1. Hospital Assessment Tool (HAT 1.0)

2. Objectives  The purpose of the project is to create a pollution prevention tool for the assessment of a hospital  This tool categorizes the hospitals based on the wastes produced, treatment methods used and suggests suitable remedial measures to be adopted by the hospitals to reduce the harmful effects of the wastes  It awards an index to the hospitals which helps in understanding the different avenues for improvement  It provides cleaner alternatives and also easily compares the sustainability of one hospital with other

3. Methodology  A comprehensive literature review on the types of pollutants produced, types of treatment methods adopted, types of recycling techniques used and on the facilities of the hospitals is done  Evaluation is done on various existing tools, which inferred that those tools just gave scores to the hospitals based on the amount of pollution produced  This formed the validation in the creation of a sophisticated tool which not only grades the hospital but also suggests necessary remedial measures to be undertaken by the hospitals  A questionnaire is prepared and based on that the pollution prevention tool is built

4. Input Required Input Storage Waste Storage Areas Waste carrying containers Labeling Inspection of Waste MSDS Waste Types of wastes Non-toxic Alternatives Training Departments where training is required Waste management Systems Employee Training Acts Purchasing Policies Accreditation of Hospital Equipment Type of Equipment Maintenance Functions Mercury Audit Replacement of Instruments Disposal Treatment Various treatment technologies Recycling Techniques Red Bag Waste Disposal Methods Amount of waste Packaging Techniques

5. Tool Development  A pollution prevention tool has been created which gives a performance index to the hospital and also provides suggestions on how to overcome the problem of waste  The tool consists of eight sections namely storage, wastes, training, acts, equipment, mercury, treatment and red bag waste  Each section has a set of questions and for each question a score of either “1” or “0” is awarded  Total scores in each section are tabulated and the sectional performances are evaluated

6. Home Page of the Tool

7. Questions on Storage I.Separate waste storage areas:  Are all wastes stored in separate storage areas?  Are the waste storage areas clearly identified? II.Waste carrying containers  Are all the waste carrying containers kept closed except filling waste?  Are all waste containers in good condition? III.Labeling of wastes  Are wastes stored in labeled containers?  The date on the container stored in storage IV.Inspection of wastes  Is the area inspected weekly for signs of spills or container deterioration?  Are these inspections documented? V.Material Safety Data Sheets  Are MSDS maintained and made readily available to all employees?

8. Screenshot of Questions under Storage Section

9. Questions on Waste I.Types of waste  What are the types of wastes produced by the hospital?  Does your hospital handle universal waste separately from other hazardous waste? II.Non-toxic alternatives  Does your hospital use non-toxic or less toxic alternatives for janitorial chemicals?  Have you evaluated the alternatives for Ethylene Oxide? III.Handling of waste  Are biohazardous wastes protected from contact with water, precipitation, wind, or animals?  Do you know what persistent, bioaccumulative toxics are and what the connection is to healthcare?

10. Screenshot of Questions under Waste Section

11. Questions on Training I.Areas where hospital training is required  Green Purchasing?  Environmental Management Systems?  Solid Waste Recycling? II.Waste management system  Does your hospital follow a waste management plan and strictly follow the plan?  Doses your facility have a waste management policy that includes:  Hierarchy of waste management  Goals of waste management program  Handling and disposal procedures for all waste streams  Pollution prevention/ Source reduction III.Employee Training  Are all employees trained to identify infectious and hazardous materials and dispose of them according to safety and disposal regulations?  Does your staff know the procedures for handling and disposal of low level radioactive wastes?

12. Screenshot of Questions under Training Section

13. Questions on Acts I.Purchasing Policies  Green products  Energy star products  Mercury  Low VOC products  Less toxic materials II.Accreditation of Hospital  Joint Commission on Accreditation of Hospital Organization (JCAHO)  American Osteopathic Association  Community Health Accreditation Program

14. Screenshot of Questions under Acts Section

15. Questions on Equipment I.Type of equipment  Biphenyl containing electrical equipment  PCB containing equipment  Reusable or disposable instruments II.Maintenance of equipment  Repair time and cost of equipment  Functions of equipment

16. Screenshot of Questions under Equipment Section

17. Questions on Mercury I.Mercury Audit  Have you conducted a mercury audit of your hospital, including an inventory of all mercury devices/sources? II.Replacement of mercury containing instruments  Have you replaced mercury thermometers?  Have you replaced mercury blood pressure units?  Have you replaced lab chemicals using mercury? III.Disposal of mercury  Is the mercury disposed in accordance with state and federal law?  Do you still purchase any equipment containing mercury?

18. Screenshot of Questions under Mercury Section

19. Questions on Treatment I.Various treatment technologies  Heating/Ventilating upgrades  Air side cooling economizer cycle  Programmable thermostats  Energy efficient lighting upgrades  Lighting occupancy sensors II.Recycling techniques  Do you recycle batteries, fluorescent lamps, paints and mercury?  Do you capture and recycle silver and X-ray film from radiology?  Are you disposing of lead containing items in aprons and lead packaging?

20. Screenshot of Questions under Treatment Section

21. Questions on Red Bag Waste I.Disposal methods  How does the hospital dispose off the medical red bag waste?  Incineration (off site)  Autoclave (offsite)  Incineration (onsite)  Autoclave (off site) II.Amount of red bag waste  How much percentage of your hospitals waste is medical red bag waste? III.Packaging techniques  Is the red bag packaging leak resistant?  Is the red bag packaging impervious to moisture?  Is the packaging of sufficient strength to prevent tearing or bursting?

