Background, Trends, Issues, and Opportunities In Healthcare
Backgrounds, Trends, Issues and Opportunities in Healthcare TR-107833-R1
Final Report, September 1999
EPRI Project Manager J. Bauch
EPRI • 3412 Hillview Avenue, Palo Alto, California 94304 • PO Box 10412, Palo Alto, California 94303 USA 800.313.3774 • 650.855.2121 •
[email protected] • www.epri.com
DISCLAIMER OF WARRANTIES AND LIMITATION OF LIABILITIES THIS PACKAGE WAS PREPARED BY THE ORGANIZATION(S) NAMED BELOW AS AN ACCOUNT OF WORK SPONSORED OR COSPONSORED BY THE ELECTRIC POWER RESEARCH INSTITUTE, INC. (EPRI). NEITHER EPRI, ANY MEMBER OF EPRI, ANY COSPONSOR, THE ORGANIZATION(S) NAMED BELOW, NOR ANY PERSON ACTING ON BEHALF OF ANY OF THEM: (A) MAKES ANY WARRANTY OR REPRESENTATION WHATSOEVER, EXPRESS OR IMPLIED, (I) WITH RESPECT TO THE USE OF ANY INFORMATION, APPARATUS, METHOD, PROCESS, OR SIMILAR ITEM DISCLOSED IN THIS PACKAGE, INCLUDING MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, OR (II) THAT SUCH USE DOES NOT INFRINGE ON OR INTERFERE WITH PRIVATELY OWNED RIGHTS, INCLUDING ANY PARTY'S INTELLECTUAL PROPERTY, OR (III) THAT THIS PACKAGE IS SUITABLE TO ANY PARTICULAR USER'S CIRCUMSTANCE; OR (B) ASSUMES RESPONSIBILITY FOR ANY DAMAGES OR OTHER LIABILITY WHATSOEVER (INCLUDING ANY CONSEQUENTIAL DAMAGES, EVEN IF EPRI OR ANY EPRI REPRESENTATIVE HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES) RESULTING FROM YOUR SELECTION OR USE OF THIS PACKAGE OR ANY INFORMATION, APPARATUS, METHOD, PROCESS, OR SIMILAR ITEM DISCLOSED IN THIS PACKAGE. ORGANIZATION(S) THAT PREPARED THIS PACKAGE EPRI Healthcare Initiative
ORDERING INFORMATION Requests for copies of this package should be directed to the EPRI Distribution Center, 207 Coggins Drive, P.O. Box 23205, Pleasant Hill, CA 94523, (800) 313-3774. Electric Power Research Institute and EPRI are registered service marks of the Electric Power Research Institute, Inc. EPRI. POWERING PROGRESS is a service mark of the Electric Power Research Institute, Inc. Copyright © 1999 Electric Power Research Institute, Inc. All rights reserved.
CITATIONS This report was prepared by EPRI Healthcare Initiative Revised from the original report by L. Friedman Principal Investigators for the original report (April 1997) J. Emmanual T. Chester The research for this report was sponsored by EPRI. The report is a corporate document that should be cited in the literature in the following manner: Backgrounds, Trends, Issues and Opportunities in Healthcare, EPRI, Palo Alto, CA, 1999. TR-107833-R1.
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REPORT SUMMARY The healthcare industry is undergoing more changes now than at any time during the past century. Electric utilities must be ready to address these changes by having up-todate knowledge about the healthcare sector. This report is an attempt to provide that information so that utility representatives are prepared to market services and technologies that meet the current needs of healthcare facilities and organizations. Background The healthcare industry is composed of a variety of public, private, and non-profit organizations. These organizations include healthcare facilities, such as hospitals, nursing homes, outpatient clinics, and doctor offices, and administrative organizations, such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations (IPAs). In addition, a few allied establishments, such as veterinarian clinics and mortuaries, share issues similar to those of healthcare facilities. Objective This report is intended to provide members of the EPRI Healthcare Initiative with general background information on the healthcare sector, including industry trends, strategic issues, and opportunities to market electrotechnologies and electric utility services. Approach This report is divided into seven chapters. Each chapter covers a specific area of concern for electric utility representatives. Chapters 1 and 2 of this document offer a general overview of the healthcare industry, including how the healthcare facilities market for electricity is affected by key players and forces. Chapter 3 is more focused on healthcare facilities—hospitals, nursing homes, and clinics. This section will examine their operation and structure as well as look at the organizations that own them. Chapter 4 concentrates on the regulatory agencies and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for healthcare facilities. Chapter 5 looks at overall energy use in the healthcare sector. v
Chapter 6 addresses selected technical issues for healthcare facilities and potential electrotechnology solutions. Finally, Chapter 7 offers strategies for marketing electricity services and technologies to healthcare providers. Results The report summarizes the major trends and issues faced by the healthcare industry today and forecasts other issues that may become important in the future. EPRI Perspective The EPRI Healthcare Initiative (HCI) is a collaborative effort with member utilities. Its purpose is to assist the healthcare industry to meet the ever-changing demands of the industry through education and the use of electrotechnology solutions that will reduce risk and liability, meet regulatory compliance demands, and ultimately provide the highest level of quality patient care. Key Words Healthcare Reform Hospitals Nursing Homes Healthcare Funding Healthcare Facilities Healthcare Statistics Regulatory Compliance Electricity Use
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CONTENTS
1
THE HEALTHCARE INDUSTRY SECTOR..................................................................... 1-1 Introduction ......................................................................................................................... 1-1 Statistical Information on the Industry.................................................................................. 1-2
2
THE U.S. HEALTHCARE SYSTEM ................................................................................ 2-1 The U.S. Healthcare System ............................................................................................... 2-1 Healthcare and the National Economy ............................................................................ 2-1 Healthcare Funding ......................................................................................................... 2-2 Major Players .................................................................................................................. 2-8 Background ................................................................................................................. 2-9 Payers ......................................................................................................................... 2-9 Providers ................................................................................................................... 2-11 The Role of Government ........................................................................................... 2-12 Catalysts for Change: Healthcare Reform and the Market ............................................. 2-13
3
HEALTHCARE FACILITIES ........................................................................................... 3-1 Hospitals ............................................................................................................................. 3-1 Classification of Hospitals................................................................................................ 3-1 Type ............................................................................................................................ 3-2 Control......................................................................................................................... 3-2 Size and Length of Stay .............................................................................................. 3-2 Private Hospitals ......................................................................................................... 3-4 For-Profit ................................................................................................................. 3-4 Catholic ................................................................................................................... 3-5 Secular and Other Religious Not-For-Profit.............................................................. 3-6 Public Hospitals........................................................................................................... 3-7 Federal Government................................................................................................ 3-7
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State and Local Government ................................................................................... 3-7 Utilization and Trends...................................................................................................... 3-7 Utilization..................................................................................................................... 3-8 For-Profit Systems....................................................................................................... 3-9 Other Networks ........................................................................................................... 3-9 Other Trends ............................................................................................................. 3-10 Services Offered............................................................................................................ 3-10 Organizational Structure................................................................................................ 3-12 Plant Engineering ...................................................................................................... 3-13 Administration............................................................................................................ 3-14 Safety and Environmental Services ........................................................................... 3-14 Medical Staff and Nursing Services ........................................................................... 3-15 Hospital Finances and Related Issues........................................................................... 3-15 Networks, Health Care Systems, Alliances.................................................................... 3-16 Nursing Homes ................................................................................................................. 3-17 Role in the Health Delivery System ............................................................................... 3-18 Structure of the Industry ................................................................................................ 3-19 Utilization and Trends.................................................................................................... 3-22 Subacute Care .......................................................................................................... 3-23 Medical and Dental Offices, Freestanding Clinics, and Other Healthcare Institutions ........ 3-25 Related, Non-Healthcare Institutions ................................................................................. 3-25 Role of Healthcare Payers in the Market ........................................................................... 3-26 Trade and Professional Organizations .............................................................................. 3-30 Trade Associations........................................................................................................ 3-31 Hospitals ................................................................................................................... 3-31 Nursing Homes.......................................................................................................... 3-34 Other Healthcare Trade Associations ........................................................................ 3-35 Other Trade Associations .......................................................................................... 3-36 Professional Groups ...................................................................................................... 3-37 Hospitals ................................................................................................................... 3-37 Nursing Homes.......................................................................................................... 3-40 Other Professional Groups ........................................................................................ 3-40 Resources and References (for Chapters 2 and 3)........................................................ 3-41
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REGULATIONS AND STANDARDS AFFECTING THE HEALTHCARE INDUSTRY ..... 4-1 Environmental Regulations, Licensing, and Accreditation ................................................... 4-1 U.S. Environmental Protection Agency ............................................................................ 4-3 Medical Waste Incineration and the EPA Rule............................................................. 4-3 CAAA Title V Applications – Pollutants from Boilers and Other Sources...................... 4-5 CAAA Title VI - Recovery of Refrigerants Requirements ............................................. 4-5 Resource Conservation and Recovery Act .................................................................. 4-6 Comprehensive Environmental Response, Compensation, and Liability Act................ 4-6 The Medical Waste Tracking Act ................................................................................. 4-6 Department of Transportation.......................................................................................... 4-8 HM-181 Regulations ................................................................................................ 4-8 Department of Labor........................................................................................................ 4-9 Occupational Safety and Health Administration ......................................................... 4-10 Permissible Exposure Limits.................................................................................. 4-10 Bloodborne Pathogen Rule.................................................................................... 4-11 Proposed Indoor Air Quality Standard ................................................................... 4-12 Guidelines on Workplace Violence in a Healthcare Setting.................................... 4-12 Department of Health and Human Services................................................................... 4-13 Substance Abuse and Mental Health Services Administration ............................... 4-13 Health Care Financing Administration.................................................................... 4-13 Public Health Service............................................................................................. 4-14 Centers for Disease Control and Prevention.............................................................. 4-14 Guidelines for Protecting the Safety and Health of Healthcare Workers................. 4-14 Guidelines for Prevention and Control of Nosocomial Infections ............................ 4-14 Guidelines and Recommendations for the Prevention and Control of Bloodborne Pathogens .......................................................................................... 4-15 Guidelines for Healthcare Workers Potentially Exposed to Tuberculosis ............... 4-17 Food and Drug Administration ................................................................................... 4-18 Center for Drug Evaluation and Research ............................................................. 4-18 Center for Biologics Evaluation and Research ....................................................... 4-18 Center for Veterinary Medicine .............................................................................. 4-18 Center for Devices and Radiological Health........................................................... 4-18 Health Resources and Services Administration ......................................................... 4-20 HRSA’s Bureau of Health Resources Development............................................... 4-21
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National Institutes of Health....................................................................................... 4-21 Nuclear Regulatory Commission ................................................................................... 4-21 Low-Level Radioactive Waste Policy Act and Amendments ...................................... 4-22 Other Federal Agencies and Regulations ...................................................................... 4-22 Department of Veterans Affairs.................................................................................. 4-22 Americans With Disabilities Act of 1990..................................................................... 4-22 Department of Energy Schools and Hospitals Program ............................................. 4-23 State Regulatory Agencies ............................................................................................ 4-24 Medical Waste Treatment Technology Efficacy Criteria ............................................. 4-24 Specific State Regulations on Medical Waste Treatment........................................... 4-25 County and Municipal Agencies .................................................................................... 4-26 Joint Commission on Accreditation of Healthcare Organizations ................................... 4-27 History ....................................................................................................................... 4-27 Scope of Accreditation Programs .............................................................................. 4-28 JCAHO Board and Staff............................................................................................. 4-29 The Accreditation Process in Brief............................................................................. 4-29 Types and Length of Accreditation ............................................................................ 4-30 Accreditation Standards............................................................................................. 4-31 National Fire Protection Association .............................................................................. 4-32 American Society of Heating, Refrigerating, and Air-Conditioning Engineers................. 4-34 ASHRAE 62............................................................................................................... 4-34 ASHRAE 90.1............................................................................................................ 4-35 American Institute of Architects ..................................................................................... 4-35 Guidelines for Design and Construction of Hospitals and Health Care Facilities........ 4-35 National Committee for Clinical Laboratory Standards................................................... 4-35 National Safety Council ................................................................................................. 4-36
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ENERGY USE IN THE HEALTHCARE INDUSTRY ........................................................ 5-1 Typical Energy Use and Energy Intensities for Healthcare Facilities ................................... 5-1 Typical Electrical Use for Healthcare Facilities .................................................................... 5-6 Typical Lighting Load Shape for Healthcare Facilities ......................................................... 5-7
6
PROCESSES AND OPPORTUNITIES IN HEALTHCARE FACILITIES.......................... 6-1 Primary Processes in Healthcare Facilities.......................................................................... 6-1 Facility Management ....................................................................................................... 6-2
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Occupational Safety and Environmental Services ........................................................... 6-2 Food Services ................................................................................................................. 6-3 Lodging Services............................................................................................................. 6-3 Administrative Services ................................................................................................... 6-3 Clinical Services .............................................................................................................. 6-3 Identifying Issues and Opportunities.................................................................................... 6-3 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Management............................................................................................... 6-7 Profile of the Medical Waste Stream in Healthcare Facilities ....................................... 6-7 Municipal Solid Waste ................................................................................................. 6-7 Infectious Waste.......................................................................................................... 6-8 Hazardous Waste ...................................................................................................... 6-10 Radioactive Waste..................................................................................................... 6-12 Issues and Opportunities in Occupational Safety and Environmental Services: Waste Minimization for Healthcare Facilities ................................................................. 6-13 Recommended Waste Minimization Options ............................................................. 6-13 Issues Regarding Waste Minimization ....................................................................... 6-18 Resources and References ....................................................................................... 6-18 Other Resources: ...................................................................................................... 6-20 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Waste Treatment ................................................................................................. 6-21 The Problem of Medical Waste...................................................................................... 6-21 Alternative Treatment Technologies For Medical Waste................................................ 6-22 Broad Categories of Treatment Processes ................................................................ 6-22 Low Heat Thermal Processes................................................................................ 6-23 High Heat Thermal Processes ............................................................................... 6-24 Irradiation .............................................................................................................. 6-25 Chemical Processes .............................................................................................. 6-25 Biological Processes.............................................................................................. 6-26 Mechanical Processes........................................................................................... 6-26 Comparisons of Selected Treatment Technologies ........................................................... 6-28 Economic Evaluation Using MATES.............................................................................. 6-30 Resources and References ........................................................................................... 6-31 Issues and Opportunities in Occupational Safety and Environmental Services: Medical Device Sterilization .............................................................................................. 6-33
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Alternative Technologies for Medical Device Sterilization .............................................. 6-35 Hydrogen Peroxide Plasma Sterilization.................................................................... 6-35 Mixed Chemical Plasma Sterilization ......................................................................... 6-36 Peracetic Acid Sterile Processing .............................................................................. 6-36 Ozonation Sterilization............................................................................................... 6-36 Electron Beam Irradiation .......................................................................................... 6-37 Issues and Organizations .............................................................................................. 6-37 Vendor Contacts............................................................................................................ 6-40 Resources and References ........................................................................................... 6-41 Issues and Opportunities in Facilities Engineering and Management: Efficient Lighting .... 6-43 Upgrading Fluorescent Systems.................................................................................... 6-44 Fluorescent Lamps .................................................................................................... 6-44 Electronic Ballasts ..................................................................................................... 6-44 Fluorescent Reflectors............................................................................................... 6-45 Lenses and Louvers .................................................................................................. 6-45 Delamping or Current Limiters....................................................................................... 6-46 Replacing Incandescents With Compact Sources ......................................................... 6-46 Lighting Controls ........................................................................................................... 6-48 Resources and References ........................................................................................... 6-50 Issues and Opportunities in Facilities Engineering and Management: Power Quality ........ 6-51 PQ and EMI................................................................................................................... 6-51 The Hospital Electrical Environment .............................................................................. 6-52 Power Quality Solutions for Healthcare Facilities........................................................... 6-55 Resources and References ........................................................................................... 6-59 Issues and Opportunities in Facilities Engineering and Management: Emergency Power............................................................................................................. 6-61 Load Transfer Devices .................................................................................................. 6-61 Uninterruptible Power Supplies ..................................................................................... 6-62 Resources and References ........................................................................................... 6-63 Issues and Opportunities in Facilities Engineering and Management: Indoor Air Quality .............................................................................................................. 6-64 Indoor Air Quality Problems in Healthcare Facilities ...................................................... 6-64 Airborne Diseases ......................................................................................................... 6-65 Medicated Aerosols ....................................................................................................... 6-65 Gases and Fumes ......................................................................................................... 6-65
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Other Pollutant Particles................................................................................................ 6-66 Electrotechnologies for Indoor Air Quality...................................................................... 6-66 Resources and References ........................................................................................... 6-69 Vendor and Other Literature ...................................................................................... 6-70 Issues and Opportunities in Facilities Engineering and Management: Ozonation for Cooling Towers ................................................................................................................. 6-72 Problems Associated With Cooling Towers ................................................................... 6-72 Traditional Treatment Methods...................................................................................... 6-73 Ozonation as an Alternative........................................................................................... 6-73 Principles of Operation .............................................................................................. 6-75 Economics of Ozonation............................................................................................ 6-76 Resources and References ........................................................................................... 6-77 Issues and Opportunities in Facilities Engineering and Management: Space Conditioning and Distribution Systems .............................................................................. 6-79 Energy-Efficient Space-Conditioning Technologies ....................................................... 6-80 Demand-Control Ventilation........................................................................................... 6-82 Room Pressure Measurement and Control.................................................................... 6-83 Dehumidification Systems ............................................................................................. 6-83 Heat Pumps .................................................................................................................. 6-85 Resources and References ........................................................................................... 6-86 Issues and Opportunities in Facilities Engineering and Management: CFCs and Refrigeration ..................................................................................................................... 6-88 Background on CFCs .................................................................................................... 6-88 Overview of the Regulations on Refrigerants................................................................. 6-89 Phaseout Schedules.................................................................................................. 6-89 CFC Excise Tax ........................................................................................................ 6-89 Recycling Requirements............................................................................................ 6-89 ASHRAE Standards ...................................................................................................... 6-90 UL Standards ................................................................................................................ 6-90 Alternative Refrigerants ................................................................................................. 6-90 Options for Refrigeration Owners .................................................................................. 6-91 Resources and References ........................................................................................... 6-92 Institutions ................................................................................................................. 6-92 Government Agencies ............................................................................................... 6-94 Selected Publications ................................................................................................ 6-95
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Issues and Opportunities in Facilities Engineering and Management: Thermal Energy Storage ................................................................................................................. 6-97 Principles of Cool Storage Operation............................................................................. 6-98 Ice Storage....................................................................................................................6-98 Chilled Water Storage ................................................................................................. 6-100 Eutectic Salt Storage ................................................................................................... 6-100 Cool Storage Control ................................................................................................... 6-101 Cool Storage Economics ............................................................................................. 6-101 Thermal Energy Storage for Space Heating ................................................................ 6-101 Resources and References ......................................................................................... 6-102 List of Hospitals with Calmac TES ........................................................................... 6-102 Printed Material, Slides, and Videos ....................................................................... 6-103 Institutions ............................................................................................................... 6-104 Issues and Opportunities in Facilities Engineering and Management: Water Disinfection and Purification ............................................................................................ 6-105 Cases of Water Contamination in Healthcare Facilities ............................................... 6-106 Chemical Treatment Methods...................................................................................... 6-106 UV Disinfection............................................................................................................ 6-108 Ozonation.................................................................................................................... 6-109 Resources and References ......................................................................................... 6-109 Issues and Opportunities in Facilities Engineering and Management: Energy Management ................................................................................................................... 6-111 Distributed EMS for a Hospital..................................................................................... 6-112 Real-Time Pricing (RTP) Controller ............................................................................. 6-113 Resources and References ......................................................................................... 6-113 Issues and Opportunities in Food Services: Efficient Cooking and Other Kitchen Technologies................................................................................................................... 6-115 Electric Cooking Technologies .................................................................................... 6-115 Kitchen Exhaust Ventilation ......................................................................................... 6-117 Heat Pump Application in Hospital Kitchens ................................................................ 6-118 Resources and References ......................................................................................... 6-118 Issues and Opportunities in Lodging Services: Ozone Laundry....................................... 6-120 Ozone-Based Laundry Operations .............................................................................. 6-120 Principles of Operation ............................................................................................ 6-121 Closed-Loop Ozone Laundry System ...................................................................... 6-122
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Open-Loop Ozone Laundry System ........................................................................ 6-123 Resources, References, and Vendors ......................................................................... 6-124 Issues and Opportunities in Information Systems and Telecommunications: Telemedicine................................................................................................................... 6-126 Modernization of Hospital Data Processing Systems................................................... 6-126 Growth of Telecommunications and Telemedicine ...................................................... 6-126 Resources and References ......................................................................................... 6-131 Issues and Opportunities: Resources of the EPRI Healthcare Initiative........................... 6-132
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HEALTHCARE PROVIDERS AS ELECTRIC UTILITY CUSTOMERS............................ 7-1
A
GLOSSARY OF COMMON TERMS ...............................................................................A-1
B SUMMARY OF SELECTED STATE REGULATORY AGENCIES AND REGULATIONS ON MEDICAL WASTE.................................................................................B-1 C ALTERNATIVE MEDICAL WASTE TREATMENT TEHCNOLOGIES: VENDOR ADDRESSES AND PHONE NUMBERS.................................................................C-1
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LIST OF FIGURES Figure 2-1 The Nation’s Health Dollar, Calendar Year 1997.................................................... 2-4 Figure 3-1 Hospital Percent Change in Number of Hospital Beds: Calendar Years 1984-97 ........................................................................................................................... 3-8 Figure 5-1 Energy Consumption and Intensity by Principal Building Activity, 1995 .................. 5-1 Figure 5-2 Breakdown of Energy Use in Trillion BTUs............................................................. 5-3 Figure 5-3 Breakdown of Healthcare Electrical Usage, Arkansas Power & Light..................... 5-6 Figure 5-4 Breakdown of Healthcare Electrical Usage, Louisiana Power & Light .................... 5-7 Figure 5-5 Typical Hourly Lighting Load Shape for a Hospital ................................................. 5-7 Figure 6-1 Issues and Opportunities in Facility Management .................................................. 6-4 Figure 6-2 Issues and Opportunities in Environmental Services and Occupational Safety ...... 6-5 Figure 6-3 Issues and Opportunities in Lodging, Clinical, Administrative and Food Services .......................................................................................................................... 6-6 Figure 6-4 Municipal Solid Waste Composition for a Typical Hospital ..................................... 6-8 Figure 6-5 Sources of Reported EMI With Medical Devices .................................................. 6-58 Figure 6-6 HEPA Filtration Installed in Ventilation or as a Stand-Alone Unit.......................... 6-67 Figure 6-7 Examples of UVGI Placement.............................................................................. 6-68 Figure 6-8 Ozonation System for Cooling Towers ................................................................. 6-75 Figure 6-9 Most Commonly Reported Clinical Applications ................................................. 6-129 Figure 6-10 Non-Clinical Applications ................................................................................. 6-130 Figure 6-11 Funding Sources.............................................................................................. 6-130
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LIST OF TABLES Table 2-1 National Health Care Expenditures: 1960 - 1997..................................................... 2-2 Table 2-2 National Health Expenditures, by Source of Funds and Type of Expenditure: 1997 ................................................................................................................................ 2-5 Table 2-3 National Health Care Expenditures Average Annual Growth Rate From Prior Year Shown, Selected Calendar Years 1970-2007.......................................................... 2-6 Table 2-4 National Health Expenditures Spending by Category and Percent Distribution, 1970-2007 ....................................................................................................................... 2-8 Table 3-1 Hospital Summary Characteristics........................................................................... 3-3 Table 3-2 Leading Multihospital Health Care Systems - 1998 ................................................. 3-5 Table 3-3 Largest Catholic Multihospital Health Care Systems - 1998 .................................... 3-6 Table 3-4 Facilities and Services Provided by Hospitals: 1997.............................................. 3-11 Table 3-5 Top Ten Nursing Facility Systems ......................................................................... 3-20 Table 3-6 Nursing Home Expenditures by Source of Funds, 1993-2005 ............................... 3-22 Table 3-7 Top Ten Subacute Care Providers ........................................................................ 3-24 Table 3-8 The Nation’s 25 Largest Individual HMO Plans ..................................................... 3-28 Table 3-9 Top 30 PPOs by Number of States Served ........................................................... 3-29 Table 4-1 Emission Limits for Hospital/Medical/Infectious Waste Incinerators......................... 4-4 Table 4-2 Examples of OSHA Exposure Limits for Chemicals Common in Healthcare Facilities ........................................................................................................................ 4-11 Table 4-3 State Regulations on Medical Waste..................................................................... 4-25 Table 5-1 Consumption and Gross Energy Intensity by Building Size for Sum of Major Fuels, 1995 ..................................................................................................................... 5-2 Table 5-2 Floorspace, Consumption, Expenditures, Intensities of All Major Fuels for Healthcare Buildings........................................................................................................ 5-3 Table 5-3 Total Energy Consumption by Major Fuel, 1995...................................................... 5-4 Table 5-4 Total Energy Expenditures by Major Fuel, 1995 ...................................................... 5-5 Table 6-1 Ten Categories of Infectious Waste......................................................................... 6-9 Table 6-2 Hazardous Wastes Generated in Healthcare Facilities.......................................... 6-11 Table 6-3 Radioactive Materials Used In Hospitals ............................................................... 6-12 Table 6-4 Sources and Types of Common Recyclable Waste in a Hospital .......................... 6-14 Table 6-5 Waste Minimization Options for Hazardous Wastes .............................................. 6-16 Table 6-6 Alternative Treatment Technologies for Medical Waste......................................... 6-26
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Table 6-7 Comparison of Selected Treatment Technologies ................................................. 6-29 Table 6-8 Advantages and Disadvantages of Various Sterilization Methods ......................... 6-34 Table 6-9 PQ/EMI Rating of Common Hospital Equipment ................................................... 6-54 Table 6-10 Hospital Equipment Isolation Chart ..................................................................... 6-57 Table 6-11 Space-Conditioning Systems for Clinics and Hospitals........................................ 6-81 Table 6-12 U.S. Phaseout Schedule for CFCs and HCFCs in Refrigeration and AirConditioning Applications .............................................................................................. 6-89 Table 6-13 Comparison for a Commercial Laundry Chain ................................................... 6-123
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1 THE HEALTHCARE INDUSTRY SECTOR
Introduction This report is intended as a resource for members of the EPRI Healthcare Initiative. The objectives of the study are: to provide general background information on the healthcare sector, to describe trends and strategic issues affecting the healthcare industry, and to identify electrotechnology and service opportunities for electric utility and healthcare personnel towards meeting the needs of the industry. The healthcare industry comprises a variety of public, private, and non-profit organizations: hospitals, nursing homes, outpatient clinics, doctor offices, and administrative organizations such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent practice associations (IPAs). This report will focus on healthcare facilities, such as hospitals, clinics, and nursing homes, since they represent a large and technically complex customer group for the electric utility industry. It will also discuss allied establishments such as veterinarian clinics and mortuaries which have some issues (such as infectious waste) similar to those of healthcare facilities. The electric utility industry is undergoing the greatest change since it was formed more than a century ago. Facing a future of greater competition, individual utilities are changing too, just as the healthcare industry. Electric utilities are reorganizing, offering more value-added services to their customers, seeking new markets, and looking at new ways to address old markets. With the changing nature of the industry, utilities may differ in how they choose to address the healthcare facilities market or may need different types of background information about the market. Reflecting these potentially varying interests, this report is organized into five major parts: Chapter 2 provides an overview of the healthcare sector and how various players and forces in the sector affect the healthcare facilities market from the standpoint of electric utilities. It is intended to provide background information on the key elements in the healthcare sector and to serve as a guide to sources of more information. Chapter 3 is a more detailed look at the organization and operation of healthcare facilities and the organizations which own and operate them. 1-1
The Healthcare Industry Sector
Regulation and accreditation are driving forces in the healthcare industry. Chapter 4 focuses on regulatory and accreditation agencies and their rules and standards that affect the industry. These include U.S. Environmental Protection Agency, Department of Health and Human Services, state agencies, the Joint Commission on Accreditation of Healthcare Organizations, and many more. Chapter 5 gives a quick overview of overall energy use in the healthcare industry as well as the typical load in a healthcare facility. Chapter 6 provides data on selected technical issues in healthcare facilities and electrotechnology solutions. Specifically, this section deals with: •
Processes that now use or could use electricity,
•
Problems that could be addressed by electrotechnologies, and
•
Service opportunities for electric utilities.
The bulk of Chapter 6 is comprised of summaries and descriptions of issues, and where possible, examples and case studies of electrotechnology and service opportunities. Each subsection lists available resources and references for more information. Chapter 7 is a brief outline of some general strategies for working with healthcare providers as important customers of electric utilities. Like the electric utility industry, the healthcare sector is making dramatic changes in its structure and operations. To keep this report timely and useful as long as possible, we have included information on trends and possible effects of changing laws and government policies. Also, we have included lists of organizations and data sources which could provide current information on the status of the sector and the medical facilities market in the future.
Statistical Information on the Industry For statistical information on the healthcare industry, this report draws on data from the Bureau of the Census and other government agencies (e.g., Health Care Financing Administration) and trade associations (e.g., American Hospital Association). It should be noted that numbers sometimes differ according to source primarily because establishments are defined differently by different groups doing the counting. Moreover, the period when data were gathered also causes discrepancies because the industry is changing so quickly. In the continuum of healthcare from acute care to longterm care, lines between categories are often ambiguous and growing more so as the industry evolves. 1-2
The Healthcare Industry Sector
Census data are an important source of statistical information about businesses and industries. The most current data from the 1997 Economic Census is expected to be made available throughout 1999 and 2000. The Bureau of Census now follows the North American Industry Classification System (NAICS) which replaces the U.S. Standard Industrial Classification System (SICS) for categorizing businesses and gathering statistical information about them. The NAICS system is the framework by which many other public and private sector groups gather statistics. NAICS was developed jointly by the U.S., Canada and Mexico to provide new comparability in statistics about business activity across North America. In the NAICS schema “Health Care and Social Assistance” includes the categories 621 – Ambulatory Health Care Services, 622 – Hospitals, 623 – Nursing and Residential Care Facilities, and 624 – Social Assistance. The following table summarizes Health Care and Social Assistance and their categories. For a more detailed description, refer to the U.S. Census Bureau (www.census.gov/epcd/naics). 1997 NIACS Healthcare and Social Assistance 621 Ambulatory Health Care Services 6211 62111 621111 621112 6212 62121 6213 62131 62132 62133 62134 62139 621391 621399 6214 62141 62142 62149 621491 621492 621493
Offices of Physicians Offices of Physicians Offices of Physicians (except Mental Health Specialists) Offices of Physicians, Mental Health Specialists Offices of Dentists Offices of Dentists Offices of Other Health Practitioners Offices of Chiropractors Offices of Optometrists Offices of Mental Health Practitioners (except Physicians) Offices of Physical, Occupational and Speech Therapists, and Audiologists Offices of All Other Health Practitioners Offices of Podiatrists Offices of All Other Miscellaneous Health Practitioners Outpatient Care Centers Family Planning Centers Outpatient Mental Health and Substance Abuse Centers Other Outpatient Care Centers HMO Medical Centers Kidney Dialysis Centers Freestanding Ambulatory Surgical and Emergency Centers 1-3
The Healthcare Industry Sector
621498 6215 62151 621511 621512 6216 62161 6219 62191 62199 621991 621999
All Other Outpatient Care Centers Medical and Diagnostic Laboratories Medical Laboratories Medical Laboratories Diagnostic Imaging Centers Home Health Care Services Home Health Care Services Other Ambulatory Health Care Services Ambulance Services All Other Ambulatory Health Care Services Blood and Organ Banks All Other Miscellaneous Ambulatory Health Care Services
622 Hospitals 6221 62211 6222 62221 6223 62231
General Medical and Surgical Hospitals General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Psychiatric and Substance Abuse Hospitals Specialty (except Psychiatric and Substance Abuse) Hospitals Specialty (except Psychiatric and Substance Abuse) Hospitals
623 Nursing and Residential Care Facilities 6231 62311 6232 62321 62322 6233 62331 623311 623312 6239 62399
Nursing Care Facilities Nursing Care Facilities Residential Mental Retardation, Mental Health and Substance Abuse Facilities Residential Mental Retardation Facilities Residential Mental Health and Substance Abuse Facilities Community Care Facilities for the Elderly Community Care Facilities for the Elderly Continuing Care Retirement Communities Homes for the Elderly Other Residential Care Facilities Other Residential Care Facilities
624 Social Assistance 6241 62411 62412 62419 6242 62421 62422 1-4
Individual and Family Services Child and Youth Services Services for the Elderly and Persons with Disabilities Other Individual and Family Services Community Food and Housing, and Emergency and Other Relief Services Community Food Services Community Housing Services
The Healthcare Industry Sector
624221 624229 62423 6243 62431 6244 62441
Temporary Shelters Other Community Housing Services Emergency and Other Relief Services Vocational Rehabilitation Services Vocational Rehabilitation Services Child Day Care Services Child Day Care Services
(Source: U.S. Census Bureau - www.census.gov)
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2 THE U.S. HEALTHCARE SYSTEM
The U.S. Healthcare System Although healthcare facilities and allied establishments are the focus of this report, these facilities are only one component of the healthcare industry, a vast and complex network of public, private, and non-profit institutions. This section introduces the healthcare sector and its constituent institutions and describes how they form and influence the healthcare facilities market.
