“Helping Manage ” Waste Volume 9, Issue 4 Hospital Winter 2007

Inside this issue: Stericycle Returning Radioactive

Stericycle Returning Radioac- Medical Waste Containers tive Medical Waste Containers 1 tericycle, Washington’s largest gamma scintillator probe. Medical waste S medical ven- tubs pause for 3 to 5 seconds on the con- EPA De-Lists Epinephrine 3 dor, has been checking incoming medi- veyor belt for the system to detect radioac- Have All Your EOC Informa- cal waste tubs at their Morton, WA fa- tivity. If a tub trips the detection alarm on tion at Your Fingertips 3 cility and increasingly discovering “hot” the conveyor belt system, an additional tubs. These discoveries typically cost scan is performed with the handheld device Homeland Security Establishes hospitals $1,000 per radioactive tub (not to confirm the reading. a National Strategy for Public counting transport costs) and have been The Washington Department of Health 3 Health and Medical Prepared- getting a lot of attention in hospitals. doesn't regard patient waste of any kind as ness This has always been an issue since being legally radioactive, even if it is radio- Stericycle has always had a policy of active. Patient waste is exempt from Wash- not accepting radioactive materials, but ington state radioactive material manage- has recently become problematic due to ment regulations. However, Stericycle equipment changes at Stericycle that doesn't have a radioactive materials license increase the detection sensitivity for and cannot accept any radioactive tubs for Our firm… radioactive materials. The current prob- treatment. DOH has no influence over ospital Waste Man- lem began in March 2007 when a Wash- Stericycle’s zero-tolerance policy towards agement is commit- H ington research facility accidentally sent radioactivity in the tubs that it treats. Both ted to assisting healthcare fa- a medical waste tub to Stericycle's treat- Stericycle and DOH consider the medical cilities in complying with haz- 125 ardous material management ment plant that contained I - really waste generator as the default responsible and waste disposal regulations hot and plenty of it. It tripped Stericy- party. As a direct consequence, hospitals and better managing their cle's tub conveyor line gamma energy are receiving more telephone calls from . Our clients are hospi- detector, which takes a fair degree of Stericycle with the irritating news that a tub tals, clinics, and medical labs. radioactivity to activate. Since then must be retrieved because it is radioactive. Our services include con- Stericycle has been much more aggres- It is important to note that the U.S. De- ducting dangerous, solid, ra- sive about checking tubs with a hand- partment of Transportation regards regu- dioactive, and regulated medi- held low-energy iodine probe, which is lated medical waste as not otherwise speci- cal waste audits; risk assess- more sensitive than their tub conveyor fied (n.o.s.), 6.2, UN 3291, PG II material. ment; hazmat audits; develop- ing waste management plans line detector when physically held It continues to retain this designation even for Joint Commission compli- closer to the tub surface. after it is found to be radioactive, so don’t ance; hazmat emergency re- Stericycle uses two radiation detec- send your assistant down to Stericycle in sponse training; and annual tion systems: a conveyor belt system his/her private vehicle to pick up the tub! dangerous waste and Pollution and a portable system. The belt system If you receive a call from Stericycle Prevention reporting. uses a Ludlum Model 177 as rate meter about a hot tub, you should contact the Our e-mail address is: and a Model 44-2 Sodium Iodide Washington Dept. of Health and immedi- [email protected]. For gamma scintillator probe. The portable ately request a Special Permit to retrieve past Hospital Waste issues, system uses a Ludlum 14C rate meter the radioactive tub. This Special Permit check our website at http:// and another Model 44-2 Sodium Iodide (Continued on page 2: Radioactive Tubs) www.hospitalwastemgmt.com. PAGE 2 HOSPITAL WASTE VOLUME 9, ISSUE 4

(Radioactive Tubs: continued from page 1) vesting about $1,000 or so in their own

