1. “Mercury Reduction: Practical Experiences from Healthcare” Presenters: St. Joseph Mercy Health System, Michigan - Pierre Gonyon, Safety Department Park Nicollet Health Services, Minnesota - Teresa Tice, Safety Manager PG

2. Why Mercury? Mercury is defined by EPA as a Persistent Bioaccumulative Toxin –Never degrades in the environment –Accumulates in living tissue, is not metabolized and excreted from the body –Toxic effects, including brain, nervous system, and kidney damage –Pregnant woman at high risk TJT

3. Why Mercury? Health Care Industry a Major Consumer of Mercury and Mercuric Compounds –Patient Care Equipment –Lab Fixatives and other Chemicals and Compounds –Plant Operations High Priority Pollutant Targeted by United States and Canada Fish Consumption Advisories –States have issued over 1600 Fish Consumption Advisories. Great Lakes at risk. PG

4. Biggest Environmental Risks Mercury devices improperly disposed of in red bags or in sharps containers. Mercury spills caused by leaking, broken, or misused devices can lead to exposure and environmental contamination. Mercury in chemicals may be released to sanitary sewer system. TJT

5. 6 Steps to a Successful Mercury Reduction Process 1. Obtain support to investigate 2. Assessment - What do you have and where? 3. Identify Alternative Products – Evaluate and perform cost analysis 4. Develop Mercury Management Policy and Phase Out Plan 5. Educate and Communicate 6. Implementation TJT

6. Step 1. Obtaining Support to Investigate Develop Resolution or Position Paper –Endorsement of Safety Committee –Present to Administration –Sign Off by Administration and Medical Staff leadership Champions –Find others who believe in the proposal. n Doctors n Nurses PG

7. Step 2. Assessment Mercury-Containing Devices/Equipment Sphygmomanometers Thermometers Esophageal Dilators (Bougies) Gastrointestinal Tubes Button Batteries Thermostats and switches Fluorescent lights Steam recorders Barometers TJT

8. Mercury-Containing Chemicals Products Containing Thimerosal Preservative Lab Test Reagents, Histology Stains –B5 Fixatives Cleaners and Degreasers Diuretics Vaccines, Ophthalmic Solutions, Nasal Sprays PG

9. Difficulty in Assessing Mercury Content in Chemicals Mercury concentrations <1% of the total chemical solution not reported –Certificate of Analysis or Heavy Metal Analysis –Product Inserts –Letters to Vendors –Technical Support –MASCO http://www.masco.org/mercury TJT

10. Performing the Assessment Target areas where used –Patient Care, Laboratory, Pharmacy, Engineering/ Maintenance Other sources –Off Site Satellite Facilities –Owned Physician Practices –Leased Spaces –Owned building Leased to Others PG

11. Assessment Method Surveys - Advantages and Disadvantages Site Visit – Physical Counts Preprinted lists TJT

12. Step 3. Identify Alternative Products Literature or internet search Purchasing Department plays a key role! –Current vendor contracts –Preferred vendors –Volume Discounts (Bulk order) –Put block on ordering of Mercury items Set up vendor demonstrations –Ask about vendor equipment take back programs Evaluate products (Clinical input important) Identify advantages and disadvantages to mercury-free products PG

13. Justifying the cost How much are you spending on: –Spill response and training –Calibration or repair of equipment –Recycling costs How much will mercury-free alternatives cost? What is the overall cost or savings to the organization? TJT

14. Cost Analysis: Sphygmomanometers BAUMANOMETER Basic Cost of Product $101 Calibration Costs: $3-10 Hazardous Waste Training: $130/(4 staff) Hazardous Spill Cleanup: $128-700 Storage/Handling/Disposal: $185 Human Health Risks: (difficult to quantify-- exposure cost/liability/law suit) Compliance Costs: (difficult to quanify-- liability costs due to mismanagement, insurance ) Environmental Cost: $461-646 ( scrubbing incinerator ) TOTAL: $1,008-1,772 ANEROID PRODUCT Basic Cost of Product: $90 Calibration Costs: none Cost of Training for Use: $20/(4 staff) TOTAL: $110 ELECTRONIC PRODUCT Basic Cost of Product:$1,200-3,000 Calibration Costs:none Cost of Training:$80/(4 staff) TOTAL:$1,280-3,080 TJT