Healthcare and the National Economy The healthcare industry affects the lives of every citizen and is a pillar of the national economy. In 1997, 4,332,805 people were employed in the 6,097 U.S. hospitals. This was in addition to nursing homes, as well as ambulatory clinics and surgical centers, and even patients’ homes served by home healthcare services. And these figures do not include the thousands of people working in the nation’s insurance companies. Healthcare is big business in the United States. According to the Health Care Financing Administration (HCFA), national healthcare expenditures amounted to $1.1 trillion in 1997. Health spending as a share of the nation’s gross domestic product (GDP) fell slightly to 13.5%, the smallest claim of health spending in the past five years. For 1993 to 1997, slow health spending growth combined with solid increases in GDP halted the steady upward path of health spending as a share of GDP that has been observed over the past three decades. Table 2-1 shows historic trends in healthcare expenditures and gross domestic product from 1960 to 1997.
2-1
The U.S. Healthcare System
Table 2-1 National Health Care Expenditures: 1960 - 1997 National Health Expenditures, Percent Distribution, and Average Annual Percent Growth: 1960 - 1997 1960
1970
1980
1990
1994
1995
1996
1997
Gross Domestic Product (Billions)
$527
$1,036
$2,784
$5,744
$6,947
$7,270
$7,662
$8,111
U.S. Population (Millions)
190
215
235
260
271
273
276
278
National Health Expend (Billions)
$26.9
$73.2
$247.3
$699.4
$947.7
$993.7
National Health Expend Per Capita
$141
$341
$1,052
$2,690
$3,500
$3,637
$3,781
$3,925
National Health Expend as % of GDP
5.1%
7.1%
8.9%
12.2%
13.6%
13.7%
13.6%
13.5%
$1,042.5 $1,092.4
(Source: Health Care Financing Administration, Office of Actuary, National Health Statistics Group)
National health spending growth is expected to accelerate from 1998 to 2001, growing at an average annual rate of 6.5%. This compares to 5.0% annual growth from 1993 to 1996 due mostly to slow spending growth in the private sector (2.9%), while public sector spending grew more quickly (7.5%). This pattern is projected to reverse with private sector health expenditures growing at faster average annual rates (7.2%) than the public sector (5.7%). The nation’s total spending for health care is projected to increase to $2.1 trillion in 2007, averaging annual increases of 6.8%. Health spending as a share of gross domestic product is estimated to increase from 13.6% in 1996 to 16.6% in 2007. The Balanced Budget Act (BBA) of 1997 is expected to slow the growth in Medicare spending between 1998 and 2002.
Healthcare Funding Healthcare funding comes from three primary sources: private health insurance, government programs, and out-of-pocket payments (also called “fee-for-service” in the healthcare industry).
2-2
The U.S. Healthcare System
Figure 2-1 shows the distribution of sources of funds used to pay for healthcare in 1997 (the latest year for which complete figures are available) and how those funds were spent. Private health insurance paid 31.9% of healthcare costs; federal programs (Medicare and Medicaid), 34.2%; out-of-pocket payments, 17.2%; state and local funds, 12.2%; and other private sources, 4.6%. Of these funds, more than 41% went to the medical facilities: 34% to hospitals and 7.6% to nursing home care.
2-3
The U.S. Healthcare System Where It Came From
“Other Private” includes industrial inplant, privately funded construction, and non-patient revenues including philanthropy. “Other Public” includes programs such as workers’ compensation, public health activity, Department of Defense, Department of Veterans Affairs, Indian health services, and State and local hospital and school health. NOTE: Numbers shown do not add to 100.0 because of rounding.
Where It Went
“Other Spending” includes dentist services, other professional services, home health care, durable medical products, over-the-counter medicines and sundries, public health, and research and construction. “Program Administration and Net Cost” is for private health insurance. (Source: Health Care Financing Administration, Office of the Actuary: National Health Statistics Group)
Figure 2-1 The Nation’s Health Dollar, Calendar Year 1997
2-4
The U.S. Healthcare System
Table 2-2 shows how these funds were allocated among the major entities in the healthcare delivery market (e.g., hospitals, physicians, nursing homes, etc.) in 1997. For example, for hospital care, $228.4 billion came from government sources, primarily through Medicare and Medicaid programs. For nursing homes, this amount was $51.4 billion. Table 2-2 National Health Expenditures, by Source of Funds and Type of Expenditure: 1997 1
Private
1
Consumer
Other
Total
Federal
State and Local
1,092.4
348.0
49.7
507.1
367.0
140.0
187.6
348.0
36.4
485.5
351.8
133.8
501.0
187.6
313.5
35.6
432.4
337.3
95.1
142.6
125.4
12.4
113.0
17.2
228.4
185.6
42.8
Total
Out of Pocket
Private Insurance
585.3
535.6
187.6
1,057.5
571.9
535.6
969.0
536.7
Hospital Care
371.1
Physician Services
Type of Expenditure National Health Expenditures Health Services and Supplies Personal Health Care
217.6
147.5
143.2
34.1
109.1
4.3
70.1
58.4
11.7
Dental Services
50.6
48.4
48.1
23.9
24.3
0.2
2.3
1.3
1.0
Other Professional Services
61.9
48.3
43.5
24.6
18.9
4.8
13.6
10.8
2.8
Home Health Care
32.3
14.7
10.7
7.0
3.7
3.9
17.7
15.4
2.3
Drugs and Other Medical Nondurables
108.9
92.9
92.9
53.0
39.9
–
16.0
9.2
6.8
Vision Products and Other Medical Durables
13.9
7.3
7.3
6.8
0.5
–
6.6
6.4
0.1
Nursing Home Care
82.8
31.3
29.8
25.7
4.0
1.6
51.4
34.5
16.9
Other Personal Health Care
29.9
3.6
–
–
–
3.6
26.3
15.6
10.7
Program Administration & Net Cost of Private Health Insurance
50.0
35.3
34.6
34.6
0.7
14.7
10.4
4.3
Government Public Health Activities
38.5
–
–
–
–
–
38.5
4.1
34.4
34.9
13.4
–
–
–
13.4
21.5
15.3
6.3
Research
18.0
1.5
–
–
–
1.5
16.5
13.8
2.6
Construction
16.9
11.9
–
–
–
11.9
5.1
1.4
3.6
Research and Construction
1
Total
All Private Funds
Government
0.0
Amounts are shown in $ billion.
Note: Research and development expenditures of drug companies and other manufacturers and providers of medical equipment and supplies are excluded from research expenditures, but are included in the expenditure class in which the product falls. Numbers may not add up to totals because of rounding. (Source: Health Care Financing Administration, Office of the Actuary, National Health Statistics Group.)
2-5
The U.S. Healthcare System
Table 2-3 National Health Care Expenditures, Average Annual Growth Rate From Prior Year Shown, Selected Calendar Years 1970-2007
Spending Category
19701980
19801990
National Health Expenditures
12.9%
11.0%
8.6%
5.0%
5.3%
6.5%
7.5%
Health Services and Supplies
13.3
11.1
8.7
5.0
5.3
6.6
7.6
13.0
11.0
8.6
4.9
4.9
6.4
7.5
Hospital Care
13.9
9.6
8.0
3.5
3.4
4.9
6.6
Physician Services
12.8
12.5
7.8
3.2
4.7
7.1
7.8
Dental Services
11.1
9.0
7.4
6.7
6.2
6.3
6.7
Other Professional Services
16.3
18.5
10.1
7.8
7.3
8.0
8.1
Home Health Care
26.9
18.6
20.3
9.7
4.8
7.8
8.0
9.4
10.7
8.0
6.6
7.7
8.4
8.8
8.2
12.1
9.9
7.6
9.3
9.6
9.8
8.8
10.7
5.6
2.6
3.8
5.3
5.7
Nursing Home Care
15.4
11.2
9.2
5.8
5.4
5.5
6.4
Other Personal Health Care
12.0
10.8
17.0
15.4
8.3
10.9
12.8
Program Administration & Net Cost
15.9
13.1
9.8
4.2
10.4
8.0
8.4
Government Public Health Activities
17.5
11.3
8.9
11.9
7.3
7.0
6.9
Research and Construction
8.1
7.7
5.8
2.8
3.2
3.7
4.3
10.8
8.4
5.9
5.5
4.1
4.4
4.7
6.2
7.1
5.7
0.0
2.1
2.8
3.7
Personal Health Care
Drugs and Other Medical Nondurables Prescription Drugs Vision Products and Other Medical Durables
Research Construction
19901993
19931996
19961998*
19982001*
20012007*
(Source: Health Care Financing Administration, Office of the Actuary) * Projected
Patterns of growth will differ substantially across types of health care services. Hospital growth is projected to lag increasingly behind growth in drugs and physicians and other professional services as the trend away from the inpatient setting towards ambulatory care settings is reinforced by the movement of Medicare beneficiaries into managed care. Growth in spending for hospital services will remain well below growth in aggregate national health spending throughout the projection interval (Table 2-3). This is particularly the case for the period through 2001: the hospital spending share is expected to fall from 34.6% in 1996 to 32% in 2001 (Table 2-4) a faster rate of decline than has been observed in recent years. 2-6
The U.S. Healthcare System
For 1998-2000 Medicare spending for inpatient hospital services is expected to grow at the lowest rate in the program’s history (an average of 3% per year), compared with 8.2% per year for 1993-1996. Growth in outpatient services also is expected to decelerate from its historically rapid pace over the coming decade, extending a decelerating trend. Medicare’s scheduled switch to a Prospective Payment System (PPS) for outpatient services in 1999 will contribute to this slowdown. Expenditures for drugs are expected to grow at fairly rapid rates through 2007 as a result of rising utilization (number of prescriptions) to intensity (including changes and mix of prescriptions). Expenditure growth for nursing home care is expected to decelerate for 1998-2000, growing 5.1% on average (down from 5.8% for 1993-1996). This slowdown is accounted for by the effects of slower growth in Medicaid expenditures and a sharp cutback in the rate of growth for Medicare spending after the introduction of prospective payment. The decline in public-sector funding is expected to be partially offset by an acceleration in privatesector funding, primarily from out-of-pocket expenditures. Slower growth in nursing home spending also reflects the somewhat slower growth of the population over age eighty-five. Growth in population for this group is expected to average 2.4%, compared with 3.2% for 1980-1996.
2-7
The U.S. Healthcare System
Table 2-4 National Health Expenditures, Spending by Category and Percent Distribution, 1970-2007 Spending Category
1970
1980
1990
1993
1996
1998*
2001*
2007*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
92.7
95.3
96.5
96.8
97.0
97.1
97.3
97.8
87.1
87.8
87.9
87.9
87.6
87.0
86.9
87.1
Hospital Care
38.2
41.5
36.7
36.1
34.6
33.4
32.0
30.4
Physician Services
18.5
18.3
20.9
20.5
19.5
19.3
19.7
20.0
Dental Services
6.4
5.4
4.5
4.4
4.6
4.7
4.7
4.5
Other Professional Services
1.9
2.6
5.0
5.2
5.6
5.8
6.1
6.3
Home Health Care
0.3
1.0
1.9
2.6
2.9
2.9
3.0
3.1
12.0
8.7
8.6
8.4
8.8
9.3
9.8
10.5
Prescription Drugs
7.5
4.9
5.4
5.6
6.0
6.5
7.1
8.0
Vision Products & Other Medical Durables
2.2
1.5
1.5
1.4
1.3
1.2
1.2
1.1
Nursing Home Care
5.8
7.1
7.3
7.4
7.6
7.6
7.4
7.0
Other Personal Health Care
1.8
1.6
1.6
2.0
2.7
2.8
3.2
4.3
Program Administration and Net Cost
3.7
4.8
5.8
6.0
5.9
6.5
6.7
7.1
Government Public Health Activities
1.8
2.7
2.8
2.8
3.4
3.6
3.6
3.5
Research and Construction
7.3
4.7
3.5
3.2
3.0
2.9
2.7
2.2
Research
2.7
2.2
1.7
1.6
1.6
1.6
1.5
1.3
Construction
4.6
2.5
1.8
1.6
1.4
1.3
1.2
1.0
Percent Distribution in National Health Expenditures Health Services and Supplies Personal Health Care
Drugs & Other Medical Nondurables
(Source: Health Care Financing Administration, Office of the Actuary.) * Projected
Major Players The U.S. healthcare delivery system comprises two general groups: payers and providers. Providers are those organizations which deliver (provide) healthcare to patients (or residents, as they are called in long-term care facilities), while payers are those organizations which pay for it. Payers are insurance companies, employers, government agencies, and individual consumers, while providers include hospitals, nursing homes, clinics, and similar facilities, as well as individual physicians and their organizations. The distinction is becoming increasingly blurred. Managed care is replacing the traditional payer-provider calculus. For example, some payers, such as insurance companies, are moving into the area of delivery of healthcare, while some 2-8
The U.S. Healthcare System
hospitals and physician groups are creating alliances and managed care arrangements with employers to provide healthcare directly. Background Many of the changes in the healthcare sector in the last decade have been due to fundamental changes in how healthcare payers reimburse providers for their services. Until the early 1980s, the most common method of reimbursement was fee-for-service arrangements in which doctors and hospitals billed payers (e.g., insurance companies or the Federal government) directly for each service performed. Changes in this system began in the early 1980s when the Federal government forced hospitals and doctors to accept a new restrictive reimbursement system known as the prospective payment system (PPS) for services provided to Medicare patients. Under the PPS system, hospitals and doctors are reimbursed according to a fixed schedule of fees based upon 470 categories of illness. These categories are known as diagnostic related groups (DRGs). This resulted in smaller receipts from Medicare patients. Hospitals tried to compensate for this loss of Medicare revenue by hiking rates to private patients (a practice known in the industry as “cost shifting”). In response, private third-party payers like insurance companies and large employers have introduced “managed care” arrangements to control costs. Managed healthcare is a system of pre-paid plans providing comprehensive coverage to voluntarily enrolled members. Managed care plans control costs in several ways such as (1) modifying physician incentives, especially in hospital use, (2) contracting with groups of doctors and hospitals to serve their members at lower prices, and (3) creating a health delivery organization (e.g., Kaiser Permanente) comprising salaried physicians and hospitals under a single management structure. In their contracts with hospitals, managed care companies frequently use “capitated plans” which typically pay hospitals a pre-negotiated fixed amount per capita each month based on the number of members in the plan. This sharply contrasts with traditional fee-for-service plans which reimburse hospitals and physicians separately for each service they provide. Hospitals involved in capitated plans have their annual gross revenue from each plan fixed by the number of subscribers in that plan and can operate profitably only when their costs are below that ceiling. This creates a strong incentive for these providers to hold down costs. Payers Although payers are key players in the healthcare market, as utility customers they are generally distinct from providers. For example, insurance companies are typical commercial institutions occupying office buildings, and as such, they fall into the 2-9
The U.S. Healthcare System
commercial market segment as utility customers rather than the healthcare segment. Consequently, this report addresses and describes payers from the standpoint of their role in the healthcare market rather than as direct utility customers. Insurance companies are an important component in the payer category. They exert enormous influence on healthcare policy at every level, and by their payment decisions they affect services offered by healthcare providers. As shown in Figure 2-1 and in Table 2-2, private health insurance is the source of one-third of all healthcare financing and 60% of private financing in 1997. Hundreds of separate organizations make up this category. In a study done in the 1980s, the private health insurance market comprised approximately 1,000 commercial insurance companies, more than 100 non-profit Blue Cross and Blue Shield insurance plans, 700 prepaid health plans or health maintenance organizations (defined below in this section), and large employers carrying their own insurance or self insuring. Employers are concerned about healthcare costs because they pay a sizable proportion in insurance premiums. They affect the healthcare market in several ways: influencing which healthcare plans their employees can join, influencing healthcare reform legislation through their trade associations, and in some cases contracting directly with healthcare providers such as hospitals and physician groups to serve their employees. Federal government payments through Medicare and Medicaid account for more than half of hospital revenues in the country. Changes in federal policies on these payments have enormous repercussions throughout the healthcare sector. For more information, see the “Role of the Government” section. Managed healthcare groups are hybrid organizations, combining a health delivery capability with a traditional payer function. These organizations typically provide prepaid plans of comprehensive coverage to voluntarily enrolled members. The two predominant types of managed healthcare are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). HMOs commonly use primary care physicians to screen patients to determine if hospitalization is required and to have as many patient services and procedures as possible performed outside of hospitals to reduce costs. Unnecessary inpatient services account for nearly a third of total U.S. hospital admissions. PPOs are a modified version of HMOs; enrollees are offered incentives to limit their provider selection to preferred providers. Managed care groups have enormous influence on the healthcare facilities market because of their power in the industry. In 1995, 46 million persons were enrolled in 562 HMOs. According to the Inter study on managed care organizations, by 2002, 140 million persons will be enrolled in managed care and Medicare and Medicaid. 1998 finds nearly 650 managed care plans. Managed care covers 86% of workers and 2-10
The U.S. Healthcare System
their families, up from 55% six years ago. (U.S. News and World Report, October 5, 1998.) Providers Patients’ needs range from intensive, highly-specialized treatment in critical care or surgical units of hospitals to basic provision of housing, meals, sanitation, and comfort in custodial care facilities. In between are healthcare in skilled nursing facilities, outpatient clinics, physician offices, and even patients’ homes. Providers are institutions which deliver this continuum of healthcare services to patients. They are particularly important in the healthcare facilities market because they are typically the institutions owning and operating major facilities. As healthcare reform and competition increasingly affect the market, providers are often changing what healthcare services they offer patients, moving to a different position along the continuum of care. For example, hospitals, faced with the need to reduce costs are increasingly using out-patient centers to replace over-night stays by patients. Similarly, nursing home systems are moving into sub-acute care in which they house and provide nursing care for patients who were formerly cared for in hospitals. Following is a description of the main types of providers. They will be discussed in more detail in subsequent sections. Hospitals are the primary institution in the nation’s health delivery system and the major focus of the healthcare market segment for the utility industry because of their visibility in the community, the large amount of energy they consume, and the complexity of their operations. In the continuum of care concept, hospitals are the providers of “acute care,” the most expensive and technologically and medically complex level of healthcare. According to the American Hospital Association, the primary function of a general hospital is to “provide patient services, diagnostic and therapeutic, for a variety of medical conditions. A general hospital also shall provide: •
Diagnostic x-ray services with facilities and staff for a variety of procedures
•
Clinical laboratory service with facilities and staff for a variety of procedures and with anatomical pathology services regularly and conveniently available
•
Operating room service with facilities and staff.
Nursing homes, frequently called nursing facilities, long term care facilities or convalescent homes, are also a major component of the market. In 1997, there were over 17,000 nursing homes in the country, ranging from skilled nursing facilities (SNFs, pronounced “sniffs”) to long-term custodial care facilities, and their number is expected to grow as they assume some functions now carried out by hospitals. Some nursing 2-11
The U.S. Healthcare System
home facilities have begun offering “sub-acute care” to patients who need extended skilled medical or rehabilitation care but not at the level or expense offered by a hospital. The trend toward managed care and strict cost control is pushing the growth of sub-acute care facilities. Another subcategory of the nursing home category is assisted living care. These are facilities offering patients a range of care levels (from semi-autonomous to traditional nursing care), depending on their health and selfreliance, in a communal setting. Although nursing homes on average use less electricity than hospitals, they are more numerous and represent a significant proportion of the healthcare facilities market for the electric utility industry. Clinics are also increasing in number and importance as payers seek lower-cost alternatives to hospitals. This category includes kidney dialysis centers, cancer treatment, and similar specialized facilities. Physicians are the gatekeepers in the managed care environment, deciding how patients will be served within the healthcare system. Though numerous and important from the standpoint of healthcare delivery, their offices represent a relatively small electrical load. They are involved in other issues, such as indoor air quality and medical waste, however, which are significant within the healthcare industry. Related, non-medical facilities include veterinary clinics, blood banks, and mortuaries. Although these facilities are not part of the healthcare sector, they have some issues in common with institutions in that sector. These include medical waste, airborne disease, and sharps disposal. As electricity customers, though, their total load is small compared to hospitals, nursing homes, and clinics. The Role of Government Government policies in healthcare are critical to all organizations involved in its delivery including hospitals and nursing homes. For example, in 1997, as Table 2-2 shows, government payments for healthcare totaled $507.1 billion. Over the past thirty years, the federal government has enacted policies to provide access to healthcare for groups who otherwise would be unable to pay for it. Those policies affecting healthcare facilities the most, such as hospitals and nursing homes, include Medicare (elderly and disabled), Medicaid (poor children and adults, disabled), and Indian Health Service (Native Americans). Current government policies on healthcare follow two principal themes: cost containment and access to healthcare. In addition there is concern for quality of care, especially related to maintenance of quality while reducing healthcare delivery costs. Although many changes are being considered at state and federal levels of government, 2-12
The U.S. Healthcare System
they almost universally assume that the current system of financing and delivering healthcare is basically sound and that policies are needed to improve the current private payer system rather than replace it with a national health insurance system.
Catalysts for Change: Healthcare Reform and the Market Fundamental changes in the healthcare insurance system and in government support of programs such as Medicare are causing enormous repercussions in the healthcare system in this country. These repercussions are influencing the way healthcare institutions conduct their business and even whether some remain in business. For example, some institutions, such as hospitals which cannot receive sufficient revenue, are being forced to close, while others are declining to serve those unable to pay. At the same time, insurers are making providers accept predetermined fees for specific services. As the system for delivering healthcare seems increasingly driven by profit motives, the tendency for government agencies to impose constraints on the system is growing. Healthcare reform is the term used to characterize the changing roles of payers and providers, along with a national reassessment of the role the federal government should play in paying for healthcare and in regulating the healthcare market. The rising cost of healthcare and the size of the nation’s total healthcare expenditures are driving the demand for changes in the system. Several factors contribute to rising healthcare costs: •
Healthcare consumers are insulated from costs which are paid by insurance companies.
•
Healthcare has traditionally been delivered through fee-for-service plans in which providers are compensated in direct proportion to the amount of services rendered, with little incentive to contain costs.
•
Healthcare is considered a necessity beyond the law of supply and demand to regulate its cost.
•
Medical practitioners often order diagnostic procedures unnecessarily to protect themselves against potential malpractice lawsuits.
•
The population is aging and requiring more healthcare.
•
Medicare and Medicaid have expanded.
•
The availability of new diagnostic and treatment technologies has encouraged their acquisition and use.
2-13
The U.S. Healthcare System
Although healthcare legislation died in Congress in 1994, the pressure for reform remains, as well as pressure to cut Medicare as a way of reducing federal budget outlays. In fact, every current Congressional healthcare reform plan included cuts in Medicare as a way to finance new programs. Medicare is an important element in U.S. healthcare and a major source of hospital revenue. The Health Care Financing Administration (410-786-3689 Medicare Statistical Hotline) reports that as of July 1998 (the latest data available), Medicare provides benefits to 38,567,298 citizens. The Medicare benefit payments exceeded $200 billion in 1998, with payments expected to be more than $228 billion in 1999. The American Hospital Association was opposed to cuts in Medicare for this reason. Although much public attention is focused on healthcare legislation in Congress, competition among providers and payers is driving changes in the sector. The roles of various providers is shifting along the continuum of care as the players juggle for market share. Hospitals are consolidating into more efficient entities, nursing facility systems are moving into areas, such as sub-acute care, formerly held exclusively by hospitals. Insurers are seeking new arrangements with physician groups. These changes will have enormous implications for utility programs addressing this sector, and many of these changes are happening at the state and regional level. Resources and References (see end of Chapter 3)
2-14
3 HEALTHCARE FACILITIES
The focus of this report is healthcare facilities, the institutions that actually deliver treatment and care to patients. These institutions comprise mainly hospitals, nursing homes, clinics, and offices of physicians and dentists. This section describes each of these groups of institutions focusing on their organization, mission, and general operation. The next section looks at their operations in more detail and discusses potential roles for electric utilities.
Hospitals Since early in this century, hospitals have been the center of healthcare delivery in the United States. In 1997 there were 6,097 AHA registered hospitals in the U.S. including 5,082 short-term hospitals. Hospital costs represent more than a third of the nation’s total healthcare expenditure of $1.1 trillion in 1997. Because of their size, complexity, budget size, and importance in healthcare delivery, hospitals are the most important component of the healthcare facilities market.
Classification of Hospitals Hospitals are the most visible component of the healthcare delivery system in this country. In addition to providing care for bed-ridden and ambulatory patients, hospitals are training sites for physicians, nurses, allied health professionals and centers for research. Hospitals are often categorized by key characteristics, such as type of care offered or governance. These categories are used by trade associations, government agencies, and other groups to organize statistical information about the institutions. The categories also provide insights into organizational issues and potential strategies for power suppliers. The American Hospital Association (AHA), the primary trade association for the hospital industry, classifies hospitals according to several categories, including type, control, size, and length of patient stay.
3-1
Healthcare Facilities
Type In classifying by type, the AHA uses two general categories: community and noncommunity. Community hospitals, as defined by the AHA, are “all non-federal shortterm general and other special hospitals whose facilities are open to the public. (Other special hospitals include obstetrics and gynecology; eye, ear, nose and throat; rehabilitation; orthopedic; and other individually described specialty services.)” In contrast, non-community hospitals, according to the AHA, include federal hospitals, long-term hospitals, psychiatric hospitals, alcoholism and chemical dependency facilities, and hospital units of institutions. Community hospitals are the most common type, with 90% of total hospital beds. Control There are two principal classes of control: public and private. Control refers to the type of organization responsible for establishing policy concerning overall hospital operation. Private hospitals may be investor-owned for-profit (sometimes called proprietary) or not-for-profit (also called voluntary). The non-profit category includes hospitals owned by religious denominations, the largest group of which by far are those of the Catholic Church. Public hospitals may be characterized by the level of government jurisdiction which owns and operates them. The AHA uses two categories of public hospitals: government-federal and government-nonfederal. Size and Length of Stay In categorizing hospitals by size one measure is number of beds, excluding bassinets for newborns. Another is average patient census, stated in patient-days per thousand days. In classifying by length of stay, two categories are typically used: short-term (less than 30 days) and long-term (more than 30 days). Table 3-1 presents some summary characteristics for hospitals, showing trends in key areas from 1972-1997.
3-2
Healthcare Facilities
Table 3-1 Hospital Summary Characteristics Hospitals—Summary Characteristics: 1972-1997 1972
1980
1990
1993
1997
Number: All hospitals
7,061
6,965
6,649
6,467
6,097
• Non-Federal
6,660
6,606
6,312
6,151
5,812
5,746
5,830
5,384
5,261
5,057
3,301
3,322
3,191
3,154
3,000
738
730
749
717
797
1,707
1,778
1,444
1,390
1,260
– Long-term gen’l & special
216
157
131
117
125
– Psychiatric
529
534
757
741
601
72
11
4
4
4
401
359
337
316
285
1,550
1,365
1,211
1,163
1,035
32.7
91.9
234.9
301.5
342.3
Personnel: All hosp (1,000)
2,671
3,492
4,063
4,289
4,333
Outpatient Visits (millions)
219.2
263.0
368.2
435.6
520.6
– Community hospitals Non-govt’l, non-profit For profit State and local gov’t
– Tuberculosis • Federal Beds: All hospitals (1,000) Expenses: All hosp (billions $)
(Source: American Hospital Association)
In addition to the AHA, the Census Bureau gathers statistics on medical facilities. As described previously, the federal government uses the North American Industry Classification System (NAICS). Census data are useful for providing information on trends in specific geographic areas, say within a particular utility service territory. The Census Bureau will make available 1997 data throughout the years 1999 and 2000. Statistics are usually updated every five years. From the standpoint of electric utility marketing programs, the key category of hospitals is control, i.e., public or private control. Although the AHA divides hospitals into public and private categories, these can be further subdivided to provide a better 3-3
Healthcare Facilities
understanding of the market. The three major categories of private hospitals are forprofit, Catholic not-for-profit, and other not-for-profit. Public hospitals include Veterans Administration hospitals and municipal hospitals. Almost all for-profit hospitals and many not-for-profit hospitals are part of a multihospital system under a single corporate owner. These are described and listed in the following paragraphs. In addition to being affiliated under a common corporate ownership, hospitals also participate in alliances which, according to a definition by the American Hospital Association, work “on behalf of individual members in provision of services and products and in the promotion of activities and ventures.” Alliances are described in “Hospital Finances and Related Issues” section. Hospital and other health sector trade associations and professional groups are described in the “Trade and Professional Organizations” section. Private Hospitals For-Profit
In 1997 there were 797 for-profit hospitals in the country, providing approximately 115,000 beds with 3,953,000 admissions and 40,919,000 outpatient visits. Almost all of the hospitals were organized into multi-hospital systems, of which there were 39. In 1999 the number of multi-hospital systems has grown to 288. The largest for-profit hospital management system is Columbia Healthcare, which merged with HCA in February 1994. The system has grown dramatically, from 22 hospitals in 1992 to 320 hospitals in 1998. Other large for-profit systems include Quorum Health Group/Quorum Health Services, Inc., Tenet Healthcare Corp., and Healthsouth Corp. Table 3-2 shows the ten largest multihospital health care systems as of 1998. This list includes for-profit and not-for-profit systems.
3-4
Healthcare Facilities
Table 3-2 Leading Multihospital Health Care Systems - 1998 # of Beds
# of Hospitals
Columbia/HCA Healthcare Corp.
55,617
320
Department of Veterans Affairs
53,315
144
Quorum Health Group/Quorum Health Resources, Inc.
28,095
259
Tenet Healthcare Corp.
24,915
129
Catholic Health Initiatives
11,484
62
Daughters of Charity National Health System
10,049
34
Magellan Health Services
5,887
66
Healthsouth Corp.
5,787
73
Universal Health Services, Inc.
5,646
37
Brim
3,438
49
(Source: The AHA Guide to the Health Care Field, 1998-1999 edition.)
Catholic
Most Catholic hospitals are owned and governed by a religious congregation, providing more limited policy discretion to a governing board of trustees. A major difference between Catholic and other not-for-profit hospitals is that Catholic institutions must obtain diocesan approval for major organizational changes such as mergers and acquisitions. Ordinary corporate or policy changes are handled as in secular non-profit hospitals. As with other for-profit and not-for-profit hospitals, Catholic healthcare institutions are frequently organized into groups, or, using the common term of the healthcare industry, systems. As of 1998, there are 45 Catholic Church-related multihospital healthcare systems. The largest Catholic management systems are Daughters of Charity National Health System and the Catholic Health Initiatives. Catholic hospitals are also organized into a trade association, namely, Catholic Health Association, which addresses issues of common interest to its members. Table 3-3 presents the largest Catholic systems.
