Hospitals see medical waste disposal as a Goliath attacking any efforts they make toward containing costs.
Conflicting federal and state infectious waste requirements have led to more redbagging, while at the same time stricter emission control standards are forcing hospitals to shut down cost-effective incinerators. The combined problems are driving hospitals into the arms of higher-cost waste disposal companies.
"We felt infection control was overapplying universal precautions (treating all patients as if they had an infectious disease)," said John Chavis, administrative director of environmental services, Kettering (Ohio) Medical Center. "They required site collection of all waste in patient rooms and we found that red bags were being used for things other than infectious waste, such as pizza boxes and soda cans."
The two-hospital, 634-bed facility now separates its waste streams and regulates what is red-bagged at a yearly cost of $25,000 for additional labor, Chavis said.
Kettering renewed its contract with WMI Medical Services, a division of Oak Brook, Ill.-based Waste Management Inc., to haul infectious waste at 28 cents per pound to be incinerated. The two-year contract was signed in June.
The facility generates 26,785 pounds of infectious waste each month and is spending about $90,000 a year to have WMI pick it up three times a week. WMI also furnishes a a 28-foot refrigerated trailer where infectious waste is stored until picked up.
Under the previous contract with WMI, waste was hauled for 27 cents a pound. Kettering's 1990 budget for infectious waste disposal was $192,000 after generating more than 711,000 pounds of infectious waste.
Carefully managing red-bagged waste has enabled Kettering to cut its infectious waste disposal budget in half. The facility projects a 1992 budget of $84,000 for an estimated 300,000 pounds of red-bagged waste.
"We are looking at alternative technologies, but Ohio only allows for autoclaving and incineration of infectious waste," Chavis said. Kettering also incinerates general waste. It owns a compacting unit that serves both facilities. Kettering trucks deliver general waste to the county incinerator three times a week. The facility pays 1.5 cents a pound to incinerate general waste. It generates 260,000 pounds a month for a total annual cost of $46,800.
The 964-bed Charleston (W. Va.) Area Medical Center operates an incinerator on each of its three campuses, the newest being 10 years old. The state legislature passed a law regulating medical waste and focusing primarily on waste reduction last January, but it isn't effective until early 1992, according to Lillian Morris, director of safety and education. Most, if not all, hospitals in the state are already complying with the regulations, she said.
Charleston Area Medical Center currently is working on a plan to segregate and ultimately reduce its waste stream. "We found that when we adopted universal precautions here, everyone began using red bags for everything, including pizza boxes and polystyrene cups," she said.
The facility generates about 380,000 pounds of waste each month, 57,300 pounds of which is handled as infectious and incinerated for 20 cents a pound.
When the Environmental Protection Agency comes out with its regulations in February, however, the facility will be faced with yet another dilemma. About 48 hospitals, or 60% of hospitals in the state, now operate incinerators. Morris says few, if any, will meet the EPA's new requirements. Consequently, CAMC has three choices: upgrade current incinerators, construct a single new incinerator serving all three campuses, or turn to a more costly waste management company.
"We looked at building a new incinerator, but that probably won't happen because we would have to go through too many public hearings and too long a permitting process," she said.
Upgrading existing incinerators would cost CAMC $2.2 million, mostly for volume-measurement and temperature controls and scrubbers. Contracting with a firm to haul waste away will cost an estimated 28 to 33 cents a pound, or at least $1.3 million a year. This would be almost three times as much as the hospital now spends to incinerate its own waste, just for hauling. Incineration costs would boost total waste costs even higher.
"We are looking at alternative technologies, (autoclaving or steam sterilization) but we are waiting for when the EPA and state regs come out before we start making any decisions," she said.
A major metropolitan hospital on the East Coast renewed a three-year contract with WMI in June to have its infectious waste hauled away for incineration elsewhere in the state. "We were having it hauled to two commercial incinerators in Ohio but we didn't like sending our waste out-of-state," the material manager said. "We felt that the longer the waste was on the road, the greater the risk of it spilling in a crash and we'd ultimately be responsible.
"We actually followed the trucks periodically to Ohio to make sure they went where they were supposed to go."
The 500-plus-bed facility generates about 6,200 pounds of red-bagged waste each day (that's almost 2.3 million pounds a year) and pays about 35 cents per pound to have it hauled away, or almost $800,000 a year.
"The biggest problem in dealing with medical waste today is that no one can decide what is infectious and what isn't," he said. "Precise definitions vary hospital by hospital, state by state. The guy that ultimately decides is Bubba at the landfill. He won't dump it."
With conflicting definitions comes more red-bagging.
"I've never heard of an infectious pizza box," he said. "And in our waste stream, we found two million polystyrene cups. That's 78 per patient. If you get people to comply with your waste rules, you can reduce your costs by 50%," this manager insists.
"When Rock Hudson was declared HIV-positive, that's when all this hit the fan. Now with Magic Johnson, we'll see another wave" of non-infectious waste being treated by staff as if it were infectious.