will relieve the transporting party of Ludlum low-energy radiation detectors Hospital Waste most U.S. Department of Transporta- (Ludlum Measurements, Inc., Sweet- tion regulations pertaining to the ra- water, TX; http://www.ludlums. com/) “Helping Hospitals dioactivity content in the tub. The and training staff to survey all their Manage Waste” DOH Permit transfers oversight au- medical waste tubs before going Publisher: thority to Washington DOH for the out. Because Washington DOH doesn't Alan B. Jones, Ph.D. unknown radioactivity and serves as regard this waste as legally radioactive Hospital Waste Management the authority to transport the radioac- there are no specific management re- 17629 N.E. 138th Street tive medical waste tub if the trans- quirements when you hold such waste Redmond, WA 98052-1226 porter should be stopped and ques- to decay to background. You must store tioned by Washington State Patrol. it somewhere in any fashion that is se- Hospital Waste is published Some Stericycle clients have been cure from untrained staff and the gen- quarterly for hospital, clinical, and medi- charged by Stericycle with radioactive eral public until the radioactivity isn't cal laboratory waste managers. medical waste tubs that contain iso- detectable by Stericycle. After the de- Hospital Waste Management is topes that don’t even appear on the cayed regulated medical waste is sent to committed to serving the Healthcare Industry by assisting hospitals in manag- facility’s radioactive use license. In- Stericycle, you must close out the Spe- ing their waste. Hospital Waste cluded in this group are facilities that cial Permit that you obtained from aims to broadcast information about don’t have a radioactive materials li- Washington DOH to transport the tub waste regulations and waste manage- cense. This frustrating situation can by contacting Washington DOH. ment initiatives and to provide helpful develop because patients may un- If you do use a Ludlum 44-2 to hints and general waste information to dergo radiation procedures in one monitor your medical waste tubs, note healthcare waste managers. medical office, then arrive on your that Stericycle has set their monitors for If this newsletter has reached you in facility’s doorstep for a surgical pro- a background count of 900—1000 cpm error, please notify the Editor by phone, cedure. The procedure creates medi- and to alarm at 1200 cpm. fax, or e-mail. If you wish to be placed cal waste contaminated with the ra- It is possible to identify a radioac- on our quarterly mailing list, please con- tact the Editor. For past issues and an dioactive isotope from the first, off- tive isotope either using a multi-channel index of articles, check our website at site procedure. The patient is under no analyzer (which can cost $5,000 to http://www.hospitalwastemgmt.com. legal obligation to tell the surgeon and $6,000 or more) or by monitoring the This newsletter is may not be aware that their bodies half-life decay of the offending waste. copyrighted by Alan still contain the radioactive materials. The most commonly-found isotope in B. Jones. Reprints are The administering physician must medical waste tubs is technetium encouraged with ac- only counsel the patient to warn an- (99mTc), which has a half-life of 6-hours knowledgement to other physician if the total effective and typically decays to background Alan B. Jones, Ph.D. dose equivalent (TEDE) to anyone within two days. The next most com- Please send any letters else is likely to exceed 100 millirem. monly-found isotope is probably iodi- or comments to: This is only likely when a patient is ne131 (131I), which has a half-life of 8.06 Alan B. Jones, Editor undergoing therapeutic treatments. days and can take about 2 months or Hospital Waste Almost all diagnostic procedures in- more to decay to background. Finally, 17629 N.E. 138th Street volving radioactivity would not result another commonly-found longer-lived Redmond, WA 98052-1226 in someone receiving a 100 millirem isotope is thallium201 (201Tl), which has Ph: (425) 883-0405 Fax: (425) 895-0067 dose from the patient. a 73-hour half-life and decays to back- E-mail: [email protected] Incredible as it may seem, your ground in approximately 3-4 weeks. http://www.hospitalwastemgmt.com facility’s surgeons may be creating Technetium 99m is seldom a lingering radioactive medical waste and not problem because by the time the waste Our Editorial Policy even know they’re doing so. Unfortu- transport truck gets to Stericycle’s Mor- While every effort was made during the development of this newsletter to insure nately, your facility has little, if any, ton plant, the isotope has decayed to accuracy, we make no warranties or cer- recourse. You must retrieve the tub background. tifications. We encourage you to contact and hold it until it is decayed to back- The problem of returned medical the references listed in the articles or ground because the hospital is invaria- waste tubs is likely to get worse as Alan B. Jones for further information bly the default responsible party. Stericycle continues to discover “hot” about any topic mentioned in this news- To prevent this situation from tubs. letter. occurring some hospitals are now in- VOLUME 9, ISSUE 4 HOSPITAL WASTE PAGE 3 U.S. EPA De-Lists Medical the locations of all fire extinguish- Have All of Your ers in your facility, by floor? All Epinephrine Salt Solutions EOC Information At such information can be visible - but - with a mouse click. For those of Your Fingertips you familiar with AutoCad, ArcEx- Washington Ecology Un- ow valuable would it be for plorer’s themes act much like the likely to Agree with Feds H you to have all of your facil- layers in AutoCad. ity’s Environment of Care information To create the GIS database you PA Region I has issued a at your fingertips? Rather than present need the assistance of an expert in E memorandum de-listing medi- an EOC Joint Commission reviewer that field. A physical survey is cal epinephrine salt solutions as with hard copy printouts of your per- needed to enter your facility’s com- acutely (waste code: mits, floor plans and information on ponents into the database using P042). In a very complicated and tech- your facility’s vents and stacks, fire ArcGIS Server. The GIS database nical ruling, EPA has determined that control areas and doors, eyewash sta- is created with the ArcGIS Server, because medical epinephrine solutions tions and emergency showers, potable, an engineering database program. use salt derivatives of the chemical and storm and sanitary water lines, USTs Anything that physically exists these salt derivatives weren’t specifi- and ASTs, you have the option now of at your facility or is on paper can cally listed by Congress, they should presenting it all electronically and be added to your facility’s GIS da- not designate as P042 wastes. graphically in a single program. tabase. Paper components – per- Epinephrine is commonly used in EOC Standard EC.3 suggests that mits, floorplans, drawings – can be vascular surgery procedures in the an organization-wide Information Col- scanned into the file as additional form of epi pens and IV infusions. lection and Evaluation System (ICES) themes. The resulting file is a This ruling follows on the heels of is developed and used to evaluate con- snapshot in time of your facility’s Colorado Department of Public Health ditions in the environment of care. components. & Environment’s August 2006 ruling Other standards call for systems to For more information on Ar- of the same. Other states and regions properly manage your facility’s main- cExplorer and conducting a survey have petitioned EPA to clarify their tenance and life safety components. to build a GIS database for your position, resulting in EPA Region I’s ArcExplorer is a lightweight GIS facility, contact Marie Rangel Men- memorandum. data viewer written in Java that is used des, Project Engineer, with P.W. However, in the autumn of 2006 to perform basic GIS functions (e.g., Grosser Consulting at 206.706. Washington’s Department of Ecology view, navigate, and query). It is a free, 5533 or by e-mail at reviewed the CDPHE’s arguments on downloadable application that operates [email protected]. epinephrine salt solutions and infor- in a stand-alone environment and does mally rejected those arguments. For not need to connect to a server. ArcEx- Homeland Security: A the time being, Ecology is unlikely to plorer is heavily used in the education accept the EPA’s arguments as any world and runs on both Windows and National Strategy for more persuasive than the CDPHE’s. Apple Macintosh computers. Public Health and Medi- States may not develop or adopt stan- When ArcExplorer is used to view dards less stringent than federal stan- a Geographic Information System cal Preparedness dards, but they are free to adopt more (GIS) database file, it shows an aerial resident Bush issued stringent standards. view of your facility with overlays of P Homeland Security Presi- Ecology was particularly disap- all the EOC elements above (and many dential Directive/HSPD-21 on Oc- pointed that EPA didn’t address epi- more, if you wish). You begin with an tober 18, 2007 to establish a na- nephrine’s environmental hazards. aerial/satellite photo of your facility, tional healthcare strategy for disas- This situation is analogous to Ecol- then activate a theme (any element of ter preparedness. This Strategy ogy’s refusal to de-list waste medical your facility; for example, vent stacks, draws key principles from the Na- nitroglycerine (waste code P081) as fire extinguishers, USTs, potable water tional Strategy for Homeland Se- acutely hazardous waste. Medical ni- lines, etc) with a mouse click that you curity (October 2007), the National troglycerine was de-listed by the fed- or the Joint Commission reviewer wish Strategy to Combat Weapons of eral government several years ago and to see. Mass Destruction (December Washington remains one of the few— Want to see the permit for a UST? 2002), and Biodefense for the 21st if not the only—state to regard medical Want to know when that stormwater Century (April 2004) that can be nitroglycerin solutions as P081 acutely line was last inspected? Want to see hazardous waste. (Continued on page 4) Hospital Waste