3-5
Healthcare Facilities
Table 3-3 Largest Catholic Multihospital Health Care Systems - 1998 # of Beds
# of Hospitals
Catholic Health Initiatives
11,484
62
Daughters of Charity National Health System
10,049
34
Catholic Healthcare West
7,412
35
Catholic Health East
5,980
18
Sisters of Mercy Health System - St. Louis
5,313
22
Marian Health System
4,692
15
Mercy Health Services
4,550
31
Sisters of Providence Health System
3,518
19
SSM Health Care System
3,499
20
Bon Secours Health System, Inc.
3,292
14
Holy Cross Health System Corp
2,743
11
Sisters of Charity of the Incarnate Word Healthcare System
2,674
11
Sisters of St. Joseph Health System
2,652
11
Hospital Sisters Health System
2,596
13
Wheaton Franciscan Services, Inc.
2,484
12
Subtotal, 15 Largest Catholic Systems
72,938
328
ALL Other Respondent Catholic Systems
27,942
144
Total, All Respondent Catholic Systems
100,880
472
(Source: The AHA Guide to the Health Care Field, 1998-1999 edition.)
Secular and Other Religious Not-For-Profit
In 1997, of the 5,082 general short-term hospitals (as defined by the AHA), 3,000 are non-government, not-for-profit. Of this total, approximately one quarter are Catholic institutions. The remainder are predominately secular, though some are affiliated with religious denominations such as Seventh Day Adventist, Methodist, Jewish, or Baptist. 3-6
Healthcare Facilities
In these institutions, policy is set by a governing board of directors, either of independent institutions or, more commonly today, of a system of non-profit institutions. Public Hospitals Federal Government
The largest operator of public hospitals in the country is the U.S. Department of Veterans Affairs (VA). As Table 3-2 indicates, the VA operates 144 hospitals, with over 53,000 beds. In addition to its acute care hospital services, the VA is one of the nation’s largest provider of long-term care services. State and Local Government
In this category, local government is by far the largest player. Of the 5,082 general, short-term hospitals in the 1997 AHA census (latest data available as of 1999), 1,260 were classified as local and state government. The largest local government hospital network is New York City Health and Hospital Corporation, although recent news stories indicate that the system is attempting to reorganize and partially privatize due to operating deficits and other problems.
Utilization and Trends The hospital industry faces a period of uncertainty. The growth of managed care is reducing hospital profits in general and forcing changes in basic operations to reduce costs and increase income. The federal government is poised to make fundamental changes in funding of two programs responsible for a large proportion of hospital income: Medicare and Medicaid. Hospitals are reorganizing, and for-profit systems are increasing their share of the market. As the demand for inpatient services has fallen, hospitals have closed staffed beds at a steady rate in an attempt to curtail overhead costs. Since 1990, 88,000 staffed community beds have closed, a ten-percent reduction in inpatient capacity. Despite these closures and because of an even faster drop in inpatient days (down 16%), occupancy rates have fallen from 64.5% in 1990 to 59.6% in 1997.
3-7
Healthcare Facilities
0
-0.5
Percent
-1
-1.5
-2
-2.5
-3 1990
1991
1992
1993
1994
1995
1996
1997
Calendar Years SOURCE: American Hospital Association: National Hospital Panel Survey, 1990-97
Figure 3-1 Annual Percent Change in Number of Hospital Beds: Calendar Years 1990-97
Utilization Despite an upward turn in admissions in 1993, the downward trend continued through 1995, with only a 1% increase from 1993 to 1997, due to systemic changes in the healthcare system, especially the move to managed care. Total admissions in community hospitals declined 13.4% between 1982 and 1993. The decline was 40% in rural hospitals over the same period. The rise of HMOs contributed to this decline because HMOs used alternatives to hospitalization as a way to hold down costs: careful case management, greater use of outpatient care, and greater emphasis on preventative care. HMO hospitalization rates were more than one-third less than the national average. Similarly, Medicare and other third-party payers are requiring that many procedures previously performed in hospitals be conducted in outpatient clinics. Consequently, corresponding to the decline in hospitalization rates has been an increase in outpatient visits to community hospitals, rising 6.1% in 1992 and 6.8% in 1993. From 1993 to 1997, community hospital outpatient visits rose approximately 23%.
3-8
Healthcare Facilities
For-Profit Systems Although industry experts predict that the hospital industry will continue to contract as managed care gathers a greater portion of the healthcare market, for-profit hospital management systems have potential to do well. Standard and Poor’s predicts that forprofit hospital systems will benefit from acquiring non-profit hospitals unable to compete in a healthcare market driven by the need to reduce operating costs. An increasing number of hospitals are associated with national systems, a tendency that is accelerating as competition increases in the healthcare field. Joining in systems offers institutions opportunities to reduce costs though economies of scale as well as to share operational and management expertise. As the number of for-profit systems increase, more hospitals will be explicitly seeking profits to share with the system owners. In the face of pressure to reduce costs, breadth of services and economies of scale will increase in importance, a situation that large, low-cost systems should be able to exploit more effectively than marginal, individual non-profit hospitals. The most recent Standard and Poor’s forecast predicts that large systems will acquire many marginal not-for-profit hospitals struggling in the current market, and will benefit from alliances with physician groups and other firms involved in outpatient services. Other Networks Non-profit hospitals are also seeking new alliances, though most frequently with other non-profit hospitals than with for-profit ventures for fear of losing their tax-exempt status. Non-profit hospitals rely primarily on public and private sector funds for capital projects and need to acquire new medical equipment to help a hospital compete in its market. Non-profit hospitals face other financial problems, including a slippage in credit ratings, which will increase the cost of capital monies. As with private and other non-profit hospitals, Catholic healthcare systems are undergoing mergers into broader healthcare networks to strengthen religious ties, establish more powerful geographically linked networks, and offer economies of scale to effectively implement managed care plans. Linkage is difficult for some Catholic hospitals because of the physical dispersion of their facilities and the ownership by different religious institutions. More than 80% of Catholic hospitals in the country belong to a health network. Catholic hospitals have facilities in four to twelve states, but none has more than 15% of the total beds in a single state. Because Catholic hospitals are often not the major providers of care in a region, they typically are less profitable, have an older physical plant and equipment, and treat more Medicaid patients. Urban Catholic hospitals could be vulnerable in a more competitive market
3-9
Healthcare Facilities
due to these shortcomings as well as to the difficulty of sharing technologies with other institutions. In some urban areas, however, Catholic hospitals are becoming major players because of their positioning in a particular market. Rural Catholic hospitals may be less vulnerable fiscally than their urban siblings since they can be an area’s sole provider of inpatient services. As the healthcare market responds to increased competition and pressures for reform, there is a trend toward consolidation, resulting in the formation of large networks both of healthcare providers and of payers. The direction of this consolidation is still uncertain but it is likely to have great influence on the market. In particular, strong payer networks, in the form of HMOs or PPOs, will be able to exert even stronger pressure on providers, e.g., hospitals, to offer steep price discounts. Strong provider networks might offer their members the opportunity to build long-term relationships with particular consumers or to move into related areas such as financing. Other Trends Although healthcare is in a period of extreme uncertainty, industry experts see several trends emerging: •
Traditional hospital providers will continue to consolidate, and excess bed capacity will be reduced through mergers.
•
Outpatient services will continue to grow.
•
Hospitals will diversify into affiliations with home health agencies and long-term facilities such as nursing homes.
•
The pressure for hospitals to reduce costs will increase.
•
Hospitals and physicians will increasingly form integrated healthcare systems.
•
HMO growth will continue.
Healthcare is delivered locally, however, and local factors such as demographics, economic conditions, and the management of particular institutions can cause variations from national trends.
Services Offered Hospitals are the primary facility delivering healthcare services, and as a result hospitals typically offer a variety of services. Table 3-4 lists the most common facilities and services provided by the 5,021 hospitals reporting and the proportion of hospitals 3-10
Healthcare Facilities
which offer each type. The most common services offered are general medical surgical for the adult (87.3% of responding hospitals), emergency department (85%), social work services (84.7%), and outpatient surgery (83.6%). Table 3-4 Facilities and Services Provided by Hospitals: 1997 Service
Hospital With Service
% of total
544 777
10.8% 15.5%
Hospital With Service
% of Total
Nutrition Programs Obstetrics Inpatient Care
2,849 3,152
56.7% 62.8%
Service
Adult Day Care Program Alcohol/Drug Abuse or Dependency Inpatient Care Alcohol/Drug Abuse or Dependency Outpatient Services Angioplasty Arthritis Treatment Center Assisted Living Birthing/LDR/LDRP Room Breast Cancer Screening
1,199
23.9%
Occupational Health Services
2,831
56.4%
1,047 346 211 3,002 3,554
20.9% 6.9% 4.2% 59.8% 70.8%
2,710 921 760 1,169 3,403
54% 18.3% 15.1% 23.3% 67.8%
Burn Care Cardiac Catheterization Laboratory Case Management
158 1,596 2,867
3.1% 31.8% 57.1%
Oncology Services Open Heart Surgery Other Special Care Outpatient Care Center (Freestanding) Outpatient Care Center Services (Hospital Based) Outpatient Surgery Patient Education Cntr Patient Representative Services
4,197 2,633 2,954
83.6% 52.4% 58.8%
Children Wellness Program Community Outreach
803 2,770
16.0% 55.2%
1,345 3,623
26.8% 72.2%
Crisis Prevention CT Scanner Dental Services Diagnostic Radioisotope Facility
822 3,770 1,372 2,793
16.4% 75.1% 27.3% 55.6%
190 1,644 1,106 1,717
3.8% 32.7% 22% 34.2%
Emergency Department Extracorporeal Shock Wave Lithotripter (ESWL) Fitness Center General Medical Surgical Care: Adult General Medical Surgical Care: Pediatric Geriatric Services
4,270 634
85% 12.6%
Physical Rehabilitation Inpatient Care Physical Rehabilitation Outpatient Services Positron Emission Tomography (PET) Primary Care Dept. Psychiatric Child/Adolescent Svs. Psychiatric Consultation/Liaison Services Psychiatric Education Svs. Psychiatric Emergency Svs.
1,368 1,807
27.2% 36%
1,136 4,385 2,509
22.6% 87.3% 50%
Psychiatric Geriatric Svs. Psychiatric Inpatient Care Psychiatric Outpatient Svs.
1,676 1,989 1,597
33.4% 39.6% 31.8%
2,046
40.7%
1,324
26.4%
Health Fair
3,290
65.5%
Psychiatric Partial Hospitalization Program Radiation Therapy
1,181
23.5%
Health Information Center Health Screenings HIV/AIDS Services
2,010 3,342 1,772
40% 66.6% 35.3%
925 177 1,554
18.4% 3.5% 31%
Home Health Services Hospice Intensive Care: Cardiac Intensive Care: Medical Surgical Intensive Care: Neonatal Intensive Care: Pediatric Long-Term Care: Intermediate Care Long-Term Other Long Term Care Long-Term Care Skilled Nursing Care Magnetic Resonance Imaging (MRI) Meals on Wheels
2,616 1,250 1,817 3,329 821 418 549 792 2,096 2,114 752
52.1% 24.9% 36.2% 66.3% 16.4% 8.3% 10.9% 15.8% 41.7% 42.1% 15%
Reproductive Health Retirement Housing Single Photon Emission Computed Tomography (SPECT) Social Work Svs. Sports Medicine Support Groups Teen Outreach Svs. Transplant Services Transportation to Health Facilities Trauma Center (Certified) Ultrasound Urgent Care Center Volunteer Svs. Dept Women’s Health Services
4,255 1,536 2,863 590 447 1,392 978 3,963 1,554 3,919 1,883
84.7% 30.6% 57% 11.8% 8.9% 27.7% 19.5% 78.9% 23% 78.1% 37.5%
645
12.8%
Neonatal Intermediate Care
(Source: American Hospital Association. Hospital Statistics, 1999 edition.)
3-11
Healthcare Facilities
Hospitals are conducting an increasing proportion of their services on an outpatient basis as a way to reduce cost. This trend is generally attributed to the increase in managed care and the accompanying pressure to lower costs. The AHA reports that from 1993 to 1997 outpatient visits to community hospitals increased by 23%, and outpatient surgeries to community hospitals increased by 16%. The number of these outpatient surgery facilities affiliated with hospitals has grown steadily in recent years. Many of these outpatient procedures are carried out in freestanding facilities and mobile care units. In addition to outpatient services, subacute care is another area which has grown steadily in the past decade. Subacute care facilities serve persons who no longer need inpatient hospital care but who are not well enough to go home. These facilities cost much less than hospitals to operate. This area is discussed below in the section on nursing facilities.
Organizational Structure Hospitals in the United States are organized hierarchically in a traditional pyramid arrangement, with authority flowing down through levels of supervisors in a system of command similar to the military. Undergirding this organizational structure is a strong system of rules and regulations addressing health, environment, and safety issues, as well as patient welfare. Organizational structures vary widely among hospitals and generalizations are difficult. To give a general look at hospital organizations, the present discussion uses the common structure of an independent not-for-profit community hospital. The internal organization of for-profit and government hospitals are similar. In not-for-profit hospitals and other healthcare organizations, the top of the organizational pyramid is the governing body which is usually the board of trustees. In a hospital operating as a single, independent unit, the board has enormous power and responsibility, because the board’s primary mission is the oversight of a single institution. In organizations comprising several hospitals (as well as other institutions or organizations, in some cases), the board is necessarily less involved with each hospital. In some not-for-profit hospitals and systems, particularly those operated by Catholic orders or other religious organizations, significant decisions such as major capital expenditures, are often made by the sponsoring organization rather than the board of directors. The board sets overall policy and has ultimate fiscal responsibility. It carries out these functions through its own committees such as finance, operations, and so on. The board is not involved in day-to-day operations of the hospital but instead delegates those duties to a chief executive officer. Until the mid-80s the position of chief executive officer, especially in not-for-profit hospitals, was often called the Administrator. More recently, though, there has been a move toward corporate titles such as President or 3-12
Healthcare Facilities
CEO, though government hospitals still use the title Administrator. This report will use the more general term, CEO. In for-profit hospitals and healthcare organizations, the policy setting function is carried out by corporate officials and ultimately the corporate board of directors. In government institutions like Veterans Administration hospitals, the policy function is set by legislation and regulations and overseen by national and regional administrators. The CEO usually directs the organization through the senior level managers (vice presidents), each responsible for a single department or function. These functions include (but are not necessarily limited to) business or fiscal services, nursing services, ancillary medical services, and support services. In addition to overseeing the CEO, the board maintains a formal relationship with the medical staff. The Board, the administration, and the medical staff are the three pillars of power in a hospital. The board sets policy and has overall responsibility for the institution. The administration carries out that policy and creates the environment in which care of patients can occur. The medical staff supervise the delivery of the medical services and along with the patients are the primary users of the hospital. Hospitals are complex organizations because of the dynamic relationship between these three groups. The doctors’ actions on patients in a hospital (and even on recommending that patients use a particular hospital) affect the operation and management of that hospital. The administration of a hospital affects the quality of care patients receive and the type of medical services available to them. Recognizing this interdependence, hospital boards often include physicians as members. Within a hospital organization, there are several functions of importance to electric utilities: Plant Engineering, Safety and Environmental Services (including Occupational Safety and Health, Waste Management, Central Supply, and Sanitation), Administration, and Medical Staff and Nursing Services. Plant Engineering The Plant Engineering Department (sometimes called Facilities Engineering or Central Facilities) is responsible for providing HVAC (heating, ventilation, and air conditioning), power and light, and facility maintenance. To carry out these responsibilities, Plant Engineering (1) operates and maintains the boiler facilities that burn natural gas to generate steam and hot water, (2) operates and maintains the central plant chillers that use electricity to provide space cooling, and (3) maintains the electrical distribution system within the hospital. In addition to these traditional physical plant functions, Plant Engineering often is responsible for maintenance of biomedical electronic equipment and for operations of telecommunications equipment. (As an example of the need for this last function, 3-13
Healthcare Facilities
Voluntary Hospitals of America, the largest alliance of hospitals in the nation, has a satellite communications system which is used for educational programs and management functions, and is available for lease by outside groups.) Often the director of plant engineering is called the hospital engineer or facilities engineer. Plant Engineering is important to electric utilities because it is the hospital department that is directly responsible for electricity supply and usage. Moreover, Plant Engineering is concerned with issues related to electricity, such as power quality, energy conservation, etc. Administration The senior level manager (vice president) in charge of support services (which include plant engineering and environmental services) is an important person in a hospital’s decision-making structure from an electric utility viewpoint. The hospital CEO has approval authority for capital projects up to a specific level, commonly $1 million; amounts above that would require approval from the board or system leadership. In some cases utility representatives might maintain regular contact with a hospital’s administration, say for large scale projects, like thermal energy storage. More commonly, however, the utility representatives work directly with the hospital engineers in developing programs and come to the administration for approval of large projects or to discuss issues such as rates or emission compliance. In considering the decision-making structure of a healthcare institution, it is important to understand that typically as the approval authority goes up, the level of technical expertise and appreciation goes down. Consequently, the type of information that must be provided by a utility for a particular project must be carefully tailored to the audience and the decision-making process of an institution. Hospital engineers need to understand the financial models required to convince a senior manager of the value of a prospective investment. The management environment is changing in hospitals as they respond to the evolving healthcare market. Reducing cost and improving quality are important themes among hospital administrators, as many are emphasizing management techniques such as Continuous Quality Improvement, Performance Improvement, and FOCUS/PDCA (Find a process to improve, Organize, Clarify, Understand, Select/Plan, Do, Check, Act). Safety and Environmental Services These functions include environmental regulatory compliance, emergency response planning, material safety data sheets, worker right-to-know programs, risk 3-14
Healthcare Facilities
management plans, occupational safety and health issues, low-level radioactive waste issues, and hazardous waste minimization and recycling programs. Another major responsibility is treatment, disposal, and tracking of medical waste. The name and location of these functions varies with the organization. In some hospitals these functions fall under the Safety and Environmental Services Departments, while in others it is the Office of the Safety Coordinator, the Staff Industrial Hygienist, or Environmental Officer. Safety officers are also likely to be in quality assurance and external compliance areas. Often hospitals designate a vice president responsible for all standards, including quality and safety. Another important department under this category is Central Services (Central Supply or Sterile Supply). This department is responsible for collecting and receiving patient-care items, equipment, and packages; the central services department also stores, processes, maintains, and dispenses these items to all parts of a hospital, and is in charge of sterilization of medical instruments. Medical Staff and Nursing Services As the people who actually deliver healthcare, these two groups would be involved in many utility programs relating to hospitals. They have enormous influence on hospital policies and procedures and could be involved in decisions relating to utility-hospital programs. For example, the infection control nurse, chief respiratory therapist, or inhouse tuberculosis specialist are key allies when dealing with the issue of airborne nosocomial (hospitalization acquired) diseases and indoor air quality. Acceptance by the medical staff and nursing services of a new medical waste treatment system could go a long way in convincing the administration to invest in a new technology. The medical and nursing staff are often the first to encounter the effects of a power quality problem.
Hospital Finances and Related Issues Traditionally hospitals have been reimbursed by payers, such as insurance companies or the federal government, separately for each service provided to a specific patient. This method is called a fee-for-service plan. In contrast, many HMOs and other managed care providers are moving toward capitated plans in which they compensate hospitals on a pre-negotiated fixed rate per capita each month, based on the number of members in the plan. Hospitals relying on capitated business have their annual revenues fixed by the number of subscribers in their managed care customer base and can operate profitably only when their operating costs fall below the revenue ceiling. This provides a strong incentive for hospitals to hold down costs and eliminate unnecessary inpatient services. In conventional fee-for-service plans the reimbursement method rewards hospitals and physicians for providing services and procedures to patients. Furthermore, a glut of hospital beds combined with cost controls and discounts demanded by managed care payers have reduced hospital profit margins and hurt their creditworthiness. 3-15
Healthcare Facilities
In 1997 nearly all hospital expenditures were funded by third parties. Medicare and Medicaid funded nearly half of all hospital expenditures, while private health insurance paid for another third. Consumers directly paid for only three percent of all hospital services. Medicare spending for hospital services grew more than twice as fast (6.4%) as overall hospital spending (2.9%) in 1997 and 60% faster than overall hospital spending throughout the 1990s. Medicaid spending for hospital services dropped in 1997 (off 2.7%) probably as a result of growing managed care enrollment, the decline in Medicaid recipients and restrictions placed on states’ disproportionate share payments to hospitals.
Networks, Health Care Systems, Alliances In the complex arena of American healthcare delivery, hospitals are not independent, stand-alone institutions. Many are part of a larger structure under a single corporate owner. (These multi-hospital systems are described earlier in this chapter.) Others are joining with payers such as insurance companies or even large employers in managed care associations, and some are even establishing their own HMOs. (These payerprovider arrangements are discussed later in this chapter under the section “Role of Healthcare Payors in the Market.”) Hospitals also participate in local and national trade associations such as the American Hospital Association or the Catholic Health Association. In addition, their managers and specialists participate in professional groups. Both of these organizations are discussed in the “Trade and Professional Organizations” section. The AHA Guide to the Healthcare Field provides the following descriptions: Networks A network is a group of hospitals, physicians, other providers, insurers, and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Networks are very fluid in their composition as goals evolve and partners change. Health Care Systems To reflect the diversity that exists among health care organizations, the term health care system identifies both multihospital and diversified single hospital systems. Multihospital Systems—is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single Hospital Systems—single, freestanding member hospitals may be categorized as health care systems by bringing into membership three or more, and at least 25 percent, of their owned or leased non-hospital organizations. Organizations provide, or 3-16
Healthcare Facilities
provide and finance, diagnostic, therapeutic, and/or consultative patient or client services that normally precede or follow acute, inpatient, hospitalization; or that serve to prevent or substitute for such hospitalization. Alliances An alliance is a formal organization, usually owned by shareholders/members, that works on behalf of its individual members in the provision of services and products and in the promotion of activities and ventures. The organization functions under a set of bylaws or other written rules to which each member agrees to abide. Alliance hospitals form with each other to improve operations by sharing of information and services, group purchasing, public relations, and joint ventures. In 1999 the AHA Guide lists thirty alliances with memberships ranging from one to over 1500. Refer to the AHA Guide for a complete listing of each category. These networks, health care systems, and alliances are important for electric utilities to contact. The American Hospital Association maintains lists of hospital groups (along with contact information) which it publishes annually in the AHA Guide to the Healthcare Field, an indispensable source of information for any organization, including electric utilities, interested in better understanding the hospital industry.
Nursing Homes As the population ages, an increasing percentage is made up of elderly people, many of whom are in need of nursing care, either at home or in a facility. This section looks at nursing facilities, one of the largest components of the healthcare facilities market. According to the American Healthcare Association (AHCA), one of the primary trade groups for for-profit long-term care organizations (along with the American Association of Homes and Services for the Aging), in 1997 there were 17,176 Medicare and/or Medicaid certified nursing facilities, with 1.8 million beds and 1.5 million residents. The typical nursing facility resident is a white female Medicaid beneficiary aged 75 years or older. It is estimated that the nursing facility population aged 65 or older will grow to 5.5 million or nearly 7% of the population aged 65 and over by 2050 (Nursing Facility Sourcebook, 1998). The average nursing facility patient needs help with activities of daily living such as eating, moving from place to place, going to the toilet, dressing, and bathing. Nearly two thirds of nursing facility residents are disoriented or have memory impairment.
3-17
Healthcare Facilities
Role in the Health Delivery System Nursing homes are primarily establishments engaged in providing inpatient nursing and health-related personal care. They do not provide diagnostic, surgical, or extensive medical services as hospitals do. Their role in the healthcare delivery system is between that of hospitals and home healthcare. The system is changing, though, as are the traditional roles of the system’s institutions. Nursing homes fall into five broad categories: •
Skilled nursing facilities (both hospital and non-hospital based)
•
Intermediate care facilities
•
Custodial care facilities
•
Subacute care facilities
•
Continuing care retirement communities
Skilled nursing facilities, according to the Standard Industrial Classification system definition, provide inpatient and rehabilitative service to patients requiring continuous healthcare, but not hospital services. Care is ordered by and under direction of physicians, and staff includes licensed nurses continuously on duty. Skilled nursing facilities are the most common type of nursing home. Intermediate care facilities also provide continuous nursing and rehabilitative services but not on a continuous basis. Personnel are on duty continuously but licensed nurses are required only part of each day. The line between skilled and intermediate nursing facilities is sometimes blurred, and various organizations account for the categories differently. Custodial care facilities provide nursing and health-related care to patients who do not require the degree of care and treatment of a skilled or intermediate care facility. Examples of custodial care facilities include convalescent homes with healthcare and homes for the mentally retarded, with healthcare. Subacute care facilities, according to a definition developed by the AHCA and the Joint Commission on Accreditation of Healthcare Organizations, provide care which is generally more intensive than care from a traditional nursing facility, but less than the acute care provided by a hospital. Subacute care is comprehensive inpatient care designed for patients with an acute illness, injury, or exacerbation of a disease process. It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific, active, complex medical conditions. Generally, subacute patients need between four and seven hours of skilled nursing care 3-18
Healthcare Facilities
each day, compared with eight or nine hours for hospital patients. Subacute care facilities charge less than acute care hospitals for similar care and services. As a result, some managed care organizations are moving hospital patients to subacute care facilities before discharge. Continuing Care Retirement Communities (CCRCs) compose a rapidly growing area providing care for more than 270,000 residents who are still ambulatory, according to the U.S. Department of Commerce. CCRCs provide housing and healthcare in a campus-style setting with convenient services such as housekeeping and meals. The levels of care range from assisted living to skilled nursing. Additional healthcare services include emergency response, health clinics, wellness programs, hospice, primary and specialty physician care, dental care, pharmacy, and physical therapy. These facilities are often very expensive and not covered by Medicare.
Structure of the Industry There are over 17,000 certified and uncertified nursing homes in the United States. The number of nursing homes may vary, the specific number depending on the definition the organization doing the counting uses for “nursing home.” Some discrepancies may be found between government data and trade associations. Both sources offer information that is useful in understanding the market. In 1997, nursing facility ownership was approximately 65% for-profit, 29% nonprofit and approximately 6% government owned and operated. Fifty-three percent of facilities were owned and operated by a national multifacility chain and 47% were independently owned or operated. In 1997, 14% of the facilities also were owned or operated by a hospital organization. (Nursing Facility Sourcebook, 1998) The industry primarily comprises several dozen public and private systems. The top ten, ranked by number of beds, is shown in Table 3-5. The two largest systems are Beverly Enterprises and Vencor.
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Table 3-5 Top Ten Nursing Facility Systems
Total Facilities
States with SNF/NF
% Medicare
% Private Pay
% Medicaid
% VA and Other
Total Operating Revenue
SNF/NF
Subacute
Assisted Living
Therapy
Pharmacy
Home Care
Other
Beverly Enterprises David R. Banks
5111 Rogers Ave. Suite 40-A Fort Smith, AZ 72919 (501) 452-6712
Pub.
64,124
n/a
574
89
31
29
26
45
n/a
$3.3 billion
58
13
n/a
13
16
n/a
n/a
Vencor W. Bruce Lunsford
400 W. Market St. 3300 Providian Ctr. Louisville, KY 40202 (502) 596-7300
Pub.
40,869
4,825
311
92
33
30
23
44
3
$2.8 billion
80
Chillers that are less than 10 years old -->
replace convert
“Resources and References” lists resources dealing with chiller selection or retrofit, as well as other information that could help a healthcare facility manager. These include comparisons of electric chillers vs. gas cooling systems, updates on the CFC phaseout, regulatory issues, etc.
Resources and References Institutions Commercial Building Air-Conditioning Center 150 E. Gilman Street, Suite 2200 Madison, WI 53703-1441 Phone: (800) 858-EPRI or (608) 262-8220 Fax: (608) 262-6209 Web: www.engr.wisc.edu/centers/tsarc/contact.htm 6-92
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EPRI’s HVAC&R Center provides toll-free phone support to member utilities seeking information on refrigerants and competitive cooling issues. The Commercial Building Air-Conditioning Center (CBAC) is EPRI’s on-line information resource for member utilities. American Society of Heating, Refrigerating, and Air Conditioning Engineers 1791 Tullie Circle NE Atlanta, GA 30329-2305 Phone: (404) 636-8400 or (800) 527-4723 Fax: (404) 321-5478 Web: www.ashrae.org The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) sponsors conferences and offers many resources materials including briefing papers, technical reports, guidelines, and conference proceedings. ASHRAE has issued the following useful material, among others: Standard 15-1994: Safety Code for Mechanical Refrigeration, Standard 34-1992: Number Designation and Safety Classification of the Refrigerants, Guideline 3-1990: Guideline for Reducing Emission of Fully Halogenated CFC Refrigerants, and The Refrigerant Recovery Book. Air-Conditioning and Refrigeration Institute 4301 N. Fairfax Drive, Suite 425 Arlington, VA 22203 Phone: (703) 524-8800 Fax: (703) 528-3816 Web: www.ari.org The Air-Conditioning and Refrigeration Institute (ARI) is a national trade association representing manufacturers of air-conditioning and refrigeration equipment. The Institute has available directories, policy recommendations, standards and guidelines. The Air-Conditioning and Refrigeration Technology Institute (ARTI) conducts research for ARI including evaluation of alternative refrigerants. ARI has released the following publications, among others: Directory of Certified Recovery and Recycling Equipment, Standard 700-93: Specifications for Fluorocarbon Refrigerants, and Standard 740-93: Performance of Refrigerant Recovery and Recycling Equipment. Association of Energy Engineers 4025 Pleasantdale Rd., Suite 420 Atlanta, GA 30340 Phone: (770) 447-5083 Fax: (770) 446-3969 Web: www.aeecenter.org
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The Association of Energy Engineers (AEE) sponsors seminars and distributes printed material dealing with CFC and HCFC phaseout issues. Refrigerating Engineers and Technicians Association 401 N. Michigan Avenue Chicago, IL 60611-4267 Phone: (312) 527-6763 Fax: (312) 527-6705 Web: www.reta.com The Refrigerating Engineers and Technicians Association (RETA) sponsors meetings and offers refrigeration service certifications. Refrigeration Service Engineers Society 1666 Rand Rd. Des Plaines, IL 60016-3552 Phone: (847) 297-6464 or (800) 809-0389 Fax: (847) 297-5038 Web: www.rses.org The Refrigerating Engineers and Technicians Association (RSES) sponsors meetings and offers refrigeration service certifications. The Alliance for Responsible Atmospheric Policy 2111 Wilson Boulevard, Suite 850 Arlington, VA 22201-3058 Phone: (703) 243-0344 Web: www.arap.com The Alliance is a coalition of U.S. companies that produce CFCs, HCFCs, and HFCs, as well as products and processes that rely on these refrigerants. Its objectives relate to legislation and advocating the industry’s position. Government Agencies U.S. EPA Phone: (800) 296-1996 or (301) 614-3396 Web: www.epa.gov/spdpublc/mbr/mbrregs.html The Environmental Protection Agency maintains a stratospheric ozone hotline to inform the public about refrigerant phaseout issues. The agency also distributes publications related to CFCs and HCFCs, including fact sheets, list of reclaimers, case histories, and rules. Among the materials in EPA’s publications list are: Final Rule Summary: Complying with the Refrigerant Recycling Rule, Short List of Alternative 6-94
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Refrigerants, Cooling and Refrigerating Without CFCs, and Resources: Air Conditioning and Refrigeration. U.S. DOE Phone: (202) 586-5000 (general information) or (202) 586-9130 Web: www.doe.gov The Department of Energy sponsors alternative refrigerant research and distributes reports and other printed information including Energy and Global Warming Impacts of CFC Alternative Refrigerants. Selected Publications “Case Study in Southern California Edison Territory: New and Rebuilt CFC-Free Chillers Provide Many Benefits.”SU-105401-R1. Commercial Cooling Update. Issue 2, Rev. 1, Electric Power Research Institute, Palo Alto, CA, April 1996. “CFCs and Electric Chillers: Selection of Large Water Chillers in the 1990s.” TR-100537. Electric Power Research Institute, Palo Alto, CA, April 1992. “Chiller Retrofit Issues.” SU-102513. CFC Update. Issue 6, Rev. 1, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, November 1995. “Chiller Selection.” CFC Update. Issue 7, Rev. 2, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, February 1996. “EPA Preparedness Campaign.” SU-102714. CFC Update. Issue 8, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, June 1993. “Industrial Ammonia Refrigeration.” TechCommentary. 5 (1), Electric Power Research Institute, Palo Alto, CA, 1993. “Information Resources.” SU-101267-R5. CFC Update. Issue 2, Rev. 5, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, March 1996. (Includes a list of refrigerant and chiller manufacturers, periodicals and newsletters, and seminars/meetings/proceedings) “Refrigerant Recycling.” SU-101269-R4. CFC Update. Issue 4, Rev. 4, Electric Power Research Institute’s Commercial Building Air-Conditioning Center, Madison, WI, October 1997.
