Beam Medical Waste Treatment Facility Laboratories for Pollution Control Technologies P.O. Box 248294 Coral Gables, FL 33124 (305) 284-2423 or 284-2908 (305) 284-2321 or 284-2885 (Fax)
Vance IDS 7381 114TH Ave. N, Suite 402 A Largo, FL 33773 (800) 273-1780 or (727) 548-9572 (727) 549-8097 (Fax) www.vanceids.com
C-8 Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Vanish Technologies, Inc. 194 Forbes Road Braintree, MA 02184 (781) 356-2211 (781) 356-2211 (Fax)
World Environmental Services Corporation/WESCO (Condor Medical Waste Treatment System) 114 14th Street, Suite B & C Ramona, CA 92065 (760) 789-6496
Waste Reduction by Waste Reduction, Inc. (WR2 Tissue Digestor) 212 Pinewoods Avenue Troy, NY 12180-7244 (518) 273-0292
C-9 blank page Target: About EPRI
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