15. Step 4. Develop Policy and Phase Out Plan Organizational Resolution to Eliminate Mercury –Hazardous Materials and Waste Policy –Vs. Written Mercury Management Policy n Exposure control plan n First Aid/Medical treatment n Mercury spill control procedures n Recycling of mercury and contaminated waste –Designate mercury reduction as your organizational PI project under JCAHO Environment of Care requirements PG

16. Organizational Resolution to Eliminate Mercury –Mercury Free Pledge  Healthcare Without Harm, MHA –Purchasing Controls  Eliminate the purchase of any new mercury containing products or devices  Product Selection or Value Analysis Committee  Environmentally Preferred Purchasing Policy –Immediately discontinue sending thermometers home with new mothers! –Mercury-Elimination Enforcement in Leasing Arrangements PG

17. Develop Phase-Out Plan Phase-out immediately (high risk of breakage, sewered chemicals) –Sphygmomanometers, Thermometers Phase out with breakage, expiration, or renovation –Thermostats, switches, Maloney Bougies –Replace Physical Plant devices with non mercury devices as they go out of service Building Demolition Checklist –Switches –Plumbing Traps TJT

18. Secure Support Secure upper management support Secure dollars –Funded Project vs Expensed to Departments –Some States Free Disposal Options (Grant Projects) –Phased Process vs all at once (Pros and cons) Secure commitment of support staff (purchasing, facilities, engineering, biomed, etc) PG

19. Step 5. Education and Communication Communicate plan across organization Then target to audience and the phase of project –Management Groups –Local safety committees or reps –Physicians and Employees Periodic Communications TJT

20. Barriers Belief barriers and resistance to change Lack of awareness among employees Availability and credibility of alternatives Coordination - Lots of people involved Cost - New products Proper budgeting by departments PG

21. Step 6. Implementation Equipment Phase-out –Order product  Confirm type and number  Complete purchase order  Obtain signature of dept manager  Send to purchasing, order placed –Upon receipt of product, coordinate change-out with Maintenance/Biomed and the affected department TJT

22. Equipment Phase-out –Arrange for training on new product with vendor –Perform change-out or installation –Package old unit for recycling.  Note: Some manufacturers are offering free disposal of old devices with purchase.  Some counties provide free drop off locations for old devices (MDEQ) TJT

23. Chemical Phase-out Minimize chemical inventory Evaluate alternative substances Lab - Sample drain traps and investigate concentrations above 0.4 ppm Find alternative ways to dispose of waste instead of sewering Make thimerosol-free pharmaceuticals available PG

24. Waste Management Waste Management Considerations –Florescent Tubes –Batteries –Manage for Recycling and Mercury Recovery  Recovery vs. Treatment and Disposal PG

25. Healthcare as Sustainable Community Leader Sponsor Community Thermometer Exchange –Partner with county agencies Work in Partnership With GPOs and Suppliers to: –Reduce Wasteful Packaging –Use Easy to Recycle Materials –Market Less Hazardous Alternatives –Demand Recycle Content In Health Care Products to Build Strong Market TJT

26. Conclusion Embrace and Promote the Concept of “Healthy Communities” “The health and well-being of the people and communities we serve, is fundamentally connected to the health and vitality of the environment and natural world we all share” PG

27. Resources Hospitals for a Healthy Environment http://www.h2e-online.org/mercury.asp MnTAP http://www.mntap.umn.edu/ Healthcare without Harm http://www.noharm.org/hcwh/issues/mercury.html EPA http://www.epa.gov/mercury/index.html http://www.epa.gov/mercury/index.html MASCO http://www.masco.org/mercury