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“Refrigerant Regulatory Issues.” SU-101190-R5. Commercial Cooling Update. Issue 1, Rev. 5, Electric Power Research Institute, Palo Alto, CA, January 1996. “Status of HCFC-22 Alternatives for Unitary HVAC.” Commercial Cooling Update. Issue 10, Rev. 2, Electric Power Research Institute, Palo Alto, CA, April 1997.
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Issues and Opportunities in Facilities Engineering and Management: Thermal Energy Storage Thermal Energy Storage (TES) has applications in hospitals, nursing homes, and other healthcare facilities. TES is a technology for storing energy in a thermal storage mass for use as off-peak energy in low-cost space conditioning. TES systems are flexible and many systems are available. The thermal storage mass is usually inexpensive, involves no moving parts, and can last for 30 to 50 years with minor maintenance. TES can meet the same cooling requirement with smaller, less expensive refrigeration equipment that has a lower electric demand during a utility’s peak demand periods while drawing most of its electric power and energy during off-peak periods. Many utilities offer time-of-use rates that include a significant reduction in electric energy prices during off-peak periods. Some advantages of TES for space cooling include: •
Potential savings in cooling costs by 20-50%
•
Savings in installed cost of refrigeration equipment
•
Savings in kilowatt demand charges
•
Possible savings due to off-peak energy use
•
Enhanced performance of cold air distribution systems
•
Possible use as backup cooling for critical cooling loads during power interruptions
In the construction of new buildings, TES systems used with cold air distribution allow for smaller ductwork. This means as much as 6 inches (152 mm) in floor-to-floor height reductions which may be significant in high-rise structures. The decrease in floor height could in turn provide savings in construction, plumbing, electrical and elevator costs. Utilities benefit from TES systems because it allows utilities to reduce peak demand and fill load valleys, improve utilization of baseload generating equipment, reduce reliance on peaking units, and improve load factors. Cool storage also allows utilities to stem peak demand growth and defer capacity expansion costs.
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Principles of Cool Storage Operation Cool storage relies on a storage medium with a high specific or latent heat to store cooling energy. Refrigeration is provided by conventional chillers or industrial-type icemaking units. Storage capacity is sized to shift all or part of a building’s demand for cooling to off-peak hours. Full storage supplies the building’s entire on-peak cooling needs. Partial storage supplies only part of the peak period cooling requirements and can be used to level off the building’s electrical demand for cooling over the whole 24-hour day or to reduce maximum demand to a predetermined level. The choice of strategy relative to full or partial cool storage is generally an economic decision. TES systems for storing cooling energy typically use ice, chilled water, or eutectic salt as the storage mass. (Each of these is described below.)
Ice Storage Ice-thermal energy storage (Ice-TES) allows for cool storage at 32°F (0°C). More than 1000 Ice-TES installations were in operation in the U.S. by the end of 1990. By making ice with electric refrigeration equipment during off-peak hours, the ice is allowed to melt to provide cooling, dehumidification, or refrigeration during the day. Actual ice storage systems require about 3 cubic feet (0.085 m3) of storage per ton-hour of cooling. An Ice-TES can be easily combined with a cold air distribution system. Alternately, industrial-grade ice-making units can be used to store energy in an ice/water mixture. These ice storage tanks are a third the size of chilled water-TES and can be stored in the central plant mechanical room, buried outside the building, or built into a basement or parking garage. Case Study: Ralph H. Johnson Medical Center, Charleston, South Carolina The Ralph H. Johnson Medical Center is a 300-bed VA hospital. Through the technical assistance of South Carolina Electric & Gas, the hospital phased out an old CFC-based chiller and replaced it with a 600-ton screw chiller using HCFC-22 along with a TES system comprised of 34 modular ice storage tanks. The hospital realized a 25% reduction in annual electrical costs while avoiding a 926 kW peak demand and shifting energy use during on-peak periods. The cold-air system provided greater comfort and increased productivity especially in surgical suites. Lower consumption and demand charges meant a savings of about $150,000 per year in electricity costs and expected simple payback of 5.5 years.
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Case Study: Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 2
The Dartmouth Hitchcock Medical Center is a 1.1 million sq. ft. (102,190 m ) facility that includes a 328-bed inpatient care hospital, a 160-physician clinic, medical research building, diagnostic and treatment facility, and separate energy plant. The central energy plant incorporates a 5,400 ton-hour ice storage system comprised on 36 ice tanks (150 ton-hours each); Calmac Manufacturing Corporation of Englewood, NJ) interconnected to a 520-ton ice-making chiller. Ice making during offpeak hours shifted an estimated 700 kW of demand. The Medical Center realized approximately $35,000 in annual electrical demand savings plus $15,000 annual savings due to reduced utility off-peak kWh charges. Installation cost was about $310,000. With a utility rebate of $185,000, net payback is estimated at 2.5 years.
Case Study: Grossmont Hospital, La Mesa, California 2
Grossmont Hospital is a 490,000 sq. ft. (45,521 m ) medical facility in La Mesa, California. A study determined that the hospital had an additional design day cooling requirement of 740 tons. This requirement was met using a 320-ton chiller and 22 ice storage banks. San Diego Gas & Electric offered a cash incentive to install the ice-TES system by Calmac Manufacturing Corporation. The new ice storage enabled the hospital to shift 232 kW off-peak and avoid a non-ratcheted $14.42 per kW time-of-use demand charge. Energy cost savings are estimated at $17,000 annually with a payback period of about three years.
Case Study: Deaconess Hospital, Oklahoma City, Oklahoma The 210-bed Deaconess Hospital in Oklahoma installed a 120-ton air cooled chiller and eight ice banks to meet a need of 250 tons of additional air conditioning. Oklahoma Gas & Electric offered a cash incentive. The ice tanks were buried under the ground. Ice storage not only cut the required chiller size in half, it also resulted in a shift of 250 kW off-peak thus saving the hospital a $9.15 per kW unratcheted utility time-of-use demand charge. Payback is estimated to be about five years.
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Case Study: St. Joseph’s Medical Center, South Bend, Indiana St. Joseph’s Medical Center added new buildings to house medical offices, outpatient clinics, and an emergency center including surgical suites. With the assistance of American Electric Power, Ice-TES, high-efficiency chillers, and a variable air-volume cold-air distribution system were installed. Cooling energy to one building is provided by a 120-ton air-cooled reciprocating electric chiller and TES tanks with 900 ton-hours storage capacity. The emergency center is cooled by an air-cooled, screw-type chiller and ice TES tanks. The results were decreased operating costs and increased occupant comfort.
Chilled Water Storage Another popular system uses chilled water to store cooling energy. Over 150 water-TES installations were operational in the U.S. at the end of 1990. During off-peak hours, water is chilled to between 40 to 46°F (4 to 8°C) by electric refrigeration equipment. During on-peak periods, the chilled water is circulated through cooling coils or heat exchangers to absorb heat and provide space cooling and dehumidification. In some facilities, fire protection water tanks may double as thermal storage. A cost analysis shows that water-TES should be considered whenever a cool storage capacity of 1000 ton-hours or more is needed. During summer months when the nighttime temperatures are 16 to 22°F (9 to 12°C) lower than daytime temperatures, an electric chiller operates efficiently with the cooler outside air and the water-TES system can take advantage of the lower temperatures. A cooling tower can be used to chill water at night.
Eutectic Salt Storage Eutectic salts, also called phase change materials (PCMs), are also used as thermal storage. Over 80 PCM-TES installations existed in the U.S. at the end of 1990. Cooling energy is stored in PCM-TES systems in the same way as ice-TES. Eutectic salts are frozen or solidified during off-peak hours and allowed to melt to provide cooling and dehumidification during on-peak periods. A PCM-TES system consists of one or more plastic containers filled with a eutectic salt. Since these are passive units, these containers may be stacked in concrete storage units or buried under parking lots or lawns. Eutectic salts have been developed to undergo phase change while absorbing or releasing large amounts of energy. Two eutectic salts freezing at 41 or 47°F (5 or 8°C) are commercially available. PCM-TES can take advantage of cooler nighttime air temperatures. The salt can be solidified using a cooling tower at nighttime.
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Case Study: Saint Mary Medical Center, Long Beach, California Saint Mary Medical Center received a $100,000 incentive payment from Southern California Edison to install a 2,500-ton-hour partial storage eutectic salt TES system in 1986. The PCM-TES system was used in lieu of a 400-ton chiller. The system shifted 500 kW of demand from on-peak to off-peak periods.
Cool Storage Control Control technology for cool storage systems generally rely on preprogrammed, timesequenced schedules for chiller and storage operation based on minimizing electrical costs for a design-day profile. Nondesign days, however, may occur 90% of the time so maximum cost savings may not be achieved. EPRI commissioned Honeywell Inc. to develop software for optimal control of thermal storage systems. The Cool Storage Supervisory Controller (CSSC) is now available for use with energy management systems. The CSSC controller predicts temperature and load and selects an operating strategy for a given day. It then updates the ambient temperature and load profile throughout the day and adjusts its operating strategy on an hourly basis.
Cool Storage Economics TES systems require an upfront incremental investment primarily for the storage tank and its auxiliaries. Unless there are space constraints, the determination of which storage strategy to employ is based on economic considerations involving the utility’s peak period, the differential rates between off-peak and peak rates, demand charges, and whether the building’s non-cooling load undergoes a large daily swing. In addition to storage costs, there are also refrigeration costs, potential savings in ductwork, pumps, fans, etc. Using a chilled water tank to double as a fire protection reservoir may lower insurance premiums. The payback period for cool storage investments is usually two to six years, although paybacks of less than a year have been documented. TES can result in a 25% savings in total electric bill, or savings of 15 to 25¢ per sq. ft. ($1.60 to $2.70 per sq. m.)
Thermal Energy Storage for Space Heating In a manner analogous to cooling storage, TES for space heating shifts the time of energy use for heating to off-peak hours. An energy storage medium is heated during nighttime hours and its heat is released on demand during the day. As in cooling 6-101
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storage, thermal storage for heating is flexible; systems can be sized to suit a room or an entire facility. A variety of storage media is used including special refractory brick, rock, cement/sand, or water. Commercially packaged systems generally use brick or rock and are marketed in a range of sizes. Central forced-air and central hydronic units are designed for easy retrofit to conventional forced-air heating systems. In central forced-air units, the thermal storage furnace replaces an exiting oil or gas unit. In hydronic units, heat is stored in water stored in large vessels and the heated water is run through pipes in the baseboard or under the floor. TES systems help provide uniform warmth. The technology is proven and reliable and requires little maintenance. Some utilities provide incentives to offset the equipment’s initial costs by offering rebates, special time-of-use rates, or off-peak rates. For a utility, TES can be part of a load management program of load shifting and increasing the use of higher efficiency baseload generating units.
Resources and References List of Hospitals with Calmac TES (Data provided by Calmac Manufacturing Corporation, Box 710, 101 West Sheffield Avenue, Englewood, NJ 07631; (201) 569-0420; Fax (201) 569-7593; www.calmac.com) Grossmont Hospital, La Mesa, CA Tri-City Medical Center, Oceanside, CA Kaiser Permanente Hospital, San Diego, CA Largo Medical Center, Largo, FL L.W. Blake Memorial Hospital, Bradenton, FL Halifax Medical Center, Daytona Beach, FL Lutheran Medical Park, Fort Wayne, IN South Bend Medical Foundation, South Bend, IN South End Medical Clinic, Louisville, KY Dartmouth Hitchcock Medical Center, Lebanon, NH Kaseman Presbyterian Hospital, Albuquerque, NM Timkin Mercy Hospital, Canton, OH Deaconess Hospital, Oklahoma City, OK Children’s Hospital, Pittsburgh, PA Kent County Hospital, Warwick, RI Baylor Hospital, Dallas, TX Gallagher Road Medical and Surgical Building, Sherman, TX Riverside Hospital, Newport News, VA
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Printed Material, Slides, and Videos “Cold Air Distribution Design Guide.” TR-105604. Electric Power Research Institute, Palo Alto, CA, 1995. “Cold Air Distribution with Ice Storage.” CU.2038R.5.92. Electric Power Research Institute, Palo Alto, CA, 1992. “Commercial Cool Storage Design Guide.” EM-3981. Electric Power Research Institute, Palo Alto, CA, 1985. “Commercial Cool Storage Presentation Material.” 2 vols., EM-4405. Electric Power Research Institute, Palo Alto, CA, 1986. “Commercial Cool Storage.” EU-3024. Electric Power Research Institute, Palo Alto, CA, 1993. “Cool Storage Marketing Guidebook.” Slide presentation and handbook. EM-5841s. Electric Power Research Institute, Palo Alto, CA, 1988. “Cool Storage Seminar.” Video lecture. EM85-03. Electric Power Research Institute, Palo Alto, CA, 1986. “Cool Storage Supervisory Controller.” CU.2021.8.89. Electric Power Research Institute, Palo Alto, CA, 1989. “Electric Thermal Storage Applications Guide and Product Directory.” CU-6741. Electric Power Research Institute, Palo Alto, CA, 1990. “Electric Thermal Storage.” BR-100589. Electric Power Research Institute, Palo Alto, CA, 1992. “Energy Efficient HVAC System Features Thermal Storage and Heat Recovery,” Eugene Bard of Bard, Rao + Athanas Consulting Engineers, Boston, MA, April 8, 1994. “Eutectic Salts-Thermal Energy Storage.” BR-100691. Electric Power Research Institute, Palo Alto, CA, 1993. “Ice-Thermal Energy Storage.” BR.100689. Electric Power Research Institute, Palo Alto, CA, 1992. “Review of Heat Storage Materials.” EM-3353. Electric Power Research Institute, Palo Alto, CA, 1983. “Rocks Around the Clock.” EPRI Journal. July/August 1987.
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“Stratified Chilled-Water Storage Design Guide.” EM-4852. Electric Power Research Institute, Palo Alto, CA, 1988. “Thermal Energy Storage for a Hospital.” TechApplication. EPRI Community Environmental Center, Riverdale, NY, 1996. “Thermal Energy Storage for Healthcare Facilities.” TechCommentary. EPRI Community Environmental Center, Riverdale, NY, 1996. “Thermal Energy Storage With Cold Air Distribution in a Healthcare Facility.” TechApplication. EPRI Community Environmental Center, Riverdale, NY, 1996. “Thermal Energy Storage.” BR-020252. Electric Power Research Institute, Palo Alto, CA, 1992. “Water-Thermal Energy Storage.” BR.100690. Electric Power Research Institute, Palo Alto, CA, 1992. Institutions ITSAC Advisory (formerly ITSAC Newsletter) and Technical Bulletins, published with EPRI support by International Thermal Storage Advisory Council 3769 Eagle Street San Diego, CA 92103 Phone: (619) 295-6267 ITSAC bulletins keep customers abreast of product developments, applications, workshops, and utility marketing initiatives, as well as provide them with a directory of cool storage component and packaged system manufacturers. Thermal Storage Application Research Center (TSARC) University of Wisconsin-Madison Phone: 608-262-8220 or 800-858-EPRI The Thermal Storage Application Research Center (TSARC) is an EPRI-funded institution established to help utilities and their customers apply thermal storage technology.
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Issues and Opportunities in Facilities Engineering and Management: Water Disinfection and Purification All water in a healthcare environment, except for sterilized water, can be a reservoir of infectious agents. The potential water reservoirs for nosocomial infections in a healthcare facility include: •
Water baths and basins
•
Hospital sinks
•
Faucet aerators and showers
•
Immersions tubs
•
Ice and ice machines
•
Ice baths for thermodilution cardiac output
•
Dialysis water
•
Hospital toilets
•
Tap water used for flowers
•
Distilled water generators and containers
•
Eye wash stations
•
Potable water
•
Cooling tower and boiler water
•
Water distribution systems.
Even potable water that is not sterile but has acceptable levels of coliform bacteria (that is, less than 1 coliform bacterium per 100 ml) can harbor several kinds of noncoliform bacteria and nontuberculous mycobacteria. Certain types of water bacteria have the capability to survive in distilled, deionized, reverse osmosis, and softened water used to supply water for hemodialysis and other medical needs. A number of reports have demonstrated the presence of gram-negative bacteria in hospital sinks; some investigators have suggested that this bacteria can pass to patients by the hands of healthcare workers contaminated during washing.
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Cases of Water Contamination in Healthcare Facilities Outbreaks linked to contaminated water in healthcare facilities have been documented in the literature: •
Legionella pneumophila cases were linked to contamination of hospital water supplies and water distribution systems
•
Six patients in an intensive care unit were infected with Pseudomonas paucimobilis found in the ICU hot water line
•
19 patients acquired pulmonary disease due to Mycobacterium xenopi found in hotwater generators and water faucets in hospital wards in 1981
•
Various outbreaks due to M. chelonae among patients have been reported: in one doctor’s office, it was due to contamination of tap water used to clean instruments; in a hospital, it was due to contamination in the hospital’s general water tanks; in a clinic, the outbreak came from the clinic’s water supply used in hemodialysis
•
Serious outbreaks of infections with Pseudomonas and Acinetobacter were traced to contaminated bath water used to thaw or warm blood products
•
Many skin infections (P. aeruginosa folliculitis) have been associated with tub immersions and contaminated whirlpool baths and hot tubs used in physical therapy and for cleaning burn wounds
•
As far back as 1903, numerous cases of outbreaks have been documented as a result of contaminated ice and ice machines used in hospitals
•
Multiple outbreaks in hemodialysis patients were due to contaminated water.
Many of these problems can be minimized by following careful disinfection procedures, use of sterile or properly disinfected water where necessary, and periodic inspection and cleaning of equipment. Distillation is used in some healthcare facilities but is energy intensive. For example, boiling a gallon of water consumes 20,000 more energy than the energy needed to disinfect the same amount of water using UV radiation (see below). Furthermore, distillation does not remove purgeable organic contaminants which are carried over into the distillate with the water vapor. Reverse osmosis is another method used especially in laboratories.
Chemical Treatment Methods Chlorination is the standard water treatment method along with coagulation, sedimentation, and filtration. Chlorination can be accomplished through the addition of 6-106
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liquid chlorine, chlorine dioxide, or salts of hypochlorous acid (e.g., sodium hypochlorite or bleach). A new chlorination-based technology, developed by Los Alamos Technical Associates, is an electrotechnology which eliminates the need to handle dangerous chlorine gas. The MIOX technology produces aqueous hypochlorous acid solution by electrolysis of sodium chloride salt pellets and water. It is currently manufactured and sold by MIOX, Inc. (5500 Midway Park NE, Albuquerque, NM 87109; 888-MIOX-H2O or 505-343-0090; Fax 505-343-0093; www.miox.com). Although chlorination is an effective, inexpensive, and readily available technology, various health concerns have been raised in recent years. Any ammonia in the water reacts with residual chlorine to form chloramines which are toxic above certain concentrations. Recently, there has also been concern over chlorine reactions with organic matter in drinking water to form cancer-causing trihalomethanes. New technologies now exist as alternatives or supplements to chlorination. Studies at the University of Arizona and Montana State University have shown that use of ionized copper and silver in conjunction with low levels of free chlorine can be effective in killing numerous species of harmful bacteria, especially Legionella pneumophila. This ionization process used in conjunction with reduced concentrations of chlorine and chloramines is an alternative for disinfecting potable hot water in healthcare facilities. The process can also be used for therapeutic baths and cooling towers. The Aqua Bio Control System (28870 U.S. 19 N, Suite 300, Clearwater, FL 33761; 813-669-5005; Fax 813-669-4701; http://aquabiotech.com/aqua/industries/poolsandspas.htm) is an advanced electrolytic process that controls and eliminates bacteria, viruses, algae, fungus, and yeast while reducing chemical usage by electrolytically generating copper and silver ions in the proper proportions for addition into water. Iodine—another halogen like chlorine—has been used as a disinfectant for years and is effective on a wide variety of bacteria. Being less reactive than chlorine, iodine produces less halogenated organic compounds. The newer iodination processes involve resinsequestered iodine systems which keep iodine attached to resin particles where pathogens are destroyed without releasing iodine into the disinfected water. However, iodine is more expensive than chlorine. The regenerable iodine system developed by UMPQUA research has been used in the Space Shuttle (NASA Tech Briefs, July 1994). Water flows through a Microbial Check Valve with an on-line iodinated ion exchange resin cartridge where microorganisms are destroyed. The new system allows for regeneration of iodine for longer-term use. The TechniCat catalytic water treatment system, distributed by ARS Enterprises (12900 Lakeland Road, Sante Fe Springs, CA 90670; 800-735-9277 or 562-946-3505) operates catalytically to alter the minerals in water and reduce the ability of minerals to form scale. By transforming minerals in water to less ionically active forms, the TechniCat unit reduces scaling, improves the efficiency of heating and reverse osmosis devices, and may possibly decrease bacteriological activity. It can be used to treat water 6-107
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supplied to hospital sterilizers, reverse osmosis water treatment devices, ice machines, autoclaves, cooling towers, boilers, washer decontaminators, etc.
UV Disinfection UV disinfection technology for destroying waterborne diseases is finding application especially in the developing world where the need is great but the technology may also be useful in healthcare and other facilities where water that is free of pathogens is critical in certain operations. In this technology, water is passed through a disinfection unit containing a lamp that generates UV-C light (so-called germicidal UV) to destroy bacteria, viruses, and other pathogens. UV disinfection is not effective in waters that are turbid or have high concentrations of suspended particles which can block UV radiation. UV destroys pathogens but is not effective on protozoan cysts such as those responsible for giardiasis which, however, can be removed by adding an appropriate filter. Other factors to consider in selecting UV disinfection are sedimentation, algae growth, and fouling, all of which can reduce the effectiveness of UV treatment. Unlike chlorination, iodination, or ionization, however, UV disinfection does not add anything to the water being treated and does not produce a taste or odor. The Ohio Pure Water Company (P.O. Box 86, North Olmsted, OH 44070; 888-644-6329; Fax 888-OHIO-FAX; www ohiopurewaterco.com) distributes a range of UV water purification systems for use in hospitals, laboratories, veterinaries, and pharmaceutical industries. The system is designed to produce disinfected and ultrapure water for pathology labs, kidney dialysis, and post-disinfection rinses. The Sanitron UV water purifiers use between 10 to 110 watt lamps with a rated effective life of 10,000 hours. The purifiers provide a dosage in excess of 30,000 microwatt seconds per sq. cm. Water enters the stainless steel, cylindrical-shape purifier chamber and flows through an annular space between the quartz sleeve of the UV lamp and the chamber wall. Wiper segments induce turbulence to insure uniform exposure to UV radiation. The wiper assembly also facilitates periodic cleaning of the quartz sleeve without interrupting the operation. Depending on the model, the whole unit can consume between 14 to 1120 watts, with capacities from 2 to 333 gallons per minute (0.45 to 7.5 m3/h). Optional features include a UV radiation level monitor (to determine if UV dosage is sufficient), elapsed time indicator, and alarm. The Center for Building Science’s Indoor Environment Program (Lawrence Berkeley National Laboratory, University of California, One Cyclotron Rd., Berkeley, CA 94720; 510-486-6155; www.lbl.gov) has developed a prototype UV Waterworks unit. UV Waterworks is an easy to use and inexpensive device with a life expectancy of 15 years; the 35-watt UV lamp inside a stainless steel chamber requires replacement every other year. A system, the size of a microwave oven, can disinfect four gallons per minute (0.9 m3/h).
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Ozonation Ozone treatment has long been used as an oxidant and disinfectant for drinking water especially in Europe. Apprehensions over the health effects of chlorine by-products have prompted more interest in ozonation in the U.S. although the formation of bromate ion and possible aldehydes during ozonation have caused some concerns. Nevertheless, ozone treatment has the advantage of not only disinfecting various types of microorganisms, it also decomposes organic compounds, assists in the removal of suspended solids in water, removes odors and tastes, controls algae, removes dyes, and oxidizes certain metals and inorganic substances. As such, it has been used not only in potable water applications but also in treatment of sewage effluents, cooling tower water, beverage water, bottled water, hazardous waste, as well as applications in the pharmaceuticals industry, laundries, bleaching, and food processing. Although ozone has a short environmental life, one possible problem is the accumulation of ozone in an enclosed work space to an unacceptable concentration; hence, ozone monitoring in air is an important occupational safety precaution. An ozonation system is composed of a power supply, feed gas preparation, ozone generator typically using corona discharge or UV energy, an ozone-water contacting device, and an off-gas treatment system. There are about three dozen ozone generator suppliers in North America manufacturing equipment that produce a wide range of sizes of ozone equipment. (For a list of vendors, the reader is referred to EPRI’s Ozone Reference Guide.) While many of the markets for ozonation are in large-scale municipal and industrial applications, compact small-scale ozonation systems also exist such as in medical device sterilization and in research laboratory applications. Ozonation for water purification in a healthcare facility would be a novel application.
Resources and References “Aqua Bio Technologies, Inc. Electronic Water Treatment: Systems Operations Manual.” Brochure, Aqua Bio Technologies, Inc., 1996. “ARS Enterprises.” Product Focus, Infection Control & Sterilization Technology. May 1996. G.V. Colombo and D.R. Greenley. Advanced Microbial Check Valve Development. Final Report, NASA Contract NAS9-15854, June 1980. Rip Rice. Ozone Reference Guide. EPRI Community Environmental Center, St. Louis, MO, April 1996. R.J.B. Turpin. “Technicat Water Treatment in Industrial and Commercial Systems.” Pamphlet #2, Technicat, Inc., Santa Fe Springs, CA.
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David Weber and William A. Rutala. “Environmental Issues and Nosocomial Infections.” Chapter 25 in Prevention and Control of Nosocomial Infections. 3rd edition, edited by Richard P. Wenzel, Williams & Wilkins, Baltimore, Maryland, 1997. Warren Weisman, Jr. and Mark J. Hammer. Water Supply and Pollution Control. 6th edition, Addison Wesley, Menlo Park, CA, 1998. “UW Waterworks: Reliable, Inexpensive Water Disinfection for the World.” Center for Building Science News. Winter 1996 issue, Lawrence Berkeley National Laboratory, Berkeley, CA, 1996. Vendor literature.
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Issues and Opportunities in Facilities Engineering and Management: Energy Management An energy management system (EMS) provides the facility manager with information about and control over facility operations. The main benefit of an EMS is energy savings which can be achieved as lighting, space conditioning, and other operations are done more efficiently, and energy use is managed to take advantage of electric utility rate structures. There are additional benefits to an EMS such as improved occupant comfort, ability to spot impending equipment failures before they happen, more efficient maintenance scheduling, and better understanding of energy use patterns. Some of the energy management strategies possible for a hospital with an EMS are: •
Adjustment of temperatures depending on time of day, day of the week, and season of the year
•
Night purging to bring in cooler outside air during the night
•
Reduction of air-conditioning energy depending on outside temperature; coordinating parameters of HVAC operation to function at highest efficiency
•
Scheduled on-off controls, e.g., turning off lights and HVAC equipment in unoccupied areas; the EMS can also provide optimum start and stop strategies for different zones in the facility
•
Resetting of boiler temperatures to reflect changing demand for steam use, hot water, and space heating
•
Capability to optimize the use of thermal energy storage
•
Controlling temperature, humidity, and other air quality parameters for patient and staff comfort; allowing for more local zone control in the healthcare facility; permitting occupant override
•
Showing alarm conditions on potentially problematic equipment
•
Monitoring operating performance for better diagnosis and maintenance scheduling
•
Monitoring demand and cycle loads to avoid peak-demand periods
•
Ability to shift energy use according to time-of-day rates, shedding loads when a demand limit is approached, etc.
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Distributed EMS for a Hospital The EMS for a hospital is typically a distributed design, with the control logic distributed to many controllers communicating with each other and each providing some part of the overall energy management control. The system is comprised of timers and setback thermostats, local controllers, sensors (such as temperature, pressure, and occupancy sensors), actuators, and one or more operator terminals. The distributed EMS often has the capability to operate at reduced effectiveness in the event of a failure in one component. The controller usually has a preprogrammed logic that can provide standard functions including closed-loop control of HVAC equipment. The EMS allows communication not only between pieces of equipment, sensors, and controllers, but also with local area networks and external systems. An EMS can be monitored on site or remotely. Available software include graphical capabilities that show data in real time and in different levels of detail. In procuring an EMS, several steps are important to ensure that the best system is obtained. Facility managers should involve energy consultants with experience in EMSs, conduct an energy audit to understand energy use patterns and identify energy savings opportunities, perform an economic analysis, develop specifications, and either solicit bids or obtain a performance contract (or guaranteed savings contract). The EPRI Healthcare Initiative has a network of consultants and EPRI staff who can assist in the acquisition of an EMS. Vital to the operation of an EMS are periodic evaluation of the data provided and ongoing maintenance of the EMS and associated equipment. EPRI’s Commercial Building Energy Management System Handbook lists companies and EMS specifications and gives data on whether the EMS is appropriate for a hospital, extended care facility, or large hospital complex. Case Study: St. Charles Medical Center, Bend, Oregon St. Charles Medical Center: • General medical and surgical facility • 181-bed hospital • Serves 9,200 patients annually 2 • 311,000 square feet (28,892 m ) St. Charles signed an energy savings guaranteed contract (HealthLink™) with Johnson Controls (about $160,000 annually in utility cost savings guaranteed over a seven-year period). After an extensive audit, twelve energy conservation measures were identified. Bonneville Power Authority helped to fund the implementation of the energy management plan. Facility operations management were consolidated by installing a Metasys® Facility Management System. Metasys allows the operation of different systems and field equipment using one Metasys workstation, using existing controls of different manufacturers and providing a higher level of operational efficiency. In 1994, St. Charles Medical Center was named Energy Star Showcase Building by the Environmental Protection Agency.
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Real-Time Pricing (RTP) Controller Real-time pricing is an hourly-based rate that reflects the time-varying cost of generating and transmitting electricity. These rates can be forecasted as little as an hour in advance. By providing healthcare customers with hourly-based pricing, customers can make optimal energy use decisions, reducing electricity usage during high RTP periods to realize savings. RTP control strategies include precooling, thermal energy storage, variable speed motors, stand-by generation, generalized load shedding, etc. The full benefit of RTP can be achieved using an RTP controller. Honeywell’s RTP Controller automatically sheds and shifts electrical equipment usage in commercial facilities in response to RTP prices. The controller software can control up to 100 points on the building automation system. The RTP controller receives RTP rates directly from the utility and implements load shedding strategies to operate the facility in a costefficient way. Example: Crawford Long Hospital, Atlanta, Georgia An RTP controller has been installed at Emory University Crawford Long Hospital in Atlanta, GA with the support of Georgia Power and EPRI’s Information Systems and Telecommunications Business Unit.
