Demystifying Mercury as the Gold Standard in Healthcare Teresa Tice, Park Nicollet Health Services ticetj@parknicollet.com and Jamie Harvie, Institute for a Sustainable Future harvie@isfusa.org

Objectives Provide resources to address the barriers to mercury elimination Address the typical hold out areas and provide practical solutions to how they are tackled Identify the low hanging fruit in laboratories

Mercury – Low Hanging Fruit Mercury is defined by EPA as a Persistent Bioaccumulative Toxin Health Care Industry a Major Consumer of Mercury and Mercuric Compounds High Priority Pollutant Released to water and atmosphere Fish Advisories

Barriers to Eliminating Mercury Equipment or Chemicals Belief Barriers and Resistance to Change Lack of awareness among employees Availability and credibility of alternatives Purchasing/Costs Cost of purchasing replacement products Budgeting process Coordination – Lots of People Involved Lack of Information (e.g. lab chemicals)

Belief Barriers Mercury: The “Gold” Standard Contain 80 -100g / unit Journal of Human Hypertension Study of 444 Hg units..”the majority… had serious problems which would give rise to major errors in bp measurement Examples of both inaccurate mercury and aneroid may be found in the literature – related to poor maintenance.

Belief Barriers – Alternatives Mercury-free Sphygmomanometers Aneroid most common as replacement Comparable in cost to mercury All must meet same voluntary AAMI testing requirements Mayo Clinic program reported aneroids provide accurate measurements when properly maintained. AHA recommends both mercury and aneroid be checked regularly

Purchasing/Costs Justifying Costs Purchasing replacement equip. costs $$ Kaiser study showed life cycle costs of aneroid 1/3 those of mercury Budgeting – Operational cost Spills Mayo Medical in two year time frame had 50 spills costing 26k Hartford Hospital in 1998 - 60k cleanup costs. JCAHO issuing recommendations on lack of Hg clean up training.

Coordination Replacing Hg Equipment Impacts wide range of staff Purchasing, Maintenance, BioMed, Employee Health, Physicians, Nurses Purchasing Dept. Role Bulk ordering for best price Contact other hospitals about vendor quality Trial product Will vendor manage old mercury units

3 Keys to Overcome Barriers A PLAN SUPPORT Upper Management Support Essential Champions EDUCATION Managers Support Areas (Maintenance, Biomed, Safety and Security, Employee Health) Employees

Challenges Pt. Isolation Rooms: Mercury thermometers Alternatives Disposable:Temp-a-dot Re-Usable: assign to room NICU: Mercury Thermometers and Sphygmomanometers Most susceptible population to Hg exposure Thermoregulation very important Reference: Accurate Measurement of Body Temperature in Neonate http://www.neonatal-nursing.co.uk/pdf/sep00bdi.pdf NICU - Neonatal Intensive Care Units Since they are the most susceptible population to even minute quantities of mercury, it was clear that the NICU was the first place to eliminate mercury."

Removing Hg from Hospital Laboratories Step 1. Examine Chemicals and Reagents Hg is common in Fixatives (B5) Hg is common contaminant (e.g. reagents w/ potassium) Hg used in preservatives (thimerosol) Hg found in secondary antibodies bound to HPR, ELISA kits, Western blot kits Step 2. Require Vendors to Disclose Hazardous Materials in Reagents MSDS generally do not identify Hg levels (<1%) Step 3. Eliminate Hg Containing Devices Barometers, Thermometers Reference: http://www.sustainablehospitals.org/HTMLSrc/IP_mercury_removelabs.html

B5/Zenkers Elimination

Mercury Filter Wastes

Used B5 Management Some Histopathology texts recommend precipitation of B5 to “remove” mercury. Precipitated B5 supernatant may contain 25 ppm of mercury. one liter discharge in 20,000 gal (75,000 l) flow will exceed a pretreatment limit of 0.300 ppb. All B5 should be sent to a mercury refiner.

Alternative to Mercury Fixatives Formalin Zn Formalin Anatech 1-800-ANATECH IBF Surgipath 1-800-225-3035 St Mary’s Duluth Clinic -218-726-4000

Summary Mercury is pervasive in healthcare facilities. Mercury devices often leak or break. Mercury containing chemicals have been disposed of down the drain in the past. Barriers can be overcome with perseverance and education Most mercury-containing items are identifiable and have cost effective alternatives

Resources HCWH – Web Site Sustainable Hospitals – Web Site Shygmo resources, Histopathology www.noharm.org Sustainable Hospitals – Web Site Comparing mercury and aneroid Sphygmo’s http://www.sustainablehospitals.org/HTMLSrc/IP_Merc_Tools_CompSphyg.html Removing Mercury from Laboratories http://www.sustainablehospitals.org/HTMLSrc/IP_mercury_removelabs.html Is there Mercury in your Coulter Counter http://www.sustainablehospitals.org/HTMLSrc/IP_Merc_Coulter.html H2E Website http://www.h2e-online.org/tools/mercury.htm