22. Screenshot of Questions under Red Bag Waste Section

23. HAT 1.0 Specifications To run HAT 1.0 Microsoft Excel is needed HAT 1.0 can be downloaded from http://p2tools.utoledo.edu/ppistools.htm http://p2tools.utoledo.edu/ppistools.htm NOTE: ” Development of a Pollution Prevention Tool for the Assessment of Hospital Waste Management Systems” to be published in Environmental Progress

24. Evaluation Method  The overall hospital evaluation score is obtained by adding sectional scores and the hospital is graded based on the total score  Cumulative score for 218 points is given at the end of the questionnaire SCORING METHOD FOR SECTIONAL AND OVERALL SCORE CategorySectional Percentage RequiredOverall Score (Tool) Required Excellent80%175-218 Good70-80%150-175 Poor60-70%125-150 Very Poor< 60%< 125

25. Suggestions for Storage Section  Wastes should be stored in separate waste storage areas  The storage areas must be clearly identified  The waste carrying containers must be kept close after filling the waste  It is advisable to have a secondary contaminant system in the waste storage area  Waste storage areas must be inspected every week for spills and container deterioration  The inspection must be documented  The storage tanks must be checked for leakages  The MSDS sheets must be maintained and made readily available to all employees

26. Suggestions for Waste Section  The Universal waste must be handled separately from other hazardous wastes  Non toxic or less toxic alternatives must be adopted for janitorial chemicals  The hospitals must evaluate the alternatives for Ethylene Oxide  The biohazardous wastes must be protected from contact with water, precipitation, wind or animals  The biohazardous wastes must be removed or refrigerated at 40C or less if odor becomes a problem  Using mop heads instead of disposable ones is advisable  Replace paper towels with air driers  Replace disposable admission kits with reusables in patient room  The trash closes and holding areas must be different for different floors  Different types of wastes should have different waste streams  Proper check has to be done for combined mixing of facility wastes or sewer disposal wastes  Alternatives must be evaluated for products containing Polyvinyl chloride(PVC) and Di 2-enthylhexyl phthalate(DEPH)

27. Suggestions for Training Section  Waste management training must be given to all the employees related to their job duties  Waste management plan must be strictly followed by the hospital  To identify better disposable system and services a comprehensive audit of various waste streams and products has to be done  Computerized tracking system would be helpful in identifying waste streams and assist in the waste seggregation program  A green team must be appointed for designing and implementing environmental programs  Environmental Preferable Purchasing policy must be adopted  Purchasing policies that encourage the opportunity to use reusable items must be adopted  There should be an education or training program on segregating, handling and minimizing regulated medical waste

28. Suggestions for Acts Section  The hospital must have a spill prevention control counter measure plan  The hospital should have National Pollutant Discharge Elimination System (NPDES) permit  The hospital must be accredited by the requirements of Joint Commission on Accreditation of Hospital Organization (JCAHO),  American Osteopathic Association and Community Health Accreditation Program  The hospital must have a written Spill prevention plan and the spill kits must be easily available and accessible

29. Suggestions for Equipment Section  The hospital must inspect PCB-containing equipment regularly for leaks and keep records of the inspections  The hospital should have central system in place for tracking and quantifying the amount of chemicals disposed of  Use of reusable medical instruments instead of disposable ones  The equipment must be repaired within 24hrs without emergency clause and/or additional costs

30. Suggestions for Mercury Section  Mercury Audit has to be conducted by the hospital  Replace mercury thermometers, mercury blood pressure units and chemicals using mercury  Dispose mercury in accordance with state and federal laws

31. Suggestions for Treatment Section  RMV hauler must be regularly audited  Comprehensive waste segregation plan has to be adopted by the hospital to ensure that the hazardous materials are not disposed of in regulated medical waste containers  Pathological wastes are to be segregated from general infectious wastes  The hospital must adopt the solid waste reduction policy  Use treatment technologies that do not produce persistent bioaccumulative toxins

32. Suggestions for Red Bag Waste Section  Red bag packaging must be leak resistant  Red bag packaging must be impervious to moisture  Red bag packaging should have sufficient strength to prevent tearing and bursting  Red bag packages must be sealed to prevent leakages during transport  Red bag packages must be puncture resistant for sharps

33. Application of Tool The HAT 1.0 was applied on a group of Connecticut hospitals This case study was obtained from “2003 Hospital Assessment Tool”, University of New Hampshire Final Score Card from Hospital Assessment Tool 1.0 Section ScoreMaximum ScoreCategory Storage1719Excellent Waste2546Very Poor Training4259Poor Acts814Very Poor Equipment1422Poor Mercury1012Excellent Treatment3034Excellent Red bag waste12 Excellent Total158218Good

34. Results The final score obtained from the HAT 1.0 is 158 which implies that the hospital falls under “good” category. The following are the assessment results of HAT 1.0 Waste management techniques need further attention More employee training is required Further work is needed to follow the laws related to hospital waste management Maintenance of hospital equipment needs special attention Hospital system is handling storage, mercury, treatment and red bag waste effectively

35. Conclusion The sectional score helps in the detailed assessment of the hospital The tool allows necessary changes in management practices related to each section to improve the overall quality of the hospital

36. Future Work  This tool will be applied on the University Medical Centre, University of Toledo for its validation.  The tool will be revised with more comprehensive suggestions to improve on waste management techniques