EPRI has sponsored the development of a Customer Communications Gateway and Utility Master Station developed by Honeywell to facilitate two-way communication between utility and customer. The system provides general data, rate data, load data, and RTP data (projected and actual operating points). For the utility, the RTP controller reduces the need for peaking electric generation and provides a platform for new customer services. At the same time, the customer’s electric utility costs are reduced and operational efficiency is improved.
Resources and References “Acquisition of Commercial Building Energy Management Systems.” BR-101640. Electric Power Research Institute, Palo Alto, CA, 1993. “Benefits of Commercial Building Energy Management Systems.” BR-101639. Electric Power Research Institute, Palo Alto, CA, 1993. “Commercial Building Energy Management Systems Handbook. TR-101638. Electric Power Research Institute, Palo Alto, CA, June 1993.
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“Honeywell Real-Time Pricing (RTP) Controller.” BR-105227. Electric Power Research Institute, Palo Alto, CA, 1995. “Operation of Commercial Building Energy Management Systems.” BR-101641. Electric Power Research Institute, Palo Alto, CA, 1993.
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Issues and Opportunities in Food Services: Efficient Cooking and Other Kitchen Technologies Electric Cooking Technologies Cafeteria and kitchen services are found in hospitals, medical centers, nursing homes, and other healthcare institutions. Today, a whole range of electric cooking technologies as well as efficient ventilation and heat pump water heating are available for kitchen applications in the healthcare industry. All-electric cooking equipment can provide the following benefits: •
Lower food costs
•
Consistently higher food quality, better product consistency, and possible reduction in food shrinkage
•
Lower ventilation and air conditioning requirements; as much as 20% lower hood ventilation costs; less heat in the kitchen
•
Improved air quality: no combustion by-products nor risk of gas leakage
•
More accurate temperature control
•
Space savings due to compact designs
•
Ease of operation; safe operation and elimination of open flames
•
Energy efficiency and energy cost savings
•
Generally lower capital cost for equipment compared to gas equipment
•
Fewer moving parts than gas equipment; lower maintenance costs
•
Faster pre-heating.
For example, the Frymaster electric fryer is an advanced technology sponsored by EPRI. It has a 50-pound (23 kg) capacity, single or dual open pot design, centerline thermostat, and boil-out mode. The solid state triac controls modulate the amount of energy to the electric elements with greater reliability and more precise temperature control. The insulation reduces standby energy consumption by about 10% over conventional electric fryers. The fryer has enhanced diagnostic features and a unique filtration system. 6-115
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Following are brief descriptions of specific electric cooking technologies supported by New England Electric. A demonstration of these technologies is available at the Culinary Arts Foodservice Exposition (CAFE) of Johnson & Wales University in Providence, Rhode Island. (The university has the largest college of culinary arts in the world operating in five campuses: Providence, RI; Norfolk, VA; North Miami, FL; Charleston, SC; and Vail, CO. The CAFE is a state-of-the-art commercial cooking center showcasing the leading electrotechnologies in cooking.) Flashbake Unit:
The unit uses intense light in the visible range to cook from the inside out, and infrared to brown and crisp. It uses only 20% of the energy of a conventional oven. A pizza is cooked in 50 seconds, New York Strip steak in 2 minutes, grilled shrimp in 20 seconds, and Angel Food cake in 4 minutes.
Induction Cooktop Range: The cooktop range provides instant and variable heat without flames. Just the pan gets hot and only when it is on the cooking surface. An electric current is induced in the pan causing it to get hot; a piece of paper placed underneath the pan will not burn. The ceramic top remains cool to the touch and is wiped clean easily. The induction cooktop range cooks faster than gas and 20% faster than current electric ranges. It takes 30 seconds to boil one pint of cold water. Electric Fryer:
With a high cooking efficiency, the electric fryer produces more french fries per hour than equivalent gas models. The heat is radiated only in the oil so no energy is lost up the flue and kitchens stay cooler. Since these fryers ensure that oil never overheats, cooking oil lasts longer. They are easier to clean and require less downtime for cleaning. Solid-state electronics have increased reliability. Streamlined designs eliminate small areas where food particles can collect and carbonize, thereby improving food taste. Electric fryers save money.
Electric Griddle:
Compared to conventional griddles heated by a gas burner underneath, the electric griddle is heated by resistance heaters clamped to or embedded into the plate. Heat is transferred more efficiently to the griddle plate and less heat is lost to the kitchen air, reducing overall energy consumption by about 30%. Chrome griddles retain heat in the griddle plate: one cannot feel much heat six inches (152 mm) above its heating surface at 400°F (204°C).
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Emissions for gas burning and concerns for gas leaks are eliminated. Cleaning times for chrome-plated electric griddles are reduced by 44% over steel-surface gas models. No flavor is transferred. Electric griddles eliminate uneven “hot spots” in the heating surface. Combo-Oven:
The combo-oven combines conventional cooking with steaming capabilities. It can roast, bake, poach, vapor grill, etc. No flavor is transferred.
Conduction Cooking:
This is cooking with direct heat by conduction and using no fans. Hot fluid is locked into the shelves. Cooking time is reduced. It can be used for cooking great quantities of food.
Rapid Chiller:
The rapid chiller uses cold fluid inside the shelving system to rapidly chill food items. It is quicker than blast freezers.
Pulper:
The pulper reduces bulk waste by 80% and allows the waste stream to be reused, therefore reducing waste haulage and labor costs. The pulper also improves sanitation.
Kitchen Exhaust Ventilation A large kitchen’s total energy costs are linked to heating, ventilation and air conditioning, and as much as 75% of this load may be attributable to operation of the kitchen’s exhaust ventilation system. Therefore, a well-designed ventilation system with Underwriters Laboratory certification would be worth the higher initial cost because of lower operating costs in the long run. A well-designed, UL-listed ventilation system offers the following benefits: •
Lower energy costs…lower CFMs can reduce exhaust volumes by 10 to 40%
•
Safer operation…many new models offer automatic fire suppression by connecting water lines to ventilator hoods; grease can be collected in troughs for regular emptying to prevent hazardous accumulation
•
Lower maintenance…many new models have self-cleaning features.
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Heat Pump Application in Hospital Kitchens Use of heat pump water heaters are also possible in kitchens. The heat pumps reduce water heating costs while providing cool air in kitchens. A case study is provided below. Case Study: Huntsville Hospital Kitchen Five 4-ton heat pump water heaters were installed in the late 1980s in the kitchen area at Huntsville Hospital, a 578-bed hospital in Alabama. In addition to providing hot water, the heat pumps helped to “spot cool” the 85 kitchen employees thus improving the working environment. Two heat pumps were placed above the refrigeration area and one above the steam unit. The heat pumps dropped the average temperature from about 95° to 76° (35° to 24°C) during meal preparation and reduced relative humidity to around 40%. The heat pump above the dishwasher not only helped cool the area but also reduced condensation by acting as a dehumidifier. The installation cost about $55,000 with a $20,000 grant from the State of Alabama, but the facility estimated an annual savings of some $14,000. Payback was actually realized in only two years because of the added benefit of heat pump water heaters: air conditioning of the kitchen space.
Resources and References Bulletin No. 818-0122, Frymaster® Welbilt™, The Frymaster Corporation, 8700 Line Avenue, P.O. Box 51000, Shreveport, LA 71135-1000; 800-221-4583, or 318-865-1711; Fax 318-868-5987; www.frymaster.com. “Cooking with Electricity: Electric Griddles Can Take A Grilling.” ElectroTechnologiesPowerful New Ideas, New England Electric. “Foodservice Sourcebook: A Quick-Reference Guide to Industry Information and Sources.” EM-6135. Electric Power Research Institute, Palo Alto, CA, 1990. EPRI’s Foodservice Sourcebook contains a directory of major distributors and manufacturers of electric ovens, fryers, broilers, griddles, ranges, cookers, kettles, skillets, steamers, coolers, refrigerators, freezers, dishwashers, hot water heaters, ventilation, and exhaust equipment. “Frying with Electricity: Electric Frying Redefines Fast Food.” ElectroTechnologiesPowerful New Ideas, New England Electric. “Huntville Hospital Kitchen Employees ‘Beat the Heat’ With New Heat Pump Water Heaters.” The Energy Manager. 4 (1), Tennessee Valley Authority and Distributors of TVA Electric Power, 1989. 6-118
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“Juicy Techniques for Cutting Costs With Electric Cooking Equipment.” Environmental Solutions: Products & Services, Southern California Edison, Edison International Company. “Optimizing Kitchen Ventilation: UL-Approved Ventilation Systems Offer Refreshing Savings.” ElectroTechnologies-Powerful New Ideas, New England Electric. “The C.A.F.E.” ElectroTechnologies—Powerful New Ideas, New England Electric.
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Issues and Opportunities in Lodging Services: Ozone Laundry Ozone-Based Laundry Operations Hospitals and nursing homes often operate their own laundry services to clean lightly soiled materials such as sheets, towels, pillowcases, bedspreads, blankets, patient gowns, and diapers. A typical 350-bed hospital with 100,000 patient-days per year may generate about one million kilograms of laundry annually; an estimated 2 billion kilograms are generated in U.S. hospitals per year. Laboratories and free-standing clinics may contract out to a traditional, commercial laundry service for the cleaning of laboratory gowns, sheets, wash cloths, etc. An ozone-based laundry system is an innovative, cost-effective, environmentally friendly alternative for healthcare facilities. One obstacle to the use of ozone-based systems is that recommended guidelines used by hospitals for washing linens are based on the traditional method of immersing laundry in water at 160°F (88°C) for 20 minutes to ensure disinfection. These guidelines date back to the 1930s and assume the use of detergent and alkali. They were necessary for isolation room and operating room linens, most of which are now in the form of disposable (non-reusable) textiles. Ozone-based laundry systems are appropriate for the bulk of a hospital’s laundry such as beddings, blankets, gowns, towels, etc. An existing laundry washing equipment can be retrofitted for the closed-loop ozone-based laundry system (described below). Ozone-based laundry systems are also available for lease. In comparison to traditional laundry services, ozone-based systems offer several key advantages: •
Shorter cleaning cycle times…therefore ozone systems save time and increase productivity
•
Operation at low temperatures…therefore water heating requirements are drastically reduced or eliminated
•
Reduced amount of chemicals and detergents…therefore effluent concentrations of residual chemicals are lower and environmental impact is lessened
•
Recycling of water (for closed loop systems)…therefore use of water and amount of sewerage are significantly reduced
•
Lower cost per pound of load compared to traditional laundry systems…therefore significant cost savings are achieved.
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There are also several important “fringe benefits” with the use of ozone-based systems: •
Longer textile life, since the major causes of fiber degeneration (hot water, alkali and sour, bleaches, long exposure to mechanical action) are reduced
•
Removal of odors
•
Disinfection
•
Production of hypoallergenic garments, since residual detergents and alkali imbedded in fiber from traditional systems (which are a contributing cause of skin irritation and may contribute to bed sores in bed-ridden patients) are reduced.
•
Reduced wear and tear of washing machine equipment in part due to reduced machine run time
Some of the disadvantages of ozone-based systems are explained below: •
Depending on the amount of ozone generated and the location of the ozone-based system, an air quality monitoring system may be needed to detect the level of accumulated ozone in the workplace.
•
Ozone will not completely clean heavy and hard-to-remove stains such as heavy food grease, mascara, inks, certain food dyes, and certain medicines. Varying amounts of a low temperature enzyme detergent may have to be added with ozone.
•
While there are about 100 ozone-based laundering systems operating in the United States (especially in hotels, correctional institutions, and commercial laundry facilities), there is little experience in ozone laundering in healthcare facilities.
The Occupational Safety and Health Administration (OSHA) guidelines for ozone levels in the work environment show a permissible exposure level of 0.1 ppm averaged during an 8-hour period. (The distinct smell of ozone can be detected by humans at concentrations as low as 0.02 ppm.) In the event of high ozone concentrations in the air, shutting off the ozone generator instantaneously cuts off production of ozone and ozone levels rapidly dissipates as ozone breaks down to its more stable form, oxygen. Principles of Operation Washing is a function of five processes: mechanical action, temperature, time, dilution, and chemistry. The chemical processes in conventional washing and soil removal include oxidation, emulsification, lubrication, flocculation, neutralization, and saponifacation. Adding ozone to the wash formula changes the wash process so much 6-121
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so that less chemicals, fewer water operations, shorter wash times, and lower temperatures are needed. Ozone is a powerful oxidizer. When used with water in cleaning laundry, ozone oxidizes fatty oils and grease that bind dirt to cloth. As dirt is removed from clothing by mechanical action of a washing machine, ozone assists in the flocculation and coagulation of dirt, making it easier to filter out of water. As an oxidizer, ozone can also break down many organic contaminants including compounds responsible for odors. Hence, ozone destroys laundry odors and eliminates the need to add scents. Using ozone with small amounts of low temperature enzyme detergents and peroxide bleaches (instead of chlorine bleaches) can result in a synergistic effect, making detergent chemicals more effective and providing good bleaching with less color degradation. Ozone also acts as an effective disinfectant by destroying bacteria and viruses in the laundry. There are basically two types of ozone-based laundry systems that may be used: closedloop or recycling system; and open-loop or non-recycling (also called a flow-through) system. Closed-Loop Ozone Laundry System Whenever water in the washing machine is drained, the dirty water is collected in a sump and pumped through a screen or coarse bag filter to remove larger particles and lint from the water. The coarsely filtered water is collected in a holding tank. Upon activation of a second-level switch, the water is pumped through a second filter which removes particles down to 20 microns in size. The filtered water then flows into a storage tank. Ozone gas is injected into a venturi mixer to form microscopic bubbles which then enter the storage tank through the bottom. As the tiny ozone bubbles rise to the surface, they oxidize odor molecules and residual chemicals, and destroy bacteria and viruses. They also carry with them smaller remaining particles, as well as any oil and grease molecules, forming a film at the surface of the water. When the storage tank fills, the film overflows through an outlet and into the sewer. Additional “make-up” water from the regular water supply line is added to the storage tank as needed. (If well water or very hard water is used, a water softener may be required.) Clean water from the storage tank is pumped into a charging or contact tank upon demand. In cases where high quality textiles are processed, a 5-micron polishing filter may be used between the two tanks to remove even smaller particles. In the charging tank, more ozone gas is bubbled through the bottom of the tank to create a residual of ozone in the water. This ozone-laden water is used whenever the washing machine calls for more water during its different cycles. 6-122
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Ozone is produced by an ozone generator and an air preparation system which concentrates oxygen in the atmosphere as it is supplied to the generator. An air compressor is needed. The system is controlled by a control panel which interfaces between the washing machine and the various pumps and level switches. The panel is also a diagnostic center to isolate problems in a system and to accelerate maintenance and repair. The system is completely automated and does not require specialized skills or training. Open-Loop Ozone Laundry System An open-loop system uses one contact tank which is filled by the local water supply line. (A water softener may or may not be required.) As in the case of the closed-loop system, the ozone generator delivers ozone gas to the bottom of the contact tank via a venturi mixer. The ozone-laden water is pumped into the washing machine on demand. Small amounts of similar additives as those used in the closed-loop system are introduced into the washer when needed, as in the case of heavily soiled linens. Dirty water is simply flushed into the drain. (Any residual ozone molecules in the dirty water would eventually break down into oxygen.) While the open-loop laundry system has the same benefits as the closed-loop system, the closed-loop system has the added advantage of a 40-50% savings in water and sewerage. The Steiner Corporation, a prominent commercial laundry chain, released the following results (Table 6-13) from its independent study of a CyclO3PSS ozone-based laundry installation at the laundry chain’s Milwaukee facility: Table 6-13 Comparison for a Commercial Laundry Chain (Milwaukee Facility, The Steiner Corporation) Before Ozone Installation
After Ozone Installation
Percent Change
825 lb (374 kg)
1101 lb (499 kg)
+33.5
637
499
-27.7
2.19 gallons (8.29 L)
1.77 gallons (6.7 L)
-23.7
Washing Labor Costs
*
*
-46
Chemical Costs
*
*
-35
148 ppm FOG
94.2 ppm FOG
-36
Pounds Processed Per Employee Hour Wash Room Person Hours Water Consumption per pound
Wastewater Results
* proprietary information; FOG = fats, oils, and greases
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Resources, References, and Vendors IES, Inc. (International EcoScience) 5862 Bolsa Avenue, Suite 102 Huntington Beach, CA 92649 Phone: (714) 799-3123 Fax: (714) 799-3013 Malcom McLean, President Wess Illing, Chief Engineer IES conducts engineering research and development on ozone systems and provides service to government and commercial facilities. They also offer an open and closed loop laundry system. CyclO3PSS Corporation 3646 West 2100 South Salt Lake City, UT 84120 Phone: (800) 972-9091 or (801) 972-9090 Fax: (801) 972-9092 www.cyclopss.com/index.htm CyclO3PSS recently introduced its OzO3-Clean™ System 200, an improved and enhanced version of its CyclO3PSS ozone washing system. Its CyclO3PSS technology has been installed in over a dozen installations in the largest of laundry facilities. The company has also developed a smaller, portable, ozone washing system called CyclO3PSS Textiles POWER System designed to demonstrate the effectiveness of ozone-based systems to commercial and industrial facilities. CyclO3PSS sees its POWER system as a step towards expanding ozone-based laundry systems in institutions including hospitals. GuestCare, Inc. 3030 LBJ Freeway, Suite 1460 Dallas, TX 75234 Phone: (800) 218-7494 or (214) 243-3035 Fax: (214) 243-0706 Web: www.etven.com/guestcare/index.html GuestCare is a major distributor of ozone laundry systems to the hospitality industry in the United States. Their GuestCare NT-800 Ozone Laundry System can handle up to one million pounds (453,600 kg) annually, uses PLC-based controls, includes ozone air monitoring, and only requires a 2’ x 5’ x 6’ (high) (0.6 × 1.5 × 1.8 m) space. Ozonation is done by vacuum injection and every system is customized to meet specific needs. They offer a one-year parts and service warranty on all components. The company installs inline water meters for “before and after” proof of savings due to ozone; they expect annual savings of 3-12% on laundry labor, 45-65% on laundry water and sewer, 50-75% 6-124
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on chemicals, and 75-95% on natural gas for hot water. GuestCare has several dozen ozone laundry installations in lodging facilities as well as in hospitals, correctional institutions, and nuclear power stations. E. Katzenelson, B. Kletter, and H.I. Shuval. “Inactivation Kinetics of Viruses and Bacteria in Water by Use of Ozone.” AWWA Journal. December 1974. Michael Martin. “Nosocomial Infections Related to Patient Care Support.” Chapter 31, Prevention and Control of Nosocomial Infections. 3rd edition, edited by Richard P. Wenzel, Williams & Wilkins, Baltimore, MD, 1997. “Ozone Cold Water Laundry.” TU E Technologies Update. TU Electric, January 1995. Jack Reiff. “Ozone Puts the Washroom On A Diet.” Textile Rental. Magazine of the Textile Rental Services Association of America, June 1995. Vendor literature
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Issues and Opportunities in Information Systems and Telecommunications: Telemedicine Modernization of Hospital Data Processing Systems The healthcare industry is 5 to 10 years behind most industries in data processing. Healthcare providers have been spending only 1-2% of their operating budgets on information technology. Several factors are compelling more hospitals to overhaul their computer systems: •
Pressure to cut costs
•
Demand for increased efficiency and productivity
•
Requirement to submit medicare claims electronically
•
Availability of powerful, low-cost computers with high-tech data processing and networking capabilities
Moreover, as Ode Keil, formerly of the Joint Commission on Accreditation of Healthcare Organizations pointed out, “Most of the medical records of this country constitute a fire hazard.” Currently, 10% of hospitals are undergoing major data processing overhauls. Analysts anticipate that hospital spending on information systems will increase to $13 billion by 1998 (compared to less than $4 billion in 1988). Increased computerization will mean that power quality issues will become more significant in coming years.
Growth of Telecommunications and Telemedicine Developments in the information superhighway, compressed interactive video, highspeed transmission cables, satellite link-ups, and other information and telecommunications technologies have created new opportunities for the healthcare industry in four major areas: 1. Administrative teleconferencing 2. Continuing medical education 3. Telemedicine 4. Community health information networking 6-126
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With mergers, acquisitions, and increasing affiliation among hospitals, the use of interactive compressed videoconferencing provides a means of enhancing management. According to VTEL, a compressed video systems manufacturer, as of 1998 the bulk of their customers adopt the technology for administrative uses. Over 1,500 VTEL systems are installed in healthcare accounts worldwide. Nationally, 37 states have VTEL systems. Continuing medical education account for about 30% of compressed video applications. One example is the Baylor Health Care System in Texas. Clinicians at the Baylor Medical Center at Garland participate in weekly one-hour continuing education programs with their colleagues at the parent facility in Dallas. The system also allows them to “attend” whole-day clinical education programs without being away from their patients. In addition, the hospital saves on travel expenses and the cost of staff replacement for that period of time. Telemedicine refers to a two-way audio and video communications network that allows hospitals and physicians access to medical and technological resources via telephone lines and satellite link-ups. Telemedicine dates back to 1959 when two-way, closedcircuit television was used. However, compressed video and other new technologies are gaining acceptance among clinicians. In a pilot study by VHA Inc. (Irving, Texas), physicians were provided compressed video technology during a six-month project. 83% said they would use the technology for diagnostic purposes, 94% said they were comfortable using it for consultations, and 100% would use it for education. Rural hospitals and physicians were among the first to utilize the new technology. Telemedicine can assist rural healthcare providers stay in touch with other professionals, stay current with medical developments, improve retention of physicians in rural areas, and possibly improve patient outcomes. Another potential benefit is improved preventive healthcare. Rural areas, however, pose major challenges: lack of telephone line capacity and reliability; lack of computerization; inability of long-distance transmission lines to meet telecommunications demands; lack of local resources for training in telecommunications technology and software; and lack of local consultants to assist in assessment and design of networks. Congress mandated the “Telecommunications Act of 1996” to ensure that effective delivery and affordable access to telecommunication services is available to schools, libraries and rural health care providers at comparable rates charged to urban areas. The Federal Communications Commission (FCC) has adopted rules to implement this requirement. There are an estimated 12,000 eligible non-profit rural health care providers including: post secondary educational facilities offering health care instruction, community health centers, and other public or non-profit facilities, including hospitals. Rural areas, as defined by the Federal Office of Rural Health Policy 6-127
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(ORHP) are those areas not located in a Metropolitan Statistical Area as defined by the Federal Office of Management and Budget (OMB). This universal service support provides discounts only for telecommunications services, Internet access, and internal connections. All telecommunications carriers that provide interstate telecommunications services are required to contribute to universal support mechanisms. For further details on the Universal Service Funds to decrease costs to eligible rural health care providers, and to obtain an application, contact the Rural Health Care Division of the Universal Service Administration Company (a non-profit subsidiary created by the FCC to administer the rural health care program) at (800) 229-5476 or www.rhc.universalservice.org. The FCC is another source of information at (888) CALL-FCC, (202) 418-7393 Kim Parker, or www.fcc.gov/healthnet. Several telemedicine bills were introduced to Congress in 1997 and 1998. “The Comprehensive Telehealth Act of 1997 (S.385)” and its companion bill “The Improved Access for Telehealth Act of 1997 (H.R.966)” provide reimbursement under the Medicare program for telehealth services. “The Medicare Telemedicine and Medical Informatics Demonstration Act of 1997 (H.R.1101)” provides for a project to demonstrate the application of telemedicine and medical informatics to improving the quality and cost-effectiveness of health care services under Medicare and other health programs. “The Rural Demonstration Act of 1997” directs the Health and Human Services Secretary to expand and strengthen the demonstration project known as the Medical Telemedicine Demonstration Program. “The Promoting Health in Rural Areas Act of 1998 (S.2603)” was another bill introduced to recognize telemedicine as a promising tool for providing medical expertise to rural communities, technical expertise to rural health professionals and facilitating interaction with peers. Although none of these bills were reported out of their respective committees, this issue is expected to continue to receive attention from Congress as it addresses health care reform in the coming session. In January 1997 the ORHP released the first major survey of rural telemedicine. “The Exploratory Evaluation of Rural Applications of Telemedicine”, conducted by Abt Associates, Inc., includes information about the extend to which telemedicine is used in rural areas, by whom, for what purposes and the costs. In early 1997, nearly 30% of the 159 hospitals surveyed in the winter of 1996 were expected to be using some sort of telemedicine to deliver patient care. Of these, 68% were expected to offer only teleradiology. More than 40% of the telemedicine programs surveyed had been providing teleconsults for one year or less. Radiology and cardiology were the most common clinical applications reported, followed by orthopedics, dermatology and psychiatry (see Figure 6-9). Telemedicine systems were also used for non-clinical applications such as continuing education for health professionals. 58% of the sample had used their equipment for four or more different non-clinical uses (see Figure 6-10). Despite growth and expansion, the cost of telemedicine remained high. Federal and 6-128
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state grants were common sources of direct funding for telemedicine programs, and the majority of sites also received hospital financial support. Third-party reimbursement for telemedicine was elusive; fewer than 25% of hub facilities had successfully negotiated payment with insurance carriers and many had not yet undertaken such negotiations (see Figure 6-11). The most common transmission technologies involved copper telephone lines (78% of telemedicine facilities and 83% of teleradiology only facilities), and dedicated telecommunication services such as T1 (76% and 29% of telemedicine and teleradiology only facilities respectively). Fiber optic lines were also commonly reported (52% of telemedicine facilities) as were switched services such as switched 56Kbps and ISDN. Satellite or microwave transmission were each mentioned by less than 10% of respondents. 38% reported availability of not only a dedicated service, but also a switched service. Utilization was low in the first years of most rural telemedicine programs. Only 17% used their system more than once each day. 60% of facilities that had been operating between one and two years had a narrow range of clinical applications whereas those operating for two or more years were more likely to have a broader set of applications (62%).
(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm) Figure 6-9 Most Commonly Reported Clinical Applications
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(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm) Figure 6-10 Non-Clinical Applications
(Source: http://www.ntia.doc.gov/reports/telemed/evaluate.htm) Figure 6-11 Funding Sources
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Utilities have long recognized the importance of information systems and telecommunications in reducing costs and providing value-added services to their customers. With this wealth of resources and experience at their disposal, utilities could assist the healthcare industry in adopting information and telecommunication-based tools and in partnering with healthcare providers to offer innovative services based on information systems and telecommunications technologies.
Resources and References Rhonda Bergman. “From the Mountains to the Prairies: Country Docs Get Set to Take a Spin on the Information Superhighway.” Hospitals & Health Networks. December 5, 1994. “The FCC’s Universal Service Support Mechanisms” and “Frequently Asked Questions On Universal Service For Rural Health Care Providers.” Federal Communications Commission (National Call Center 1-888-225-5322). Roger Guard and Mary M. Langman. “Legislative Priorities for Medical Libraries.” MLA News. (#301):22, Nov/Dec. 1997. “Health Care Hospitals, Drugs and Cosmetics: Current Analysis.” Standard & Poor’s Industry Survey, April 1994. Marianne Puckett and Mary M. Langman. “Legislative Update - Part 2.” MLA News. (#313):7, Feb. 1999. “REA Address Highlights.” Rural Telecommunications. 12 (3) May/June 1993. “Rural Facilities Tap Telemedicine.” Modern Healthcare. 24 (6), February 7, 1994. Kathryn Taylor. “We’re (Almost) All Connected: Providers’ Booming Interest in Telemedicine May Spur More Development.” Hospitals & Health Networks. September 20, 1994. Telecommunications Act.” Health Factor, 5 (3), August 1997, quarterly newsletter of the Dept. of Family Medicine, University of South Dakota School of Medicine. “Telemedicine Report to Congress.” Jan. 31, 1997, Office of Rural Health Policy, www.ntia.doc.gov/reports/telemed/evaluate.htm.
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Issues and Opportunities: Resources of the EPRI Healthcare Initiative The EPRI Healthcare Initiative (HCI) is a collaborative effort with member utilities. Its purpose is to assist the healthcare industry to meet the ever-changing demands of the industry through education and the use of electrotechnology solutions that will reduce risk and liability, meet regulatory compliance demands, and ultimately provide the highest level of quality patient care. Some of the issues in the healthcare industry not discussed in this report or only mentioned in passing are: •
Construction and renovation issues
•
Facility safety management
•
Security and security systems for healthcare facilities
•
Environment of care management
•
Healthcare quality assurance
•
Safety database management
•
Benchmarking for the healthcare industry.
A comprehensive list of publications, services, and training programs, along with a description of the Healthcare Initiative can be found in “EPRI Healthcare Initiative Products and Services Catalog” (BR-107072-R2) and subsequent editions. Resources are available from: EPRI Healthcare Initiative 50 Main Street, Suite 1260 White Plains, NY 10606 914-644-8358 or 800-424-EPRI Fax: 914-644-8761
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7 HEALTHCARE PROVIDERS AS ELECTRIC UTILITY CUSTOMERS
As the healthcare sector is a large and complex customer segment, it offers an important marketing opportunity for electric utilities that can understand and respond to the needs of the institutions it comprises, especially hospitals, clinics, and nursing homes. A recent study by RKS Research and Consulting in North Salem, New York, found that 68% of hospital and healthcare executives surveyed (representing 1,000 separate facilities nationwide) are willing to pay 13% more than the commodity price of electricity for additional reliability, convenience, and tailored services (Healthcare Facilities Management, May 1996). Less than half—45%—would switch suppliers for a price reduction of 5%, while half expressed interest in working out a deal with the local provider. Among the services sought after by hospital and healthcare executives are simplified electric rates, energy audits, backup power, and an empowered utility account executive as a single point of contact to meet their specific needs. Interestingly, a survey by the American Hospital Association, sponsored by EPRI in 1994, revealed that electric utilities were not considered as sources of information or value-added service by the majority of hospital contacts (hospital engineers, facility managers, safety professionals, environmental managers, planning directors, etc.). The results of three focus groups showed that respondents did not see utilities as a resource on alternative treatment alternatives, energy-related and environmental regulation, lighting, indoor air quality, HVAC, TB engineering controls, water heating, cooking, design and remodeling, or energy-related advocacy. There was a general lack of knowledge or understanding of alternative treatment technologies. A small percentage of respondents noted having used utility services for facility energy audits, power quality audits, or performance contracting. An effective utility program for the healthcare sector could be based on the following five basic concepts: •
Be a low-cost provider – The healthcare sector is increasingly cost conscious and electric utility programs should be sensitive to this.
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Healthcare Providers as Electric Utility Customers
•
Provide value-added services – As shown by the RKS survey, in addition to reduced energy costs, value-added service is sought after by healthcare executives. While healthcare facilities use large amounts of electricity, they have other related needs which open up a marketing opportunity for utilities. Many of these are electrotechnology or service opportunities as described in this report: medical waste treatment, sterilization of instruments, power quality service, efficient lighting, thermal energy storage, indoor air quality, ozonation for cooling towers, ozonebased laundry, emergency power, water purification, electric cooking, etc. However, as the AHA survey pointed out, many facility engineers, environmental managers, safety officers, etc. are not aware of these resources that utilities can provide. Therefore, it is important for a utility representative to let it be known to the customer that the utility can provide a broad menu of services. Recognizing the challenges facing the healthcare industry, as described in this report, utilities can make a proactive, customer-focused commitment to help the industry by providing assistance and expertise in many areas. In this way, the utility becomes a valued resource for cost-effective products and services vital to the survival and competitiveness of the facility.
•
Create partnerships with the customers – Healthcare institutions are changing rapidly, not just by choice but by a need to survive in an increasingly competitive environment. This climate of change creates opportunities for utilities to form new relationships with their healthcare customers. Again, as revealed by the RKS survey, many healthcare executives are interested in working out deals with suppliers. New partnerships could involve arrangements in financial as well as traditional technical areas. Technically-oriented partnerships could involve endeavors such as demonstrating a new medical waste treatment technology or ozone-based laundry. Partnerships could involve the local hospital association as well. Financiallyoriented partnerships might be helping to finance infrastructure improvements such as telecommunication. In addition to EPRI tailored collaboration projects, utilities could also assist in the purchase of a new technology under a shared savings arrangement with EPRI. The possible partnership arrangements are many and depend on the specific needs and culture of each institution. Partnerships set the stage for customer retention.