The 417-bed St. Vincent Hospital, Green Bay, Wis., shut down its incinerator last fall and joined two other hospitals in the area in signing a 10-year contract with WMI to have infectious waste hauled away, according to Don Geraghty, director of materials management.
The hospital pays 44 cents per pound have infectious waste hauled away, plus an $80-a-pound tipping fee per pickup. WMI picks up waste three times a week and supplies boxes, liners and tape. St. Vincent generates about 300,000 pounds of infectious waste a year, for which it pays nearly $145,000 to dispose. The hospital was paying 5.5 cents per pound to incinerate on site.
The hospital knew its incinerator required an overhaul to comply with new emission standards. Specifically, it needed a scrubber system that would have cost $325,000, Geraghty said. "We didn't want to upgrade because of the expense and because we're located in the middle of an affluent neighborhood."
More planning needed
Generally, hospitals are in a quandary when faced with the arduous task of disposing of medical waste, especially when it comes to dealing with the forthcoming EPA regulations, an outgrowth of the two-year Waste Tracking Act, which ended in June.
"I see poor planning on what hospitals are going to do with infectious waste," said Jan Runkle, vice president of clinical resources, McFaul & Lyons Inc., a Trenton, N.J.-based consulting firm.
"They need to go to state agencies and understand current and potential legislation and they need to see what types of technologies are out there. Right now they're just sitting back and waiting. If they're waiting for the government to tell them what to do, then it will be a long wait, because the government will only tell them what they can't do."
Alternatives to the two approved methods of incineration and autoclaving (steam sterilization) include chemical disinfection (hydrogen peroxide), chemical waste encapsulation, electron beam irradiation sterilization, electropyrolysis, gas-vapor sterilization (ethylene oxide), laser treatment, mechanical-chemical disinfection, microwave disinfection, plasma pyrolosis and thermal inactivation (dry-heat sterilization). All require shredders to render the waste unrecognizable. (See "Waste disposal alternatives" page 14.)
Robert Spurgin, president, Spurgin & Associates, an environmental consulting firm in Irvine, Calif., sees a continuing trend away from onsite incineration in favor of offsite disposal and alternative technologies.
"When I started in this business in the mid-1970s, it cost $20,000 for an incinerator," Spurgin said. "Today, it's $750,000 to $1 million." The higher cost is due largely to tougher emission control standards and the need for additional equipment.
Frank Mastroianni, senior loss control consultant for the New York-based insurance brokerage firm Johnson & Higgins, works with about 10 hospitals, many of which have their waste hauled off site, thinks incineration nonetheless is the method of choice.
"If a hospital can comply with state and federal regulations, handle the initial and operating costs and deal with NIMBY incineration is the most cost-effective way of disposal," Mastroianni said. "There is a lesser risk of exposure to workers in handling the waste." Mastroianni was director of safety at Memorial Sloan Kettering Cancer Center, New York, from 1983 to 1989.
Mastroianni suggests that to minimize waste disposal costs, a hospital should know the definition of infectious waste, identify waste streams, segregate infectious from general waste, train employees on handling and disposal of each type and use recyclables.
More than 456,000 tons of medical waste are generated each year, according to the National Solid Waste Management Assn. The EPA estimates 359,000 tons of that comes from hospitals.
Waste management services generated $1.06 billion in fees in 1990, nearly double the $527 million in fees in 1986, before universal precautions, according to Frost & Sullivan Inc., New York. Sales of infectious waste management products such as containers, disinfectors and incincerators were $371.7 million in 1990, up from $252.1 million in 1986.
One hospital bucking the trend of going with a hauler is Beloit (Wis.) Memorial Hospital, which is planning to upgrade its 21-year-old incinerator by April 1992, according to Greg Scalise, director of material management.
The 174-bed facility is requesting bids this month. The hospital already spent $50,000 in consulting fees and estimates the upgrade will cost at least $250,000, plus another $250,000 because the incinerator is being moved up one floor to the boiler room. A grant from the state is expected to cover some costs, Scalise said.
The upgrade will include scrubbers, more burn chambers, a conveyor belt and emission control devices. Beloit Memorial also will have to do ash testing.
Beloit Memorial generates 164,000 pounds of infectious waste each year, accounting for 20% of total waste. Beloit spends an average of nine cents a pound to incinerate, which will increase to an estimated 14 cents, still cheaper than paying 28 cents a pound for hauling to be incinerated.
The incinerator now burns about four bags an hour, three hours a day, six days a week; the new one will burn more productively at two 50-pound boxes every six minutes and operate six hours a day, six days a week, he said.
"During the next six months to a year, there's going to be a lot of hospitals in Wisconsin that will have to make some very hard decisions," he said. "They will either have to shut down incinerators, replace them or contract out.
"If you shut down your incinerator, however, it will be very hard to get a permit to build another and that leaves you at the mercy of the disposal companies."