Alan B. Jones, Ph.D. Hospital Waste Management 17629 N.E. 138th Street Redmond, WA 98052-1226 Phone: 425-883-0405 Fax: 425-895-0067 E-mail: [email protected] TO: http://www.hospitalwastemgmt.com

“Helping Hospitals Manage Waste”

(Continued from page 3) health to provide early warning and ongoing characterization generally applied to public health and medical prepar- of disease outbreaks in near real-time. edness. Those key principles are the following: (1) Countermeasure Stockpiling and Distribution: Recog- preparedness for all potential catastrophic health nizing that State and local government authorities have the events; (2) vertical and horizontal coordination across primary responsibility to protect their citizens, the Secretary levels of government, jurisdictions, and disciplines; of Health and Human Services, shall develop templates, us- (3) a regional approach to health preparedness; (4) ing a variety of tools and including private sector resources engagement of the private sector, academia, and other when necessary, that provide minimum operational plans to nongovernmental entities in preparedness and re- enable communities to distribute and dispense countermea- sponse efforts; and (5) the important roles of indi- sures to their populations within 48 hours. viduals, families, and communities. Mass Casualty Care: The structure and operating princi- In particular, “The assumption that conventional ples of our day-to-day public health and medical systems public health and medical systems can function effec- cannot meet the needs created by a catastrophic health tively in catastrophic health events has, however, event. Collectively, our Nation must develop a disaster proved to be incorrect in real-world situations.” medical capability that can immediately re-orient and coordi- The four most critical components of public nate existing resources within all sectors to satisfy the needs health and medical preparedness are biosurveillance, of the population during a catastrophic health event. countermeasure distribution, mass casualty care, The impact of the “worried well” in past disasters is well and community resilience. Although those capabili- documented, and mitigating the mental health consequences ties do not address all public health and medical pre- of disasters can facilitate effective response. paredness requirements, they currently hold the great- Community Resilience: Where local civic leaders, citi- est potential for mitigating illness and death and zens, and families are educated and are empowered to miti- therefore will receive the highest priority in our pub- gate their own risk, where they are practiced in responding to lic health and medical preparedness efforts. events, where they have social networks, and where they Biosurveillance: The Secretary of Health and have familiarity with local public health and medical sys- Human Services shall establish an operational na- tems, there will be community resilience that will signifi- tional epidemiologic surveillance system for human cantly attenuate the requirement for additional assistance.