•
Establish a local team to coordinate with the EPRI Healthcare Initiative – the Healthcare Initiative is constantly identifying and developing ways for utilities to better serve and support the healthcare industry. To make the most effective use of this resource, utilities could establish a local team to work with the Healthcare Initiative, involving utility representatives who specialize in environmental issues, power quality, building performance, etc. This team would implement programs from the Healthcare Initiative that are appropriate to the healthcare customers in the service territory.
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Healthcare Providers as Electric Utility Customers
Other ideas for maximizing the resources of the Healthcare Initiative include: inviting healthcare customers to attend HCI meetings and conferences; providing customers with HCI publications and resources reprinted with your company’s logo; organizing workshops and seminars on selected topics of interest to healthcare customers in your service territory through the HCI; using tailored collaboration funds to subsidize services or help purchase electrotechnologies for your major customers; offering a demonstration project or a shared cost-savings arrangement to a customer in conjunction with an electrotechnology vendor and EPRI; sponsoring a prominent member of the healthcare industry in your area to participate in the advisory committee of the HCI; and serving in one or more of the committees of the Healthcare Initiative. Include on the utility team a person from the healthcare industry – Having a person on the utility team with a substantial experience in the healthcare sector will add credibility. Such a person would understand the issues and dynamics of the industry, speak the “language” and provide insights on how to best approach organizations within this customer group. Such a person could identify the key players, such as the CEO, an executive vice president, director of facilities engineering, department head, or chief financial officer in a hospital, who may be the best person(s) to approach for a particular project or proposal. This is the concept that developed into the EPRI Regional Healthcare Marketing Network. In this program the national HCI database, products and services are customized for the utilities current market segment or projected customer targets. Each utility will address the market in different ways, but an effective program has as its foundation a knowledge of the customer and a commitment to provide innovative products and services at a competitive price.
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A GLOSSARY OF COMMON TERMS
Accreditation with commendation—Accreditation granted to an organization by the JCAHO if the survey of all required components of the organization is completed, an accreditation decision grid score of 90 or higher is attained with no individual grid element scores of 4 or 5, and no type I recommendations are given. Ambulatory care—Medical services provided on an out-patient basis. Aspergillus—An allergen fungal spore found in the atmosphere and in indoor air capable of causing Aspergillosis, an infection in the tissues or mucous surface in the lungs and capable of spreading to other organs. Autoclave—Sterilizer for sterilizing medical and surgical instruments by exposure to steam at 121° to 132°C in a sterilizing chamber. Biohazardous waste—See Infectious waste. Bloodborne pathogen rule—An OSHA rule based on the assumption that blood and certain body fluids (amniotic, pericardial, peritoneal, synovial, cerebrospinal, semen, and vaginal fluids) of all patients are potentially infectious for human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens, and healthcare workers are required to take precautions to avoid exposure to these fluids. Capitation—A method of reimbursement under some managed care plans in which providers receive a fixed fee per person in the covered (enrolled) population, regardless of the amount and cost of services used by that population. Central services—That department in a hospital that collects and receives used patientcare items and equipment, and packages, processes, stores, maintains, and dispenses these articles to the rest of the hospital; also called Sterile Supply. Chemotherapeutic waste—Waste contaminated with antineoplastic or cytotoxic agents used in the treatment of cancer and other diseases. Chlorination—The addition of liquid chlorine, chlorine dioxide, or hypochlorite to water or medical waste for the purpose of disinfection. A-1
Glossary of Common Terms
Cleaning—The removal of foreign material, such as soil, from medical instruments and generally precedes sterilization or disinfection. Community hospitals—As defined by the AHA, are “all non-federal short-term general and other special hospitals whose facilities are open to the public. (Other special hospitals include obstetrics and gynecology; eye, ear, nose and throat; rehabilitation; orthopedic; and other individually described specialty services.)” In contrast, non community hospitals, according to the AHA, include federal hospitals, long-term hospitals, psychiatric hospitals, alcoholism and chemical dependency facilities, and hospital units of institutions. Community hospitals are the most common type, with 90% of total hospital beds. Conditional accreditation—Accreditation granted by the JCAHO to an organization not found to be in substantial compliance with the standards but believed to be capable of remedying the deficiencies within six months. Conditioned space—Parts of a building that are heated and/or cooled to provide comfort to the occupants. Continuing care retirement communities (CCRCs)—Institutions which provide housing and healthcare in a campus-style setting with convenient services such as housekeeping and meals. The levels of care range from assisted living to skilled nursing. Additional healthcare services include emergency response, health clinics, wellness programs, hospice, primary and specialty physician care, dental care, pharmacy, and physical therapy. These facilities are often very expensive and not covered by Medicare. Cooling Tower—A device that removes heat absorbed by cooling water through the process of evaporation so that the water can be reused. Custodial care facilities—Institutions which provide nursing and health-related care to patients who do not require the degree of care and treatment of a skilled or intermediate care facility. Examples of custodial care facilities include convalescent homes with healthcare and homes for the mentally retarded, with healthcare. Demand control ventilation (DCV)—Ventilation wherein the amount of air provided to a conditioned space is modified in response to changes in occupant distribution. Dessicant—A sorbent material that removes water or water vapor. Diagnostic Related Groups (DRGs)—A system by which the federal government reimburses hospitals on a fixed-fee basis for Medicare patients.
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Glossary of Common Terms
Disinfection—The elimination of many or all pathogens but not necessarily the destruction of all living organisms such as resistant bacterial or fungal spores; different processes can achieve varying levels of disinfection. Drift—Water in the form of droplets and water vapor that rise and escape from the top of a cooling tower. Electromagnetic interference (EMI)—An incompatibility of a device and its electromagnetic environment resulting in an adverse effect on the performance of the device. Electron beam irradiation—The treatment of materials, such as medical waste or medical instruments, for the purpose of sterilization or disinfection by exposure to ionizing radiation generally consisting of high energy electrons. Emergency power supply system (EPSS)—The system used to provide an alternative, emergency source of power; it consists of one or more transfer switches and generators. Environment of Care (EC) - Plant, technology, and safety management standard of the JCAHO which includes safety, security, control of hazardous materials, emergency preparedness, life safety, medical equipment, and utility systems. Ethylene oxide (ETO) sterilizer—Sterilizer to sterilize medical and surgical instruments by exposure to ethylene oxide gas in a sealed chamber; ethylene oxide is a highly toxic, flammable, and explosive gas, and is a probable carcinogen. Eutectic material—Salts that undergo a phase change when absorbing and releasing energy in thermal energy storage systems. Fee for service—A payment arrangement under which patients and other payer groups pay providers (doctors, hospitals, etc.) separately for each service performed. Harmonic distortion—A change in the sinusoidal wave shape of voltage or current caused by nonlinear loads that draw nonsinusoidal currents from a system. Health maintenance organization (HMO)—A health insurance plan through which subscribers receive comprehensive medical services from affiliated providers for a preset, prepaid annual fee. Heat pump—A device that moves energy in the form of heat from a substance at lower temperature to another substance at a higher temperature by means of a mechanical device such as a compressor which operates off an outside power source.
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Glossary of Common Terms
HEPA filter—A high-efficiency particulate air filter having a particle collection efficiency of 99.7% or greater for particles up to 0.3 microns. Home healthcare—A method of delivering medical services to patients in their homes rather than in medical facilities. Independent practice association (IPA)—An organization contracting with a managed care plan to deliver services at a single capitation rate. The IPA in turn contracts with individual providers to deliver services, either on a capitation basis or fee-for-service basis. Independent practitioner organization (IPO)—An organization of providers, usually physicians, contracting with a variety of health plans for a variety of services, such as health care. The primary differences between an IPO and an IPA is that most IPAs contract with a single HMO, while an IPO may contract with multiple types of plans, and IPOs generally do not assume financial risk. Indoor air quality (IAQ), acceptable—Air in which there are no known contaminants at harmful concentrations and to which a substantial majority of persons exposed do not express dissatisfaction. Infectious waste—Waste materials that are considered to be a potential health hazard due to possible contamination with pathogenic agents; also referred to as red bag waste because of the color of plastic bags commonly used in hospitals to segregate infectious waste; sometimes referred to as biohazardous waste and marked with the international biohazard symbol; see also Regulated medical waste. Intermediate care facilities—Institutions which provide continuous nursing and rehabilitative services but not on a continuous basis as do skilled nursing facilities. Personnel are on duty continuously but licensed nurses are required only part of each day. The line between skilled and intermediate nursing facilities is sometimes blurry, and various organizations account for the categories differently. Investigational device exemption—An exemption given to manufacturers of medical devices intended solely for investigational use, thereby allowing manufacturers and researchers to gather safety and effectiveness data using human subjects. Legionella—The bacterial strain (in particular, Legionella pneumophila) that can cause a pneumonia-like illness known as Legionnaires’ Disease or Legionellosis; the bacteria thrives in warm, damp, and stagnant conditions, as in cooling tower water, humidifiers, etc., and has the potential of contaminating air. Lumen—The inner open space of any tubular-shaped device as one finds in an endoscope or other medical device; lumened instruments are difficult to sterilize. A-4
Glossary of Common Terms
Managed care—A supervised system of financing and providing healthcare services for a defined population group. Health maintenance organizations are a common form of managed care. Managed competition—A proposed government-sponsored healthcare system which is designed to stimulate competition in the healthcare industry by aggregating healthcare purchasers into cooperatives to negotiate provision of healthcare services more costeffectively than in the current system. Medicaid—A joint federal-state program providing medical or nursing home services to persons with a low-income. Medical device report (MDR)—A report to the FDA of incidents that reasonably suggest that a medical device has caused or contributed to a death or serious injury. Medical waste—Solid or liquid waste generated from a healthcare facility or healthrelated institution; see also Infectious waste and Regulated medical waste. Medicare—A federally-funded national health insurance program for persons over 65, and for the disabled. Micron—One-millionth of a meter. Microwave drying—The use of microwave energy generated by magnetron tubes to dry linens, clothes, and other fabrics. Municipal solid waste—Solid waste (not including infectious, hazardous, or radioactive wastes) generally collected in hospital trash bins or dumpsters and removed for disposal in a municipal landfill. Nosocomial infections—Infections not present or incubating in a patient at the time of hospital admission but subsequently acquired as a result of hospitalization. Outdoor air—Air from outside a facility not previously circulated through the ventilation system. Ozone—An unstable form of molecular oxygen (O3) usually formed by an electrical discharge in air; ozone is a powerful oxidizing and disinfecting agent. Pathogens—Microorganisms that can cause diseases. Pathological waste—Tissues, organs, and other body parts removed during surgery, autopsy, or other medical procedures and subsequently discarded.
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Glossary of Common Terms
Peak clipping—The reduction of peak electric load by direct load control. Permissible exposure limit (PEL)—An allowable exposure level to chemicals in the workplace as determined by OSHA and generally expressed as an average exposure concentration over an 8-hour shift. Plasma—A physical state of matter obtained by adding sufficient energy to a gas so that atoms and molecules form free electrons and ions. Power quality (PQ) problem—Any voltage, current, or frequency deviation that results in the failure or misoperation of equipment. Preferred provider organization (PPO)—A healthcare plan which contracts with independent providers (physicians and hospitals) at a discount for services. A PPO may be risk bearing, like an insurance company, or may be non-risk-bearing. An example of the latter is a physician-sponsored PPO which markets itself to insurance companies or self-insured companies via an access fee. Premarket notification—A notification submitted by manufacturers (at least 90 days before marketing a device for the first time) to the FDA showing that the device is substantially equivalent to an existing, legally marketed product; also known as a 510(k) notification or submission. Provisional accreditation—Accreditation granted by the JCAHO to an organization that elects to use the Early Survey Policy and meets the initial standards requirement. Pyrolysis—A process involving chemical and physical changes as a result of intense heat, generally in the absence of oxygen or air. Real-time pricing (RTP)—An hourly-based pricing rate that reflects the time-varying cost of generating and transmitting electricity. Recycling—The use, reuse, or reclamation of materials from a waste stream; one of the components of waste minimization. Red bag waste—See Infectious waste. Regulated medical waste—A classification of medical waste used for regulatory purposes generally consisting of the following classes: cultures and stocks, pathological waste, blood and blood products, used sharps, animal waste, isolation wastes, and unused sharps; sometimes included are discarded medical equipment contaminated with infectious material, surgery waste, laboratory waste, and dialysis wastes.
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Glossary of Common Terms
Return air—Air returned from a conditioned space to be recirculated or expelled through the exhaust. Skilled nursing facilities—Institutions which provide inpatient and rehabilitative service to patients requiring continuous healthcare, but not hospital services. Care is ordered by and under direction of physicians, and staff includes licensed nurses continuously on duty. Skilled nursing facilities are the most common type of nursing home. Source reduction—Any activity that reduces or eliminates the generation of waste at the source, usually within a process; one of the components of waste minimization. Sterile supply—That department in a hospital that collects and receives used patientcare items and equipment, and packages, processes, stores, maintains, and dispenses these articles to the rest of the hospital; also called Central Services. Sterilization—The inactivation of all forms of microbial life. Subacute care facilities—Institutions which generally provide more intensive care than a traditional nursing facility but less than acute care provided by a hospital. Subacute care facilities charge less than acute care hospitals for similar care and services. As a result, some managed care organizations are moving hospital patients to subacute care facilities before discharge. Subacute care facilities are a new area of nursing home care. Telemedicine—The practice of medicine involving the use of two-way audio and video communication networks thereby allowing healthcare facilities and providers access to medical and technological resources via telephone lines and satellite link-ups. Thermal energy storage (TES)—A system involving the storage of energy in a thermal mass for use in cooling or heating during off-peak periods in conjunction with space conditioning. Transfer Switch—A device that allows the transition from a normal power source to an alternative emergency generator and back again. Transient—A high-voltage pulse that is extremely short and fast; also called a spike. Tuberculosis—An infection primarily of the lungs caused by inhalation of a sufficient number of droplets containing Mycobacterium tuberculosis or related species. Ultraviolet germicidal irradiation (UVGI)—An air disinfection technology whereby an air stream is exposed to ultraviolet radiation (specifically at 253.7 nm wavelength, also known as germicidal UV or UV-C) for the purpose of destroying germs.
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Glossary of Common Terms
Uninterruptible power supply (UPS)—A type of battery back-up system designed to provide continuous power to critical loads. Universal precautions—A set of precautions issued by the CDC designed to prevent the transmission of bloodborne pathogens and which became the basis for OSHA’s Bloodborne Pathogen Rule. Valley filling—The building of off-peak electric loads . Voltage sag—A period of lower than normal voltage usually lasting from a half cycle to a few seconds. Voltage surge—A period of higher than normal voltage. Waste minimization—The reduction, to the extent feasible, of waste generated at a facility as well as waste subsequently treated, stored, or discarded. [The definition of terms used in analyses of the healthcare industry are taken from several sources including Dun & Bradstreet, American Hospital Association, and the US Department of Commerce.]
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B SUMMARY OF SELECTED STATE REGULATORY AGENCIES AND REGULATIONS ON MEDICAL WASTE
[NOTE: This section provides a simplified summary of state regulations and is not a comprehensive, complete, or precise description of the laws and regulations. It is not intended for the purpose of compliance, legal advise, or legal analysis. Some of the rules and regulations may have been revised since the time of this writing. The reader should contact the appropriate state agency or agencies for the complete text of regulations and any revisions.] Alabama Alabama Department of Environmental Management Land Division Solid Waste Branch 1751 Cong. W.L. Dickinson Drive Montgomery, AL 36109-2608 (334) 271-7730 (334) 279-3050 (Fax) www.adem.state.al.us The agency that deals with medical waste is the Solid Waste Branch, Land Division, of the Department of Environmental Management. The regulations, found in Chapter 335-13-7 (Division 13) of the Solid Waste Program, set requirements for the following: generators; collection, storage, and transport of treated and untreated waste; treatment measures; and disposal of treated and untreated waste. Some exemptions are provided for generators producing or transporting less than 220 pounds (110 kg) of medical waste per month. Medical waste is defined as: animal waste, blood and body fluids, microbiological waste, pathological waste, renal dialysis waste, sharps, and surgical waste. Generators who produce these wastes are required to prepare and update written plans to ensure proper management of medical waste. The regulations specify, among others, packaging and labeling requirements, permits for storage and transport of untreated waste, and storage, transport and disposal requirements. Approved treatment methods are incineration, steam sterilization, chemical disinfection-encapsulation, and “other B-1
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
treatment methods” if approved by the Department. An alternative method must demonstrate that it provides protection to the public and environment equal to incineration and steam sterilization. Wastes—particularly sharps, dialysis, pathological and animal wastes—must be rendered unrecognizable prior to final disposal. Alaska Alaska Department of Environmental Conservation Air and Solid Waste Management Section 410 Willoughby Avenue, Suite 105 Juneau, AK 99801 (907) 465-5162 (907) 465-5164 (Fax) www.state.ak.us/local/akpages/ENV.CONSERV/home.htm Pathologic or infectious wastes are regulated by the Department of Environmental Conservation under the Solid Waste Management Regulations. Infectious waste is a “special waste” defined as: laboratory, surgical, and hospital waste; surgical specimens; specimens in contact with persons who have a suspected or diagnosed communicable disease; substances in contact with pathogenic organisms; disposable material from outpatient areas and emergency rooms; and equipment such as syringes and needles. The regulations require that pathological or infectious waste must first be disinfected or sterilized and then packaged for disposal, or must be incinerated in a pathological waste incinerator before disposal. Arizona Arizona Department of Environmental Quality Waste Programs Division Solid Waste Unit 3033 North Central Avenue Phoenix, AZ 85012 (800) 234-5677 or (602) 207-2300 www.adeq.state.az.us Medical waste is defined as “any solid waste which is generated in the diagnosis, treatment, or immunization of a human being or animal or in any research relating to that diagnosis, treatment, or immunization, or in the production or testing of biologicals, but not including hazardous waste…” (Arizona Revised Statutes, section 49-701.6) The authority to regulate disposal of medical waste is the Arizona Department of Health Services which gives licenses to facilities such as hospitals, clinical laboratories, B-2
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
and nursing homes. There are no specific waste disposal regulations for doctors, dentists, clinics, veterinarians, and funeral homes. The Department of Environmental Quality has been authorized to write rules for off-site treatment, storage, transport, and disposal of medical waste from all facilities. Until the rules are finalized, the Department recommends treatment by incineration, steam sterilization, chemical disinfection, encapsulation, microwave treatment, or sewer disposal (for liquid waste). Promulgation of new rules is expected in 1999. Arkansas Arkansas Department of Health Medical Waste Disposal Program 5800 West Tenth Street, Suite 401 Little Rock, AR 72204 (501) 661-2920 or (501) 661-2893 (501) 280-4706 (Fax) http://health.state.ar.us The state’s rules and regulations are described in the booklet “The Management of Medical Waste From Generators and Health Care Related Facilities” (March 7, 1995) by the Arkansas Department of Health. The regulations define medical waste and promulgate requirements for: identification, segregation, packaging, labeling, storage, transport, treatment, and disposal of medical waste. Specific requirements are provided for commercial transporters and commercial facilities that treat and dispose of waste. Medical waste is defined as waste from a generator or healthcare facility which, if improperly treated, handled or disposed of may transmit an infectious disease. The following are listed as specific examples of medical waste: pathological waste, liquid and semi-liquid blood, contaminated items, microbiological waste, and contaminated sharps. In particular, the regulations apply to hospitals, long-term care facilities, laboratories, professional offices, clinics, as well as blood banks, funeral homes, abortion clinics, birthing centers, health maintenance organizations, pharmacies, etc. Medical waste generated at home is exempted. The rules require that medical waste be segregated from other waste at the point of generation. The approved treatment methods are: incineration; sterilization by steam, dry heat, chemical vapor, or ethylene oxide; and disinfection by thermal inactivation (using microwave or dielectric energy) or by a chemical agent. Other alternative technologies have to be evaluated and approved by the Department. Among the criteria for evaluation are environmental impact, worker safety, and level of microbial inactivation. Treated waste that is rendered unrecognizable need not have special packaging and labeling when transported or disposed. Transporters, mobile treatment B-3
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
systems, and commercial facilities that treat, store and/or dispose of medical waste are required to have a permit. The Department also requires a verbal and written report of all incidents involving the release of medical waste to the environment. California California Department of Health Services Medical Waste Program 107 S. Broadway, Room 3028 Los Angeles, CA 90012-4405 (213) 897-7570 (213) 897-7370 (Fax) www.dhs.cahwnet.gov/ps/ddwem California’s Medical Waste Management Act (Chapter 6.1, Division 20, Health and Safety Code) regulates storage, treatment, and transport of medical waste. It is enforced by the state’s Department of Health Services and any local agency (usually county health departments) who choose to enforce the requirements. The Act specifies the types of generators and requirements for each type of generator with regards to storage and registration, requirements for haulers, permits for treatment facilities, containment and storage, and treatment methods. Medical waste is waste generated as a result of diagnosis, treatment, or immunization of humans or animals; medical research; and production or testing of biologicals. Medical waste includes sharps and biohazardous waste (which means laboratory waste, waste containing microbiological specimens, surgery specimens or tissues, animal parts or carcasses, waste containing blood or blood products, isolation waste, surgical waste fixed with formaldehyde or other fixatives, and chemotherapeutic waste). Excluded from the definition are microbiological cultures used in food processing and biotechnology, body fluids unless they contain blood, non-biohazardous waste (such as paper towels or paper products), hazardous waste, radioactive waste, household waste, and waste from normal veterinarian, agricultural, or animal livestock management on a ranch or farm. A generator that produces less than 200 pounds (91 kg) per month is called a “small quantity generator.” If the small quantity generator treats its waste on-site, it must register with the state, maintain records, and be subject to biennial inspections. It must obtain a permit if it utilizes a common storage facility. A “large quantity generator” (producing more than 200 pounds (91 kg) per month) is required to register, maintain tracking records, and be subject to annual inspections. Transporters must be registered, and all off-site treatment facilities and transfer stations must be permitted and inspected.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste may be treated by: incineration in a method approved by the department (e.g., controlled air, multi-chamber incinerator); sewage discharge of liquid and semiliquid lab waste and microbiological specimens; steam sterilization in accordance with a specified procedure; and alternative methods. Sharps must be decontaminated by incineration, steam sterilization, or disinfection by an alternative method. As of 1994, the approved alternatives not requiring a permit are: mail disposal services for sharps; Needlelyzer; Saf-Gard Suction Sanitation System for suction canisters; and Isolyser Liquid Treatment System and Sharps Management System. The approved methods requiring a permit or registration are: BioMedical Waste Systems; Disposal Science Inc. Sharps Disposal; DOCC Demolizer; Sanitec Microwave; MedMark International MedAway-1; Medical SafeTEC; Mediclean Technology; Medifor-X Dispoz-All-2000; Nutek Electron Beam (no longer available); Plasma Energy Applied Technology; Spintech TAPS; Stericycle; Synthetica; Thermokill; and Winfield Condor. Colorado Colorado Department of Public Health and Environment 4300 Cherry Creek Drive So. Denver, CO 80246-1530 (303) 692-1000 www.state.co.us/gov_dir/cdphe_dir Colorado House Bill 89-1328 (CRS 25-15-401 et seq.) applies to all generators of infectious waste and sets minimum requirements for generators on handling their infectious waste. Infectious waste is defined as waste capable of producing an infectious disease; for waste to be infectious, it must contain pathogens with sufficient virulence and quantity such that exposure by a susceptible host could result in disease. The law takes the U.S. EPA’s categories of infectious waste, developed in 1986, in designating infectious waste: isolation waste, blood, blood products, body fluids, pathological/anatomical waste, contaminated sharps, and contaminated laboratory or research waste. Responsibility for regulating facilities that store and treat infectious waste is jointly shared between the Colorado Department of Health and the local county or municipality. Under the law, generators must develop an on-site infectious waste management plan which specifies handling, labeling and packaging, contingencies for spills, staff training, designation of person responsible for implementation, and provisions for treatment and disposal. The plan must be available to haulers, licensing agencies, and regulators. The law also includes sections on liability and penalties. Treatment following written procedures must be documented. Colorado accepts incineration, autoclaving, chemical disinfection, as well as discharge of liquid/semisolid waste to a sewage treatment system, as appropriate treatment methods. Other methods may be approved by the Department of Health. Recognizable body parts must be disposed by incineration or interment. B-5
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Connecticut Connecticut Department of Environmental Protection Solid Waste 79 Elm Street, 4th Floor Hartford, CT 06106-5127 (203) 424-3316 http://dep.state.ct.us State regulations are found under Biomedical Waste Management, section 22a-209-15 of the Regulations of Connecticut State Agencies. Biomedical waste is first defined as untreated solid waste (or a container that has not been decontaminated) generated during the administration of medical care or medical research, excluding hazardous waste, home healthcare waste, discarded personal hygiene material, medical equipment used by farmers for livestock, and collected samples taken for enforcement purposes. A small quantity generator is defined as a biomedical waste generator producing or transporting less than 50 pounds (23 kg) per month. (Some exemptions are allowed for the small generator.) The generators of biomedical waste are required to segregate biomedical waste to the extent practicable and prepare a written biomedical waste management plan. The regulations also specify packaging, storage, transport, personal protection, decontamination, spill response, recordkeeping, and tracking requirements. With regards to treatment and disposal, chemotherapy waste must be incinerated, and pathological waste incinerated or interred. Infectious waste must be incinerated or discharged into a sanitary sewer if in liquid or semi-solid form. The regulations allow use of a steam sterilizer to decontaminate biomedical waste but must be in accordance with specific operating, testing, and recordkeeping requirements. (A recent amendment includes specific requirements for gravity flow and vacuum sterilizers.) The regulations require sharps to be rendered unrecognizable. Alternative methods must be at least equivalent to incineration in protecting public health and the environment, and must be approved in writing by the state. Written procedures for using an approved method must be incorporated in the management plan. Delaware Delaware Department of Natural Resources and Environmental Control Solid Waste Management Branch 89 Kings Highway P.O. Box 1401 Dover, DE 19903 (302) 739-3689 or (302) 739-3820 www.dnrec.state.de.us/solid.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Infectious waste regulations are found in Section 11 (Special Wastes Management) of Regulations Governing Solid Waste, adopted on November 1989. Infectious waste is defined as “solid wastes which may cause human disease and may reasonably be suspected of harboring human pathogenic organisms, or may pose a substantial present or potential hazard to human health or the environment” when improperly managed. Categories include biological wastes (e.g., blood and blood products, pathological waste, cultures, stocks, laboratory waste, animal waste, dialysis waste), sharps, discarded biologicals, isolation wastes, and contaminated residues resulting from cleanup of spills. The regulations require permits for any generator treating, storing, or disposing of infectious waste. Small quantity generators, defined as producing less than 50 pounds (23 kg) per month, are not required to obtain a permit for storage. As part of the permit requirements, the generator submits a plan for the management of the waste. Regulations on packaging, labeling, storage, spill containment and cleanup, recordkeeping and reporting, transportation, and manifest tracking are provided. Restrictions are imposed on the siting of infectious waste treatment facilities. There are also provisions dealing with the closure of a facility. The regulations require that waste cannot be compacted or ground until after the waste has been rendered noninfectious. Anatomical parts must be incinerated or interred. The approved treatment methods are steam sterilization, incineration, or other methods that render the waste non-infectious. The regulations provide performance standards for steam sterilization. For other treatment methods, an initial efficacy test must be conducted to demonstrate that a specified reduction or kill of test microorganisms is achieved; afterwards, periodic verification tests on test or indicator microorganisms are required at least quarterly. Records must be retained for at least three years. Florida Florida Department of Environmental Protection Biomedical Management Waste Program Bureau of Solid and Hazardous Waste Twin Towers Office Building 2600 Blair Stone Road Tallahassee, Florida 32399-2400 (904) 488-0300 or (904) 487-0004 (904) 921-8061 (Fax) www2.dep.state.fl.us Regulations are found in Chapter 62-712 (Biomedical and Biological Waste Management) of the DEP regulations (1994), available from the Bureau of Solid & Hazardous Waste, Solid Waste Section, Mail Station 4565, Department of Environmental Protection (address above). Biomedical waste (also called biohazardous waste) is defined as any solid or liquid waste that may present a threat to humans, and B-7
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
