Hospital Assessment Tool

(HAT 1.0)

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

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

Input Required

Input

Storage Waste Training

Types of wastes

Non-toxic Alternatives

Departments where training

is required

Waste Storage Areas

Waste carrying

containers

Labeling

Waste management

Systems

Employee Training

Acts Equipment Mercury TreatmentRed

Bag Waste

Inspection ofWaste

Purchasing Policies

Accreditation of Hospital

Type of Equipment

Functions

Maintenance

Mercury Audit

Disposal

Replacement ofInstruments

Various treatment

technologies

Recycling Techniques

DisposalMethods

Amount of waste

MSDS

PackagingTechniques

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

Home Page of the Tool

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?

Screenshot of Questions under Storage Section

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?

Screenshot of Questions under Waste Section

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?

Screenshot of Questions under Training Section

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

Screenshot of Questions under Acts Section

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

Screenshot of Questions under Equipment Section

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?

Screenshot of Questions under Mercury Section

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?

Screenshot of Questions under Treatment Section

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?

Screenshot of Questions under Red Bag Waste Section

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

• NOTE: ” Development of a Pollution Prevention Tool for the Assessment of Hospital Waste Management Systems” to be published in Environmental Progress

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

Category Sectional Percentage Required Overall Score (Tool) Required

Excellent 80% 175-218

Good 70-80% 150-175

Poor 60-70% 125-150

Very Poor < 60% < 125

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

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)

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

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

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

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

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

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

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

SectionScore Maximum Score Category

Storage 17 19 Excellent

Waste 25 46 Very Poor

Training 42 59 Poor

Acts 8 14 Very Poor

Equipment 14 22 Poor

Mercury 10 12 Excellent

Treatment 30 34 Excellent

Red bag waste 12 12 Excellent

Total 158 218 Good

ResultsThe final score obtained from the HAT 1.0 is 158 which implies that the hospitalfalls 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

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

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