includes non-liquid tissue and body parts from humans and other primates, lab and veterinary waste, discarded sharps, blood, blood products, and body fluids. The definition also includes used adsorbents and disposable devices saturated with blood. The regulations cover transport, registration, storage, treatment, disposal, recordkeeping, and preparation of contingency plans. All biomedical waste transporters must be registered with the department and the waste must be properly segregated, packaged, and labeled. Specific requirements are given for packaging and labeling, with references to U.S. DOT regulations. Off-site biomedical waste storage requires a general permit. Biomedical waste must be treated within 30 days of collection from a generator using one of the following: incineration, microwaving and shredding, chemical disinfection, and sterilization in a steam sterilizer following specific operating requirements. Biomedical waste may also be disposed in a sewage treatment system. Alternative treatment methods have to have approvals from the Department. Approval must be requested in writing for a specific facility and treatment method and a demonstration of effectiveness and safety of the technology must be made. Georgia Georgia Department of Natural Resources Environmental Protection Division Commercial and Industrial Solid Waste Program 4244 International Parkway, Suite 114 Atlanta, GA 30354 (404) 362-2671 www.ganet.org/dnr Regulations are found in the following sections of the Rules of Solid Waste Management, Chapter 391 (Solid Waste Management) of the Department: 391-3-4-.04 (General); 391-3-4-.06 (permit by rule for collection, transportation, processing, and disposal); 391-3-4-.08 (solid waste thermal treatment operations); and 391-3-4-.15 (biomedical waste). The regulations apply to all facilities generating biomedical waste including hospitals, blood banks, clinics, dental offices, funeral homes, HMOs, labs, physicians offices, veterinaries, nursing homes, research facilities, home healthcare organizations, etc. Partial exemptions are given to facilities generating less than 100 pounds (45 kg) a month. In the regulations, biomedical waste is defined as any solid waste which contains pathological waste, biological waste, cultures and stocks of infectious agents and associated biologicals, contaminated animal carcasses, chemotherapy waste, and contaminated discarded medical equipment and parts not including supplies and materials.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The permit by rule allows collection, transfer station, inert waste landfill, waste treatment, and sludge disposal operators to operate as long as certain conditions are met, including notification of the Department director. On-site thermal treatment (combustion) operators must treat no less than 75% of their own waste, routinely sample bottom and fly ash, meet air quality standards, provide fire protection, and supervision. Lead batteries, radwaste, or regulated amounts of hazardous waste must be kept out of the biomedical waste stream. Specific storage, containment, and transport provisions are given. The following are the accepted methods of treatment: incineration in a thermal treatment facility, autoclave (except for chemotherapy waste), and methods specifically granted approval by the director. Fluids and semisolid waste may be discharged to a sewage facility. Recognizable body parts may not be buried in a landfill. Hawaii Hawaii Department of Health Office of Hawaiian Health P.O. Box 3378 Honolulu, HI 96801 (808) 586-4080, or (808) 586-4410 www.hawaii.gov/doh The Hawaii Rules for Management and Disposal of Infectious Waste are found in Title 11, Chapter 104 of the Hawaii Administrative Rules under the authority of section 321-21, Hawaii Revised Statutes. Infectious waste is defined as any waste containing pathogens capable of causing infectious disease including infectious isolation waste, cultures and stocks, blood, blood products, body fluids, pathological waste, contaminated sharps, and contaminated animal waste. The rules refer to CDC, EPA, and other federal agencies for proper handling and treatment of infectious waste. Regulations for transportation within and without the generating facility as well as storage are provided. Generators and transporters must develop a written infectious waste management plan including provision for contingencies. Depending on the type of wastes, they may be treated by incineration, autoclaving, wastewater disposal (blood and body fluids), and chemical disinfection. Infectious waste that has not been properly treated can be disposed in permitted or authorized disposal sites. Recognizable body parts must be incinerated or disposed according to other applicable laws. Treated non-incinerated waste must be clearly marked as noninfectious. Violators of any provisions of the regulations are subject to administrative penalties not exceeding $1000 per separate offense. The regulations include provisions related to liability.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Idaho Idaho Department of Health and Welfare 450 W. State Street Boise, ID 83720-0036 (208) 334-5500 (208) 373-0502 (Division of Environmental Quality) www2.state.id.us/dwh Medical waste had been regulated under solid waste but legislation for specific regulation of infectious waste has been proposed. The administrative rules and standards are available from the Office of Administrative Rules (208) 334-3577. Illinois Illinois Environmental Protection Agency 2200 Churchill Road, P.O. Box 19276 Springfield, IL 62794-9276 (217) 524-3300 (217) 524-3289 (PIMW Coordinator) (217) 782-3397 (general information) www.epa.state.il.us Regulations for potentially infectious medical waste (PIMW), adopted by the Illinois Pollution Control Board, are found in Title 35, Subtitle M of the Illinois Administrative Code under the authority of Title XV of the Illinois Environmental Protection Act. The term potentially infectious medical waste or PIMW is categorized under “special waste” and refers to waste generated in connection with diagnosis, treatment, or immunization of humans or animals, and waste in relation to medical research or production/testing of biologicals. PIMW wastes include: cultures and stocks, pathological waste, blood and blood products, used sharps, animal waste, isolation waste, and unused sharps, but exclude household waste, treated waste (except sharps), and decontaminated sharps rendered unrecognizable. The regulations require the segregation of PIMW into sharps, oversized PIMW, and all other PIMW. Packaging, labeling, transport, and storage requirements are provided, and in general off-site operations require a permit. With regards to treatment, the State requires that any treatment process must demonstrate its ability to eliminate the infectious potential through an Initial Efficacy Test (IET) and Periodic Verification Tests (PVT) which are described in detail in Sections 1422.124 and 125 of the Code. Autoclaves, incinerators, and ethylene oxide units installed and operated before June 21, 1993 are not required to perform the IET. Compaction and rupture of containers are not allowed prior to treatment unless these are integral parts of the treatment process. Quality assurance programs are also required including a written plan to describe B-10
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
operating parameters and designate responsible personnel. Disposal of residues from PIMW treatment are also regulated; incinerator ash is considered an industrial process waste and must be managed as a special waste. In addition, if more than 50 pounds (23 kg) of PIMW per month are generated, an annual report specifying quantities and disposition of treated waste must be submitted to the agency. Untreated PIMW is banned from all landfills. Decontaminated sharps must also be rendered unrecognizable or placed in a proper package prior to disposal. Indiana Indiana State Department of Health Communicable Disease Division 2 North Meridian Street Indianapolis, IN 46206 (317) 233-7665 www.isdh.state.in.us/doh Regulations on medical waste are found in Rule 3 (Infectious Waste) codified in 410 IAC 1-3-1 through 1-3-29. Infectious waste is defined as waste that epidemiologic evidence indicates is capable of transmitting a dangerous communicable disease. Included are contaminated sharps; infectious cultures and stocks; pathological waste; blood and blood products; carcasses, body parts, blood and body fluids, and bedding of laboratory animals; and other intermingled wastes. The rule requires a written policy and procedures to address specific requirements. General and, at times, specific requirements on containment, storage, and transport are given in the rules. Approved treatment technologies are: incineration, steam sterilization, chemical disinfection, thermal inactivation, irradiation, or discharge in a sanitary sewer or septic system. The subsequent section, Rule 4 (Universal Precautions), deals with training, equipment, personnel policy, and precautions to prevent contamination of employees of healthcare facilities with blood or other body fluids. Iowa Iowa Department of Natural Resources Wallace State Office Building 502 E. 9th Street Des Moines, IA 50319-0034 (515) 281-8941 or (515) 281-8934 www.state.ia.us/government/dnr/organiza/epd/index.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste treatment and disposal regulations were covered broadly in Chapters 102 and 104, Title VIII (Waste Management and Disposal) of the Iowa Code. Under the present regulations, infectious waste was designated a special waste and could be placed with regular municipal solid waste if rendered nonpathological, did not contain free liquids, and sharps were incinerated or mechanically destroyed. Generators had to notify the hauler and landfill regarding the infectious waste. Kansas Kansas Department of Health and Environment Bureau of Waste Management Forbes Field, Building 740 Topeka, KS 66620-0001 (785) 296-1600 (785) 296-1592 (Fax) www.kdhe.state.ks.us/waste Regulations regarding medical services waste are found in K.A.R. 28-29-27. “Medical services waste” is defined as waste materials potentially capable of causing disease or injury and generated in connection with human and animal care though inpatient and outpatient services. Not included are hazardous and radioactive wastes. The regulations require segregation of medical services waste from other solid wastes at the point of origin. There are also requirements for storage, collection, and transportation. Medical services waste must be disposed at an authorized facility on the same day as they are collected. Processing of the waste must be done in such as way as to prevent dispersal of aerosols and liquids. Where feasible, medical services waste should be processed before transportation off-site. Processes include sterilization by autoclave or chemical treatment; grinding, melting, or pulverizing sharps; discharge of liquids into a sanitary sewer; incineration; or disposal in a hazardous waste disposal facility or a sanitary landfill. Disposal in a sanitary landfill requires an industrial solid waste disposal authorization which must be obtained from the Solid Waste Section of the Bureau of Waste Management at (913) 296-1121 or (913) 296-1167. Kentucky Kentucky Department of Environmental Protection Resource Conservation and Local Assistance Branch Division of Waste Management 14 Reilly Road Frankfort, KY 40601 (502) 564-6716 www.nr.state.ky.us/nrepc/dep/waste/dwmhome.htm
B-12
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The Natural Resources and Environmental Protection Cabinet’s Department of Environmental Protection does not have requirements specific to transport, storage, collection, and disposal of medical waste. Nevertheless, the Department created the Infectious Waste Task Force in 1988 to develop recommendation for handling. These recommendations are in effect and serve as a basis for regulatory actions. The Department’s Division of Air Quality (502-564-3382) deals with permitting of medical waste incinerators. The Transportation Cabinet registers vehicles of haulers of municipal solid waste, which includes infectious waste haulers. Under the Infectious Waste Task Force recommendations, the major categories of infectious waste are: microbiologicals (infectious cultures and stocks), blood and blood products, all discarded sharps, pathologicals (tissues, organs, body parts), animal waste, miscellaneous biomedical waste (such as bandages, dressings, etc.), and isolation waste. The Task Force recommends segregation and labeling of infectious waste at the point of generation. General recommendations are made on storage and transport. Recommendations are also made dealing with public education, enforcement and penalties, waste minimization, and other issues. Treatment of infectious waste must result in non-hazardous, non-infectious, and unrecognizable waste. The accepted treatment methods are incineration, autoclaving, and sanitary sewer disposal (in keeping with applicable sewerage regulations). Alternative treatment technologies must obtain prior review and approval by both the Cabinet for Human Resources (502-564-7398) and the Natural Resources and Environmental Protection Cabinet. Louisiana Louisiana Department of Environmental Quality Office of Solid and Hazardous Waste Solid Waste Division P.O. Box 82178 Baton Rouge, LA 70884-2178 (225) 765-0355 (225) 765-0617 (Fax) www.deq.state.la.us/oshw/hw/hw.htm Louisiana Department of Health and Hospitals Office of Public Health 325 Loyola Avenue New Orleans, LA 70112 (504) 568-5051 (504) 568-2609 (Fax) www.dhh.state.la.us/oph/ophmain.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Office of Public Health Division of Environmental Health Services 6867 Bluebonnet Baton Rouge, LA 70811 (504) 568-5181 (infectious waste) Office of Public Health Assistant Secretary 1201 Capital Access Road Box 3214 Baton Rouge, LA 70802-3214 (225) 342-8903 Medical waste disposal is subject to various regulations by the Louisiana Department of Health and Hospitals (DHH) and the Louisiana Department of Environmental Quality (DEQ). These agencies also follow rules from the federal Occupational Safety and Health Administration regarding packaging and labeling of certain types of waste such as sharps. Under a memorandum of understanding between the two state agencies in 1993, both agencies would share authority over transportation and treatment of medical waste. DHH, however, would regulate packaging, labeling, storage, and the approval of alternative technologies and DEQ would handle permitting and approval of commercial (off-site) treatment facilities, transportation, and treatment in relation to landfilling. The regulations governing packaging, labeling, storage, transport, and treatment of medical waste are in Chapter XXVII of the Louisiana Sanitary Code under the Department of Health and Hospitals. There are also brief sections regarding the landfilling of medical waste in Chapter 13, Part VII, Title 33 of the Louisiana Administrative Code under Solid Waste Regulations of the Department of Environmental Quality. DEQ has been authorized to draft new regulations for transportation, incineration, and disposal of medical waste. The Department of Health and Hospitals defines several terms—medical waste, infectious biomedical waste, and potentially infectious biomedical waste—of which the latter is used most extensively. Potentially infectious biomedical waste includes cultures and stocks; pathological waste; blood and blood products; sharps; bandages, diapers and other disposable material used for infected wounds or by isolation room patients; and commingled waste. Small healthcare and medical facility generators are defined as those producing less than 25 kg (55 pounds) of potentially infectious biomedical waste a month (not including sharps) or less than 5 kg (11 pounds) of sharps a month. Large generators that treat their waste at an off-site facility must follow packaging, labeling and transport requirements. Generators that treat their waste on site must prepare an annually updated contingency plan on how they expect to manage their medical waste should their on-site treatment system become inoperative. B-14
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Acceptable treatment methods are: incineration, steam sterilization (under specified conditions), disposal of liquids in a sanitary sewer following Sanitary Code requirements; thermal inactivation (under specified conditions), chemical disinfection (using approved chemical agents), and irradiation (only with written approval of the State Health Officer). Body parts must be buried, cremated, or disposed by means authorized by law. Sharps may be incinerated, or encased in plaster or in other substances (approved by the State Health Officer) within a tightly closed container, or treated in a way that renders them unrecognizable and precludes their release if compacted. Treated waste may be disposed of in a permitted landfill. Still recognizable medical waste must carry a supplemental label specifying the treatment method and date and the name/initial of the person responsible for treatment. Maine Maine Department of Environmental Protection State House Station 17 Augusta, ME 04333 (207) 287-7688 or (800) 452-1942 www.state.me.us/dep/mdephome.htm The Biomedical Waste Management Rules, under the authority of 38 MRSA Section 1319-0, are found in 06-096 CMR Chapter 900. In general, wastes of a biological origin are covered under this rule, whereas those of a chemical origin would fall under the Hazardous Waste Management Rules. The definition of biomedical waste includes discarded blood/blood products/body fluids or waste saturated with them, pathological waste, sharps, cultures and stocks, carcasses and other waste from animal research, and cytotoxic drugs/chemotherapy waste not regulated as hazardous waste. The rule prohibits mixing biomedical waste with other hazardous or radioactive wastes. Facilities generating less than 50 pounds (23 kg) of biomedical waste per month are exempted from most of the rules. For generators, the rules require registration and development of a written management plan, and define standards for packaging, labeling, handling, storage and recordkeeping. There are specific rules and licensing requirements for transporters, transfer facilities, and treatment/disposal facilities. With regards to treatment methods, pathological waste must be incinerated or interred and blood/blood products/body fluids can be incinerated or discharged through a sewer or septic system. All other biomedical waste must be incinerated in a licensed incinerator (incineration is considered a method of treatment and not of disposal). However, a petition can be submitted to the Board of Environmental Protection for approval of an alternative technology; demonstration of effectiveness and safety equivalent to incineration must be made. Application for licensing of a treatment and disposal facility is made to both the Bureau of Oil & Hazardous Materials Control (for a biomedical waste treatment facility license) and to the Bureau of Air Quality Control (for an air emission license). B-15
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Maryland Maryland Department of the Environment 2500 Broening Highway Baltimore, MD 21224 (410) 631-3000 or (800) 633-6101 www.mde.state.md.us/reference/index.htm Medical waste regulations are found in Chapters 11-13 under Subtitle 13 of Title 26, Department of Environment regulations, under the authority of §§7-201 et seq., 9-252, 9-314 of the Annotated Code of Maryland. “Special medical waste” is defined as composed of anatomical material, blood, blood-soiled articles, contaminated material, microbiological laboratory waste, and sharps. They are considered controlled hazardous substances and subject to other provisions. Excluded are household waste, waste generated in handling animals (unless the animal has a transmittable disease), ash or by-products from incineration, etc. A person generating less than 50 pounds (23 kg) per month is exempted from the regulation. The regulations promulgate standards applicable to generators which include manifest, packaging, labeling, recordkeeping, and international shipment requirements. Generators who treat, store, dispose or transport special medical waste are required to obtain a Maryland Identification Number. There are specific transporter regulations. Sharps cannot be disposed in a solid waste landfill unless first incinerated and mechanically destroyed. Massachusetts Massachusetts Department of Public Health Division of Community Sanitation 305 South Street, 1st Floor Jamaica Plain, MA 02130 (617) 983-6761 (617) 983-6770 (Fax) www.magnet.state.ms.us/dph/csanskel.htm 105 CMR 480.001 to 480.7000, Chapter VIII of the State Sanitary Code, Department of Public Health, set forth the requirements for storage and disposal of infectious waste or physically dangerous medical or biological waste. The term “infectious or physically dangerous medical or biological waste” includes blood and blood products, pathological waste, cultures and stocks, contaminated animal carcasses/body parts/bedding, sharps, and biotechnological by-product effluents. The regulations define storage, labeling, recordkeeping, and manifest requirement, as well as administrative and enforcement procedures. A medical waste tracking form is B-16
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
provided by the Department. The approved methods of treatment are steam sterilization, gas sterilization, chemical disinfection, incineration at an approved facility, and other approved methods. Specifically, under the regulations, blood and blood products may be disposed of in the municipal sewerage or septic system or may be incinerated or sterilized using gas, chemical or steam prior to disposal in an approved sanitary landfill. Sharps shall be contained in puncture-resistant containers and disposed of by incineration or by rendering noninfectious and physical destruction. Blood-saturated materials, cultures and stocks, dialysis waste, and laboratory waste may be incinerated or rendered noninfectious by steam, incineration, thermal inactivation, or chemical disinfection and disposed of in an approved sanitary landfill. Biotechnology by-product effluents may be processed by steam sterilization, chemical disinfection, incineration at an approved facility, or other approved methods with additional requirements. Pathological waste and animal carcasses must be incinerated or interred. Other treatment methods may be approved under the condition that scientific studies validating the process are accepted by the Department. Michigan Michigan Department of Public Health 3423 N. Logan/Martin Luther King Jr. Boulevard P.O. Box 30195 Lansing, MI 48909 (517) 335-8024 or (800) 444-6472 www.mdch.state.mi.us Medical waste regulations are found in Part 138 (Medical Waste) of the Public Health Code, Sections 333.13801 through 333.13831. Medical waste is defined as cultures and stocks, liquid human and animal waste, pathological waste, sharps, and contaminated wastes from animals, except any of these that may be generated from a household, agricultural business, home for the aged, or home health care agency. The regulations specify requirements for storage as well as containment depending on whether the waste is incinerated on-site or not. Approved methods for decontamination of waste are specified according to the type of waste. These methods include autoclaving, incineration, and flushing down a sanitary sewer. Some types of waste can be disposed in a sanitary landfill. Alternative methods are accepted for some types of waste but only after approval by the department. Facilities that generate, store, decontaminate, or incinerate medical waste (referred to as “producing facilities”) must register and submit a written medical waste management plan which contain certain required information. The plans are reviewed by the department. In addition, the regulations specify packaging, procedures for the investigation of reports and violations, the creation of an interdepartmental medical
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
waste advisory council and a medical waste emergency response fund, and training requirements. Minnesota Minnesota Pollution Control Agency Solid Waste Section Ground Water and Solid Waste Division 520 Lafayette Road St. Paul, MN 55155-4194 (800) 657-3864 or (612) 296-6300 www.pca.state.mn.us/netscape.shtml The permanent rules relating to infectious waste management are in Minnesota Rules Chapter 7035 adopted by the Pollution Control Agency under the authority of the Infectious Waste Control Act. Infectious waste is define as laboratory waste, blood, regulated body fluids, sharps, and research animal wastes that have not been decontaminated. All untreated infectious waste must be segregated and may not be compacted prior to incineration or disposal. There are requirements for labeling, containment, disposal, storage, transportation, the preparation and certification of management plans, and financial assurance. Sharps must be placed in puncture-resistant containers. Incineration requires an air emission permit and must operate in compliance with other regulations. In addition to incineration, the other accepted methods are autoclaving under specific conditions, as well as other methods (grinding, microwaving, etc.) that require approval by the commissioner of the agency. Mississippi Mississippi State Department of Health 2423 North State Street P.O. Box 1700 Jackson, MS 39215-1700 (601) 576-7960 (601) 576-7505 (Fax) www.msdh.state.ms.us/msdhhome.htm Mississippi Department of Environmental Quality Office of Pollution Control P.O. Box 10385 Jackson, MS 39289-0385 (601) 961-5171 www.deq.state.ms.us B-18
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The State Department of Health has “Adopted Standards for the Regulation of Medical Waste” governing the handling and treatment of infectious waste on site. They are also responsible for alternative technologies treated in house. Under their regulations, “infectious medical waste” includes wastes from care of patients and animals with specific transmittable diseases, cultures and stocks, blood and blood products, pathological waste, contaminated carcasses/body parts/bedding of animals, discarded sharps, and other wastes classified by the department. The term “medical waste” is defined as all other waste generated in patient care, diagnostic or research areas, that is non-infectious but aesthetically repugnant. The Department of Environmental Quality addresses infectious waste disposal through specific conditions in solid waste management permits that generally prohibit acceptance of waste not rendered noninfectious. They also regulate transport (not requiring licensing) and off-site management (requires an operating permit) of infectious waste through the Nonhazardous Solid Waste Management Regulations. Under the Department of Health regulations, all generators must have a waste management plan to include storage, containment, labeling, and treatment. Infectious medical waste must be segregated at the point of origin. Compaction or grinding shall not be used to process infectious medical waste unless the waste is rendered noninfectious. The acceptable methods are incineration in an approved incinerator, sterilization by heating in a steam sterilizer under specified conditions, discharge of liquid or semi-liquid waste in an approved sewerage system, interment or incineration of recognizable anatomical remains, and chemical sterilization using sterilants recognized by U.S. EPA. Missouri Missouri Department of Natural Resources Solid Waste Management Program P.O. Box 176 Jefferson City, MO 65102 (800) 334-6946 or (573) 751-5401 www.dnr.state.mo.us/deq/swmp/homeswmp.htm Infectious waste is covered under Chapter 260, Section 203 and 204, of the Missouri Solid Waste Management Law, and the regulations are found in Title 10, Division 80, Chapter 7 (Infectious Waste Management) of the Code of State Regulations. Infectious waste includes isolation waste; contaminated surgical, dialysis and laboratory wastes; cultures and stocks, blood and blood products; pathology waste; and sharps. Regulations exist also for small quantity generators producing 100 kilograms or less of infectious waste per month. Hospitals can accept infectious waste for treatment from small quantity generators and other hospitals as defined in the regulations, but the hospital treating the waste needs to submit a notice of intent to the department.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The regulations include provisions on packaging, tracking, and transportation of infectious waste. Sharps, whether generated at a hospital or individual residence, must be packaged in rigid, leakproof, puncture-resistant containers. Requirements are set forth for infectious waste processing facilities which can use any of two approved methods: incineration or steam sterilization; other methods may be approved by the department on a case-by-case basis. Hospitals may treat infectious waste by autoclaving, incineration, chemical disinfection, or other methods approved by the department. Once treated, the waste must be certified as having been treated prior to disposal in a landfill. Montana Montana Department of Environmental Quality Waste Management Division Solid Waste Program 2209 Phoenix Avenue P.O. Box 200901 Helena, MT 59620-0901 (406) 444-2544 www.deq.state.mt.us The Infectious Waste Management Act (75-10-1001 to 1006) is enforced by the Department of Environmental Quality, formerly the Department of Health and Environmental Sciences. Infectious waste includes cultures and stocks, human pathological waste, free-flowing human blood or blood products, and sharps. The regulations require segregation of infectious waste at the point of origin. There are also provisions for storage, transportation, treatment, and disposal, as well as licensing and regulation. Employees handling or managing infectious waste must receive training. Generators and transporters must develop contingency plans. Compaction or other mechanical manipulation of infectious waste is prohibited. The treatment methods are incineration, steam sterilization, chemical sterilization using approved techniques, sewer discharge for liquid or semisolid infectious waste, and incineration or interment for body parts. Nebraska Nebraska Department of Environmental Quality Integrated Waste Management Section P.O. Box 98922 Lincoln, NE 68509-8922 (402) 471-2186 (402) 471-2909 (Fax) www.deq.state.ne.us B-20
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Medical waste regulations are found under Special Wastes in Chapter 12 of Title 132 (Integrated Solid Waste Management Regulations) with definitions given in Chapter 1. Infectious waste includes blood, blood products, body fluids, infectious sharps, laboratory waste, contaminated animal parts, and other wastes identified by infectious waste generators. Infectious waste cannot be disposed of at a solid waste disposal area unless first rendered non-infectious by incineration, autoclaving, or other treatment method approved by the department. Other requirements applicable to special wastes must also be met. Nevada Nevada Department of Conservation and Natural Resources Division of Environmental Protection Bureau of Waste Management Solid Waste Branch 333 W. Nye Lane Carson City, NV 89706 (702) 687-4670 or (702) 687-5872 (general information) (702) 687-6396 (Fax) www.epa.gov/swerust1/states/nevadaul.htm Medical/infectious waste regulations are found in Sections 444.589, 444.646 and 444.662 of the Nevada Administrative Code. The definition of “medical waste” makes reference to Appendix G of 49 CFR 173, U.S. Department of Transportation regulations, and includes cultures and stocks, pathological wastes, human blood and blood products, sharps, animals waste, isolation waste, and unused sharps. Medical waste can be deposited at approved sites under specified conditions. Storage and transport requirements are also provided. New Hampshire New Hampshire Department of Environmental Services Waste Management Division 6 Hazen Drive Concord, NH 03301-6509 (603) 271-2900 (603) 271-2925 (infectious waste) (603) 271-2456 (Fax) www.state.nh.us/des/biowmd.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Infectious Waste regulations are found in Part Env-Wm 2604.01 to 2604.05 as well as Part Env-Wm 2207.02 of the Solid Waste Rules. Infectious waste includes cultures and stocks; pathological wastes; blood and blood products; sharps; contaminated animal carcasses, body parts, or bedding; waste from human or animal patient care, surgery, or autopsy; laboratory wastes; dialysis wastes; discarded medical equipment and parts in contact with infectious agents; biological waste and discarded materials contaminated with blood and other secretions from humans or animals in isolation; discarded preparations from genetically altered living organisms and their products; and other waste materials determined by the director to pose a threat to human health or the environment. The regulations include requirements for storage, transportation, treatment, and disposal of infectious waste, as well as treatment and disposal exemptions. There are limited permit standards for infectious waste processing or treatment facilities. The regulations require treatment that achieves high-level disinfection, specifically, a four Log reduction of Bacillus subtilis, by incineration, steam sterilization, chemical disinfection, or gas disinfection. Pathological incineration is the preferred treatment method. Recognizable body parts must be incinerated or interred. Non-infectious liquid blood or body fluids may be disposed in a sanitary sewer. Sharps infectious waste require incineration. New Jersey New Jersey Department of Environmental Protection and Energy Division of Solid Waste Management P.O. Box 414 401 E. State Street Trenton, NJ 08625 (609) 984-6880 (609) 984-6874 (Fax) www.state.nj.us/dep/dshw/hwr New Jersey Department of Health and Senior Services Division of Environmental and Occupational Health Consumer and Environmental Health Services P.O. Box 369 Trenton, NJ 08625 (609) 984-2193 or (609)-588-2577 (general information) www.state.nj.us/health The regulations for regulated medical waste are found in Subchapter 3A of 7:26 New Jersey Administrative Code. Regulated medical waste includes cultures and stocks, pathological wastes, blood and blood products, sharps, animal waste, isolation wastes,
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
and unused sharps. The state requires registration of generators, transporters, intermediate handlers, and destination facilities. Prior to transport off-site, wastes must be segregated to the extent practicable, separating sharps, fluids greater than 20 cc, and other medical waste. There are also packaging, storage, decontamination, labeling, marking (identification), tracking, recordkeeping, and reporting requirements. Specific requirements for transporters and operators of a regulated medical waste incinerator. Treatment methods are incineration, steam sterilization, chemical disinfection, irradiation, thermal inactivation, or any other effective method approved by the Department of Health. The Department of Health has developed efficacy standards such that a minimum 4 Log reduction in certain bacteria and viruses is achieved. New Mexico New Mexico Environment Department Solid Waste Bureau Harrold Runnels Building 1190 St. Francis Drive P.O. Box 26110 Santa Fe, NM 87502-6110 (505) 827-2775 www.nmenv.state.nm.us Infectious waste requirements are found under Special Waste in Section 706, Part VII, of the Environmental Improvement Board/Solid Waste Management Regulations. The rules apply not only to hospital and clinics but also to intermediate care facilities, HMOs, health agencies, laboratories, medical buildings, physicians and dentists offices, veterinarians, funeral homes, etc. Infectious waste includes microbiological laboratory wastes, pathological wastes, disposal equipment and materials requiring special precautions, blood and blood products, used sharps, and contaminated animal carcasses, body parts, and bedding. Anyone treating infectious waste must certify in writing that the waste has been rendered noninfectious, and such certification must be provided to transporters or disposal facilities. The regulations include provisions for storage, containment, treatment, and disposal. Compaction, grinding, or similar devices are not allowed before the waste has been rendered noninfectious or unless approved by the department. Body parts must be disposed of by incineration or interment. Otherwise, the acceptable methods of treatment, in accordance with certain provisions, are incineration, steam sterilization, and sewer discharge for liquid or semi-solid waste. Other methods may be approved by the secretary if efficacy can be demonstrated (namely, a 4 Log reduction for B. stearothermophilus or B. subtilis, and a 6 Log reduction in specified vegetative bacteria, fungi, parasites, viruses, and microbacteria). B-23
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
New York New York State Department of Environmental Conservation Division of Solid Waste 50 Wolf Road Albany, NY 12233-1011 (518) 485-8940 or (800) 342-9296 (800) 312-9296 (hazardous waste) (518) 457-7744 (Fax) www.dec.state.ny.us/website/dshm/sldwaste/index.htm New York State Department of Health Regulated Medical Waste Program Wadsworth Center P.O. Box 509 Empire State Plaza Albany, NY 12201-0509 (518) 458-6483 or (518) 485-5378 The original regulations on regulated medical waste were mainly in Subparts 360-10 and 360-17 of Part 360, Title 6 of the New York Codes, Rules, and Regulations (NYCRR) under the statutory authority of the Environmental Conservation Law. The definition of regulated medical waste, found in 6 NYCRR 364.9, was any medical waste that was a solid waste (as defined elsewhere) generated in the diagnosis, treatment, or immunization of human beings or animals, in medical research, or in production of biologicals. It included cultures and stocks of infectious agents, associated biologicals; human pathological wastes; liquid human blood, blood products, items saturated with blood; sharps; contaminated animal carcasses, body parts, and bedding of animals exposed to infectious agents; surgery or autopsy waste in contact with infectious agents; laboratory waste in contact with infectious agents; dialysis wastes in contact with blood; biological waste and discarded materials contaminated with blood and other fluids from humans who were isolated to protect others; and unused sharps. Excluded were hazardous and household wastes, incinerator ash, treatment residues, human remains intended for interment or cremation, and samples transported off-site by EPA or State designated enforcement personnel. Different regulations or exemptions applied depending on whether a generator produces or transports off-site 50 pounds (23 kg) of less per month. The regulations have since been amended by Section 1389 aa-gg under Chapter 438 of the Public Health Law of 1993. A pamphlet “Managing Regulated Medical Waste” by the NY Department of Health provides interpretive guidelines for implementing revisions to the Public Health Law. Among the changes are the definition of medical waste which reduces the number of subcategories to the following: cultures and stocks, human pathological waste, human blood and blood products, sharps, animal waste, B-24
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
and any specific items designated by the Commissioner of Health. One notable change is that IV bags and associated tubing are no longer considered regulated medical waste. (It should be noted that the federal EPA has adopted New York’s definition for some rulemaking.) Under the original regulations, New York requires segregation to the extent practicable of sharps, fluids greater than 20 cc, and other regulated medical waste. Facilities involved with storage, transfer, and disposal of regulated medical waste must comply with permit requirements to construct and operate, as well as operational requirements. Sharps must be treated and destroyed before landfilling. Recognizable body parts and animal carcasses must be disposed of by interment or incineration. Treated regulated medical waste or treated and destroyed medical waste (TDMW) may be disposed of only in landfills or approved incinerators. The approved treatment methods for regulated medical waste are (see Section 360-17.5 for specific operating conditions): incineration, autoclaving, sewerage system discharge for liquid or semi-liquid waste, and other treatment methods approved by the commissioner of the New York State Department of Health. Approval as an alternative treatment requires a written application which includes testing and supporting documentation to be able to determine efficacy. Each treatment unit is required to successfully complete an approved validation testing program. The revised regulations requires hospitals and nursing homes to establish procedures for accepting sharps waste from private residences effective July 1, 1996. As before, all alternative treatment alternatives must be approved. Evaluation is conducted by the Regulated Medical Waste Program (RMWP) of the Department of Health. A list of approved technologies can be obtained from the RMWP. North Carolina North Carolina Department of Environment, Health, and Natural Resources Division of Solid Waste Management P.O. Box 27687 Raleigh, NC 27611-7867 (919) 733-4984 (919) 761-2390 (West NC) (919) 486-1191 (East NC) www.ehnr.state.nc.us/EHNR The Medical Waste Management rules are mainly found in 15A NCAC 13B, Sections 1200 et seq. of the North Carolina Administrative Code. Medical waste is comprised of general waste (no special requirements), sharps and blood or body fluids less than 20 cc (requiring packaging), and regulated medical waste which requires treatment. Regulated medical waste means blood and body fluids in volumes greater than 20 cc, microbiological waste (cultures, stocks, etc.), and pathological waste (including animal B-25
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
carcasses and body parts exposed to pathogens). North Carolina does not require registration of generators. The regulations provide requirements for packaging, storage, transportation, treatment, and disposal. Some exemptions from packaging, labeling, storage, and recordkeeping requirements are allowed depending on whether the generator or treatment facility is an integrated medical facility (i.e., one of more healthcare facilities located in one county or two contiguous countries, affiliated with a university or under common ownership or control, and serving a single service area) or not. Labeling requirements differ from those of OSHA. Sharps must be packaged in rigid, leak-proof, and puncture resistant containers and can be disposed of with general solid waste. Facilities treating regulated medical waste generated off-site require a permit by the Solid Waste Section. The acceptable methods of treatment are incineration or sanitary sewerage disposal for blood and body fluids; incineration, steam sterilization, microwave treatment, or chemical treatment for microbiological waste; and incineration for pathological waste. Other methods require approval by the Division. North Dakota North Dakota Department of Health and Consolidated Laboratories Division of Waste Management 1200 Missouri Avenue P.O. Box 5520 Bismark, ND 58506-5520 (701) 328-5150 (701) 328-5200 (Fax) www.health.state.nd.us/ndhd/environ The Regulated Infectious Waste rules are found in Chapter 33-20-12 of the Department regulations. Under the regulation, regulated infectious waste refers to cultures and stocks, pathological waste, blood and blood products, sharps, animal waste, isolation waste, and unused sharps. North Dakota requires segregation of regulated infectious waste from other waste, and segregation of sharps at the point of origin. All regulated infectious waste must be incinerated or disinfected; sharps not incinerated must be rendered nonsharp. Blood and blood products can be discarded through the municipal sewage system. Other requirements for containment and handling are included in the management standards for regulated infectious waste.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Ohio Ohio Environmental Protection Agency Division of Solid and Infectious Waste Management P.O. Box 1049 Columbus, OH 43216-1049 (614) 728-3778 (614) 728-3898 (Fax) www.epa.ohio.gov/new/divs.htm The Division of Solid and Infectious Waste Management of Ohio EPA regulates infectious waste and the regulations are found mainly in OAC-3745-27 of the Ohio Administrative Code. In addition, the Division of Air Pollution Control (614-644-2270) regulates infectious waste incinerators. Infectious wastes include cultures and stocks, laboratory waste, pathological wastes, isolation wastes, human and animal blood and blood products, contaminated animal wastes, sharps, and other materials determined by the public health council as infectious waste. There are separate generator standards depending on whether a facility generated less than 50 pounds (23 kg) per month (small generator) or not. Siting criteria and permitting requirements for an infectious waste treatment facility are specified in OAC 3745-27-37, -50, and -51. The regulations promulgate standards for generators, transporters, operators of infectious waste treatment facilities, as well as packaging, storage, and registration requirements. Small generators are required to segregate at the point of generation, place sharps in specified containers, and maintain records, among other requirements. Facilities generating 50 pounds (23 kg) per month or more also need to segregate waste at the point of generation, place sharps in containers specified in the rule, and treat waste on site or at an off-site facility, employ only registered transporters, provide information if required, record spills or accidents, and develop spill containment and clean-up procedures. Untreated liquid or semi-liquid infectious waste may be discharged in a disposal system. Under Ohio regulations, incineration, autoclaving, limited chemical submersion of cultures, sharps encapsulations (by Disposal Science, Inc.), and Sanitec microwave (on a site-specific basis) are the approved treatment technologies. OAC rule 3745-27-38 governs alternative treatment technology approvals. The rule states specific efficacy requirements and detailed microbial testing protocols. Persons seeking approval of their technology must submit test results and other documentation.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Oklahoma Oklahoma Department of Environmental Quality Waste Management Division Solid Waste Compliance Unit P.O Box 1677 Oklahoma City, OK 73101-1677 (405) 702-6100 (405) 702-6225 (Fax) www.deq.state.ok.us The Department of Environmental Quality regulates handling, storage, transport, tracking, treatment, and disposal of medical waste. The relevant regulations are contained in Oklahoma Administrative Code 252:500 Subchapter 15 (Biomedical Waste). Incinerator air emissions are under the Air Quality Service of the department, and waste management practices of nursing homes are part of the licensing program of the Oklahoma State Department of Health (405-271-5600). Subchapter 15 applies to hospitals and other facilities that do not have on-site incineration or cremation. Biomedical waste is defined as materials which are to be discarded and which are infectious, i.e., any substance that may cause injury or disease to humans and the environment but are not regulated as waste. The specific list of infectious waste follows the EPA categories (cultures and stocks; blood and blood products; pathological waste; contaminated sharps; contaminated animal wastes; wastes from surgery, autopsy, etc.; laboratory waste; dialysis waste; isolation waste; and contaminated medical equipment). In addition, Oklahoma recognizes chemical wastes such as pharmaceutical waste, laboratory reagents, cytotoxic/antineoplastic agents, and other chemicals contaminated with infectious agents. Biomedical waste generators that treat off site are required to follow labeling, packaging, safe handling, and storage requirements. Once packaged, compaction of untreated infectious waste is prohibited. There are standards provided for commercial (off-site) waste processing facilities including specific standards for biomedical waste incinerators. The approved treatment methods are: incineration in an approved incinerator, stream sterilization, chemical disinfection, and any other method approved by the department. Oklahoma specifies incineration in an approved incinerator as the preferred method. Approval of commercial alternative methods are done on a case-bycase basis. Specifically designed incinerators are the only accepted way of treating antineoplastics and cytotoxic drugs.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Oregon Oregon Health Division Center for Disease Prevention and Epidemiology CD Program 800 NE Oregon Street, #21 Portland, OR 97232 (503) 731-4023 www.ohd.hr.state.or.us/cdpe/welcome.htm Oregon Department of Environmental Quality Waste Management and Cleanup Division Solid Waste Policy and Programs 811 SW Sixth Avenue Portland, OR 97204-1390 (503) 229-5913 or (800) 452-4011 (503) 229-6922 (infectious waste) www.deq.state.or.us/wmc/cleanup/clean.htm Oregon Public Utilities Commission Transportation Safety Division 550 Capital Street NE Salem, OR 97310-1380 (503) 378-5915 www.odot.state.or.us The various portions of the infectious waste disposal regulations are regulated by the Health Division (dealing with alternative treatment technologies), Department of Environmental Quality (dealing with incineration and landfills), and Public Utilities Commission (dealing with transportation of infectious waste). The rules dealing with infectious waste disposal are in ORS 459.386 through 459.405, and in Oregon Administrative Rules 333-18-040 through 333-18-070. The regulations define four basic kinds of infectious waste: pathological waste, biological waste, cultures and stocks, and sharps. The regulations require all generators, including diabetics in private residences and doctors offices, to segregate infectious waste from other wastes. Generators producing less than 50 pounds (23 kg) a month are exempted from specific portions of the law. There are certification and recordkeeping requirements for transporters. Storage requirements are also provided. Pathological waste must be incinerated or treated in the same manner as cultures and stocks if the Department of Environmental Quality determines that incineration is not reasonably available. Cultures and stocks must be incinerated or sterilized by steam sterilization or other means prescribed by the Health Division. Other treatment methods must be approved by the National Sanitation B-29
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Foundation or other nationally recognized third parties. Liquid or soluble semi-solid biological wastes may be discharged into the sewage treatment system that provides secondary treatment. Body parts must be incinerated or disposed of in a manner similar to cultures and stocks. Uncompacted sharps not incinerated or autoclaved may be sent to a landfill if kept in its special container. The Environmental Quality Commission may approve other methods of treatment and disposal by rule. Pennsylvania Pennsylvania Department of Environmental Resources Bureau of Waste Management P.O. Box 8471 Harrisburg, PA 17105-8471 (717) 783-2388 www.dep.state.pa.us/dep/deputate/airwaste/wm/default.htm Hazardous Waste: www.dep.state.pa.us/dep/deputate/airwaste/wm/hw/hw.htm The regulations for infectious and chemotherapeutic waste are found in Chapters 271 to 285 (Municipal Waste Regulations) of Title 25 of the Pennsylvania Code. Infectious waste is defined as municipal and residual waste generated in the diagnosis, treatment, immunization, autopsy, or preparation for interment or cremation of humans or animals, including waste from related research or production/testing of biologicals. Several exceptions are made including wastes from individual residences. Chemotherapeutic waste is defined as that resulting from production or use of antineoplastic agents but not including waste that would be classified as hazardous waste under other regulations. The following sections deal specifically on infectious and chemotherapeutic waste: 271.101 to 271.102 – general provisions for permits; 271.711 to 271.744 – general permit requirements relative to infectious and chemotherapeutic waste; 273.401, 273.411, 273.511, 273.512 – additional requirements for disposal of processed infectious and chemotherapeutic waste; 283.302 – additional requirements for processing of infectious and chemotherapeutic waste; 283.402 - infectious waste monitoring; 285.131 to 285.148 – storage and marking requirements; and 285.222 to 285.434 – transportation and transporter requirements (including provisions related to discharges and spills). Under the regulations, a facility processing infectious and chemotherapeutic waste onsite shall be considered to have a waste processing permit if it uses an autoclave and renders the waste unrecognizable, or an incinerator that burns at least 50% of its own waste and accepts other waste only from small quantity generators (those that generate less than 220 pounds (100 kg) per month). Specific requirements are provided for small quantity generators. No permits are needed for temporary storage (24 hours or less). B-30
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Commercial processing facilities must apply and obtain a permit from the Department of Environmental Resources. Under specific circumstances, the Department may issue general permits on a regional or statewide basis for a category of infectious and chemotherapeutic waste processing facility (excluding commercial facilities). The regulations require segregation of the infectious and chemotherapeutic waste stream at the point of generation. There are provisions for the storage of infectious and chemotherapeutic waste as well as residues of processed waste. For example, infectious and chemotherapeutic waste must be stored using refrigeration for up to 30 days (up to 90 days if frozen) and contained in such as way as to prevent leakage and odors. The regulations specify that disinfection of infectious waste must be monitored and, in general, the waste must be rendered unrecognizable. This entails microbiological analysis of the residue or of microbiological indicators and at different frequencies, depending on the method of disinfection used. Compaction and grinding are not allowed prior to disinfection, and the processed waste can only be disposed of in approved landfills. Landfill operators must comply with specific requirements to dispose of processed infectious and chemotherapeutic waste. Anatomical remains must be incinerated and sharps must be rendered unusable prior to disposal. Body fluids may be disposed by discharge into a permitted sewage system with secondary treatment. Although the regulations do not specifically mention alternative technologies, they require that disinfection processes “other than thermal processing or incineration” must ensure the total destruction of specified indicator organisms in 95% of samples tested during disinfection. The microbiological analysis of indicators must be conducted every 40 hours during the operational life of the facility and the results made available to the Department upon request. Rhode Island Rhode Island Department of Environmental Management Office of Waste Management 235 Promenade Street Providence, RI 02908-5767 (401) 277-2797 (401) 222-3812 (Fax) http://webster.doa.state.ri.us:8888/dem_wastemgt The rules and regulations governing the generation, transport, storage, treatment, management, and disposal of regulated medical waste is found in Regulation DEM-DAH-MW-01-92 under the authority of Chapter 23-19.12 of the General Laws. Regulated medical waste is defined to include cultures and stocks, pathological wastes, blood, blood products, body fluids, sharps, animal waste, isolation waste, unused sharps, spill/cleanup material, and mixtures. Hazardous and household wastes, B-31
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
incinerator ash, human remains, etiologic agents being transported, and enforcement samples are excluded. In general, generators must register and obtain a registration number. The regulations require segregation of regulated medical waste to the maximum extent practicable. Packaging and containment, storage, decontamination, on-site transport, labeling and marking, on-site treatment/destruction, and reporting requirements are provided. Recordkeeping requirements for on-site incineration, steam sterilization, or other treatment or destruction methods are specified. There are also transportation requirements including permitting, EPA notification, tracking, etc. With regards to acceptable treatment methods, liquid regulated medical wastes must be incinerated or discharged into a sanitary sewer system with approval; pathological wastes must be incinerated; sharps and unused sharps must be incinerated, chemically disinfected, or steam sterilized followed by grinding/shredding; other regulated medical waste such as cultures and stocks must be incinerated, chemically disinfected, or steam sterilized followed by grinding/shredding. The director can approve alternative technologies if they are proven through tests to meet a specified efficacy standard. South Carolina South Carolina Department of Health and Environmental Control Bureau of Solid and Hazardous Waste Management 2600 Bull Street Columbia, SC 29201 (803) 734-5360 www.state.sc.us/dhec/eqchome.htm The Infectious Waste Management Regulations are found in regulations R.61-105 under the authority of the South Carolina Infectious Waste Management Act. Under the regulations, infectious waste includes sharps, microbiologicals, blood and blood products, pathological waste, isolation waste, and contaminated animal waste. All generators of waste have to register (except for private residences). Under the regulations, only small quantity generators (producing less than 50 pounds (23 kg) per month) can transport their own waste. The regulations require segregation of infectious waste from solid waste as close to the point of generation as practical. Other requirements include packaging, labeling, storage, manifesting, disinfection of containers, along with specific regulations for transporters and permitted treatment facilities. Liquid or semi-liquid waste may be discharged into an approved wastewater treatment disposal system, and recognizable body parts my be interred or donated for research. The accepted treatment methods prior to disposal in a sanitary landfill are: incineration, steam sterilization, chemical disinfection, and other approved methods. A “Guide to the South Carolina Infectious Waste Management Regulations R.61-105” by the Department (December 1994) provides a listing of the current treatment techniques: B-32
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
chemical disinfection by hydrogen peroxide, chemical encapsulation, electron beam irradiation, electropyrolysis, gas sterilization using ethylene oxide, incineration, laser treatment, mechanical/chemical disinfection, microwave disinfection, plasma pyrolysis, steam sterilization, and thermal inactivation or dry heat sterilization. South Dakota South Dakota Department of Environment and Natural Resources Joe Foss Building 523 East Capitol Avenue Pierre, SD 57501-3181 (605) 773-3152 www.state.sd.us/state/executive/denr/denr.htm The Medical Waste regulations are in Title 74, Article 35 of the Department regulations. Regulated medical waste is defined to include cultures and stocks, pathological waste, blood and blood products, sharps, animal waste, isolation waste, and unused sharps. The regulations include recordkeeping, standards for incinerator emissions, container requirements, storage, labeling, decontamination, and identification requirements. Other incinerator requirements are specified. The accepted disposal methods are incineration in accordance with conditions specified in the regulations, steam sterilization, chemical disinfection, or an equally effective treatment method upon approval by the department. Tennessee Tennessee Department of Health Division of Health Care Facilities 425 5th Avenue North Nashville, TN 37247-0508 (615) 741-7221 (615) 741-7051 (Fax) www.state.tn.us/health/hcf Tennessee Department of Environment and Conservation Division of Solid Waste Management 5th Floor L & C Tower 401 Church Street Nashville, TN 37243-1535 615-532-0780 www.state.tn.us/environment/swm/index.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Tennessee’s infectious waste management program is managed between three divisions: Division of Health Care Facilities which regulates handling and treatment of infectious waste, Division of Solid Waste Management which approves disposal of these wastes in sanitary landfills, and the Division of Air Pollution control (615-532-0554) which sets standards for infectious waste incinerators. Regulations are found in Hospital Rules and Regulations (Chapter 1200-8.2.02(e)), Solid Waste Processing and Disposal (rule 1200-1-7), and Infectious Waste Incineration Rules and Regulations (Chapter 1200-3-25). Infectious waste is defined as solid or liquid wastes containing pathogens with sufficient virulence and quantity such that exposure by a susceptible host could result in disease. Waste categories include isolation wastes, cultures and stocks, blood and blood products, pathological wastes, all discarded sharps, animal wastes, and other wastes. The regulations require that infectious waste be segregated from other wastes at the point of origin. Packaging, storage requirements, and incinerator permitting are also specified. Wastes can be treated by incineration, steam sterilization, or some other process that renders it non-infectious. Liquid or semi-liquid infectious wastes may be discharged in a sewer system. All remains, except those cremated or buried, must be incinerated or discharged to the sewer after grinding. Some categories of infectious waste may not be disposed of in a sanitary landfill, or may be disposed of only after being treated and packaged in a specified way. Texas Texas Natural Resource Conservation Commission P.O. Box 13087, MC-124 Austin, TX 78711-3087 (512) 239-1000 www.tnrcc.state.tx.us/homepgs/direct.html Texas Department of Health 1100 West 49th Street Austin, TX 78756 (512) 458-7541 (512) 458-7686 (Fax) New rules on medical waste management, adopted in 1995, are found in Chapter 30 of the Texas Administrative Code, in particular, 30 TAC 330.1001-330.1010. Medical wastes are considered “special wastes from health care related facilities” identified by the Board of Health as requiring special handling to protect human health or the environment. Such waste includes blood and other body fluids, microbiological waste such as cultures and stocks, pathological waste including body parts, sharps, and B-34
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
animal waste such as carcasses exposed to pathogens. There are also regulations governing medical waste found in Chapter 25 TAC §§1.31 et seq. under by the Texas Department of Health. Separate regulations dealing with low-level radioactive waste disposal are found in Chapter 31 of the Texas Administrative Code under the Texas Low-Level Radioactive Waste Disposal Authority. Except for homes and lodging establishments, all generators of medical waste are required to segregate those wastes from ordinary trash and to treat them using an approved treatment method. The approved methods are: chemical disinfection, incineration, encapsulation (for sharps only), steam disinfection, thermal inactivation, chlorine disinfection/maceration, and moist heat disinfection (such as microwave disinfection). The rules specify which of these approved methods can be used for each major type of waste and that an “approved alternate treatment process” can also be employed. Depending on the type of waste, the treated residues may be deposited in a sanitary landfill, into a sanitary sewer system, or interred. Some types of waste must be rendered unrecognizable or must be labeled as treated waste before final disposal. The level of documentation of treatment depends on the amount of medical waste generated. Entities generating 50 pounds (23 kg) or less per month must keep minimal information on the treatment as specified in the rules. Facilities generating more than 50 pounds (23 kg) a month must, in addition, keep a record of written procedures for operation and testing of equipment or for preparation of chemicals used. Depending on the amount generated, testing must be conducted once a month or more frequently (e.g., weekly for those generating greater than 200 pounds (91 kg) a month) to demonstrate a 4 Log reduction of appropriate biological indicators. Routine parameter monitoring (for example, temperature, pressure, pH, etc.) may be substituted for biological monitoring for cases where the manufacturer has documented compliance based on those specific parameters. The rules specify requirements for transporters of untreated medical waste. These requirements include registration, vehicle requirements, labeling, insurance, recordkeeping, etc. Requirements are also provided for medical waste collection stations, storage, and treatment using mobile systems. Utah Utah Department of Environmental Quality Division of Solid and Hazardous Waste 288 North 1460 West Salt Lake City, UT 84114-4880 (801) 538-6170 (801) 538-6715 (Fax) www.eq.state.ut.us/eqshw/dshw-1.htm
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The infectious waste requirements are in section R315-316 of the Utah Administrative Code promulgated by the Solid and Hazardous Waste Control Board. The standards apply to any health facility, transporter, storage/treatment/disposal facility, but exempt health facilities generating 200 pounds (91 kg) or less of infectious waste per month. The regulations specify general operational, storage, containment, transportation, treatment, and disposal requirements. Facilities are required to prepare and maintain a management plan which includes segregation procedures. Infectious waste may be incinerated, sterilized in a steam sterilizer, discharged to a sewage treatment system with secondary treatment if liquid or semi-solid and approved by the sewage treatment operator, or disposed in a permitted Class I, II or V landfill. Specific conditions are provided for each treatment process mentioned. Recognizable body parts must be incinerated or interred. Other treatment or disposal methods may be used upon approval of the executive secretary. Vermont Vermont Agency of Natural Resources Department of Environmental Conservation Solid Waste Management Division 103 South Main Street, West Building Waterbury, VT 05671-0404 (802) 241-3444 or (802) 241-3888 (802) 241-3296 (Fax) www.anr.state.vt.us/dec/wmd.htm The Solid Waste Management Division regulates general solid waste, conditionally exempt small quantity generator (ESQG) hazardous waste, and infectious waste. Other wastes from a hospital or other healthcare facility may fall under the category of hazardous waste or radioactive waste. Hazardous waste is regulated by the Hazardous Materials Management Division. Infectious waste is defined as including isolation wastes, cultures and stocks, blood and blood products, pathological waste, contaminated laboratory waste, sharps, dialysis waste, experimental animal carcasses and body parts, experimental animal bedding and other animal wastes, contaminated food products, and contaminated equipment. Under the Hazardous Waste Management Regulations, infectious wastes from hospitals, clinics, doctors offices, mortuaries, laboratories, etc. are considered “Listed Waste” and designated VT 07. Section 6-802(b) of the Solid Waste Management Rules requires that infectious waste be made non-infectious by disinfection, sterilization, or incineration prior to disposal in a certified landfill. After treatment, the waste must still be handled separately from general solid waste. They must be labeled as infectious waste that have been treated in the manner prescribed and must be disposed in an isolated area. B-36
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Virginia Virginia Department of Environmental Quality Waste Management Board P.O. Box 10009 Richmond, VA 23240-0009 (804) 698-4000 or (800) 592-5482 www.deq.state.va.us/info/direct.htm Medical waste regulations adopted by the Virginia Waste Management Board are found in VR 672-40-01:1. Regulated medical waste is defined as meeting either of two criteria: (1) any solid waste that is suspected by the health care professional in charge of being capable of producing an infectious disease in humans, or (2) any solid waste that belong to one the following categories: cultures and stocks, blood and blood products, tissues and other anatomical wastes, sharps, animal wastes, residues from clean-up of spills, and any waste contaminated by or mixed with regulated medical waste. Some exemptions are made, such as sewage sludge, hazardous waste, etc. The regulations provide general requirements for packaging, labeling, spill management, closure, recordkeeping, and other issues. The general requirements for treatment and disposal state that the waste must be incinerated, steam sterilized, or treated by an alternative method. Special requirements apply to incineration and steam sterilization. Special requirements are also provided for the accepted alternative technologies, namely, dry heat treatment, microwave treatment, and chlorination. Other technologies must petition for review by submitting a “Petition for Evaluation and Approval of Regulated Medical Waste Treatment Technology”; as with other treatment methods, a permit is required to operate an alternative technology. Alternative methods must comply with other requirements pertaining to operation controls and records. The regulations also state that the treated waste, except incinerated waste, must be shredded or ground (except for small processes treating no more than five pounds (2 kg) per day average). Untreated waste cannot be disposed of in a solid waste landfill. The regulations note that radioactive material must be managed under regulations by the U.S. Nuclear Regulatory Commission and the Virginia Department of Health. Special requirements are given for storage facilities and transportation of regulated medical waste. Other provisions relate to permit applications, issuance procedures, and variances.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
Washington Washington Department of Ecology Northeast Regional Office 3190 160th Avenue SE Bellevue, WA 98008-5452 (425) 649-7000 www.wa.gov.ecology - or Washington Department of Ecology M.S. PV-11 Olympia, WA 98504-8711 (206) 407-6000 Requirements for biomedical waste management are found in Chapter 70.95K RCW (which provides a statewide definition but does not prescribe a statewide management program), Chapter 175 Laws of 1994 (for residential sharps disposal), biomedical waste transportation rules by the Washington Utilities and Transportation Commission, Department of Ecology rules on incinerators, and various local infectious waste management programs, among others. Biomedical waste is limited to animal waste, biosafety level 4 disease waste, cultures and stocks, human blood and blood products, pathological waste, and sharps. Residential sharps collections including the use of pharmacy return programs as dropoff sites, are provided in the regulations. In addition to incineration, other waste treatment technologies may be evaluated by the department of health in consultation with the department of ecology and local health department. West Virginia West Virginia Department of Health and Human Resources Office of Environmental Health Services 815 Quarrier Street, Suite 418 Charleston, WV 25301 (304) 558-2981 (304) 558-1291 (Fax) www.wvdhhr.org Regulations dealing with infectious medical waste are found in Sections 64-56-1 through 64-56-20 of the West Virginia Administrative Rules (Title 64, Series 56). Infectious medical waste is defined as capable of producing an infectious disease if it has been, or is likely to have been, contaminated by a pathogen not routinely and freely B-38
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
available in the community, and if the pathogen is in sufficient quantity and virulence to transmit disease. Infectious medical waste specifically includes: cultures and stocks, blood and blood products, sharps, animal wastes, isolation wastes, clean-up residues, and waste mixed or contaminated by infectious waste. Excluded are remains and body parts being used for medical purposes, remains lawfully interred or cremated, personal products, etc. The regulations describe the general permit application and approval procedures, as well as packaging and labeling, spill management, storage, transportation, manifesting, recordkeeping, and reporting requirements. There are also provisions for fees, inspections, enforcement orders, hearings, and penalties. All infectious medical waste management facilities must submit an infectious medical waste management plan. The acceptable methods of treatment are: incineration, steam treatment, discharge to a sanitary sewer, and “any other alternative method approved in writing and permitted by the secretary” (of the Department of Health and Human Resources). Specific requirements are given for each. To apply for approval as an alternative method, the results of an efficacy test must be submitted along with other documentation. The secretary may issue provisional approval until an appropriate trial period can validate performance. Wisconsin Wisconsin Department of Natural Resources Bureau of Waste Management Medical Waste Coordinator WA/3 P.O. Box 7921 Madison, WI 53707-7921 (608) 266-2111 or (608) 266-0061 (608) 267-2768 (Fax) www.dnr.state.wi.us/org/aw/wm The medical waste rules that apply directly to generators and transporters include Chapter NR 526 and Section NR 520.04, Table I of the Wisconsin Administrative Code. The rules consist of three parts: general provisions, infectious waste management, and medical waste reduction requirements for hospital, clinics, and nursing homes. Infectious waste include contaminated or unused or disinfected sharps, bulk blood and body fluids, microbiological laboratory waste including cultures, human tissue, as well as tissue, bulk blood, or body fluids from animals carrying an infectious agent transmittable to humans. Medical waste means infectious waste and other waste that contains or may be mixed with infectious waste.
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Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
The safety requirements for infectious waste management cover segregation, handling, storing, transporting and shipping, treatment and disposal. Sharps must be incinerated, disinfected, or otherwise treated to render them non-infectious, broken, and nonreusable. The accepted treatment methods are: incineration, steam disinfection, chemical disinfection, mechanical grinding with chemical disinfection, mechanical grinding with heat disinfection, gas disinfection, and other methods that render the waste non-infectious. However, certain types of waste must be treated only by prescribed methods. There are minimum requirements for all treatment facilities. The regulations also require medical waste reduction if they generate more than 50 pounds (23 kg) per month. This involves adoption of a policy that commits to an audit of waste management practices, setting waste reduction goals, examining alternatives to disposable items, etc. Generators producing more than 500 pounds (227 kg) per month had to implement their reduction plans by November 1, 1995; those producing between 200 to 500 pounds (91 to 227 kg) per month, by November 1, 1996; and those between 50 to 200 pounds (23 to 91 kg) per month, by November 1, 1997. Wyoming Wyoming Department of Environmental Quality Solid and Hazardous Waste Division Herschler Building 122 West 25th Street Cheyenne, WY 82002 (307) 777-7758 (307) 777-7682 (Fax) www.deq.state.wy.us Wyoming Department of Health Preventive Medicine Division 117 Hathaway Building 4th Floor Cheyenne, WY 82002 (307) 777-7657 (307) 777-7439 (Fax) http://wdhfs.state.wy.us/WDH/default.htm Wyoming has no specific rules or guidelines for the handling, treatment, storage, transport, or disposal of infectious waste. However, a facility that commercially treats quantities of infectious waste is required to obtain a solid waste treatment permit and requirements as described in Chapter 1 (general provisions), Chapter 6 (transfer, treatment, and storage), and Chapter 7 (financial assurance) of the solid waste rules and regulations. Moreover, the Wyoming Department of Health has published standards requiring institutions such as hospitals and other healthcare facilities to follow acceptable plans controlling handling, segregation, treatment and disposal of infectious B-40
Summary of Selected State Regulatory Agencies and Regulations on Medical Waste
waste. With regard to treatment methods, the Department of Environmental Quality agrees with the recommendation of EPA’s Guide for Infectious Waste Management (May 1986) which includes incineration, steam sterilization, etc.
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C ALTERNATIVE MEDICAL WASTE TREATMENT TEHCNOLOGIES: VENDOR ADDRESSES AND PHONE NUMBERS
[N.B.: Neither EPRI, members of EPRI, nor any persons acting on behalf of them (a) makes any warranty, expressed or implied, with respect to the use of any apparatus or process in this report, or (b) assumes any liabilities with respect to the use of, or for damages resulting from the use of, any apparatus or process in this report.] Aegis Bio-Systems, LLC (JYD-1500) 3324 French Park Drive, Suite A Edmond, OK 73034 (888) 993-1500 or (405) 341-0190 (405) 844-9364 or (405) 341-4667 (Fax) www.JYD-1500.com American Immuno Tech LLC 320 Kalmus Drive Costa Mesa, CA 92626 (888) 543-8991 (714) 241-8435 (Fax)
[email protected] American Delphi, Inc. (Environmental Disposal System ) 7110 Fenwick Lane Westminster, CA 92684 (800) 854-6464 (714) 894-0515 www.americandelphi.com
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Antaeus Group (SSM-150) 10626 York Road, Suite D Hunt Valley, MD 21030 (410) 666-6160 (410) 666-6110 (Fax) www.antaeusgroup.com Bio-Oxidation Services, Inc. (Bio-Oxidizer) 613 Third Street 120 E. Grant Street Annapolis, MD 21403 (410) 990-9430 or (888) 463-3927 (410) 990-9431 (Fax) www.bioxidation.com BioSterile Technology, Inc. (Biosiris) 4104 Merchant Road Fort Wayne, IN 46818 (219) 489-2962 or (888) 710-3792 (219) 489-3654 (Fax) www.biosterile.com Brincell (Ster-O-Lizer) P.O. Box 27488 Salt Lake City, UT 84127 (801) 973-6400 or (877) 973-6400 Circle Medical Products 3950 Culligan Avenue, Suite D Indianapolis, IN 46218 (317) 357-8080 (317) 357-8349 (Fax) CMB Maschinenbau und Handels Gmb H. (Sintion) A-805 Graz Plabutscherstrasse 115 Austria 43-316-685515 43-316-685515-10 (Fax) www.sintion.at www.nmwrc.com/sintion1.html
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Daystar/Prometron Technics Corp. c/o M. Funai Masuda, Funai, Eifert & Mitchell, Ltd. One East Wacker Drive Chicago, IL 60601 (312) 245-7500 (312) 245-7467 (Fax) Delphi Research, Inc. (MEDETOX) 701 Haines Avenue NW Albuquerque, NM 87102 (505) 292-9315 DOCC, Inc. (Demolizer) 240 East 76th Street New York, NY 10021 Donlee Technologies, Inc. 693 North Hills Road York, PA 17402-2211 (717) 755-1081 (717) 755-0020 (Fax) Ecolotec, Inc. 100 Springdale Road, A-3, Suite 290 Cherry Hill, NJ 08003 (609) 346-2447 (609) 346-1779 (Fax) Electro-Pyrolysis, Inc. (EPI/Svedala DC Arc Furnace) 996 Old Eagle School Road Wayne, PA 19087 (610) 687-9070 (610) 964-8570 (Fax) Enertech Environmental (SlurryCarb) 739 Trabert Avenue NW Atlanta, GA 30318 (404) 355-3390 (404) 355-3292 www.enertech.com
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
HI Disposal Systems, LLC (Plasma-Based Pyrolysis-Vitrification) National City Center 115 West Washington Street, Suite 1265 Indianapolis, IN 46204 (800) 995-1265 or (317) 693-1265 (800) 973-1265 (Fax) www.hawkinsindustries.com Industrial Microwave Company, Inc. (MWD 20) 545 Brandywine Drive Colorado Springs, CO 80906 (719) 540-0823 (719) 540-0835 (Fax) Integrated Environmental Systems (Plasma Enhanced Melter – PEM) 1535 Butler Loop Richland, WA 99352 (509) 946-1901 www.cenet.org/evtec/eval/iet.htm Isolyser Company, Inc. (Isolyser LST and SMS) 4320 International Blvd. Norcross, GA 30093 (770) 806-9898 www.orex.com KC Mediwaste, L.C. 4219 University Blvd. Dallas, TX 75205 (214) 528-8900 (214) 528-0467 (Fax) Leslie Industries P.O. Box 13405 Tallahassee, FL 32317 (805) 422-0099 Lynntech, Inc. 7610 Eastmark Drive College Station, TX 77840 (409) 693-0017 (409) 764-7479 (Fax) www.lynntech.com C-4
Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Mark-Costello Company 1145 Dominguez Street Carson, CA 90746 (310) 637-1851 (310) 762-2330 (Fax) www.mark-costello.com Med-Compliance (Encore) 5307 El Paso Drive El Paso, TX 79905 (800) 274-4627 (915) 778-8359 (Fax) Medzam/SAFETEC 1055 East Delavan Avenue Buffalo, NY 14215 (800) 456-7077 www.saftec.com MSE Technology Applications, Inc. Eastern Region 9104 Forest Shadow Way Fairfax Station, VA 22039-3344 (703) 690-9317 (703) 690-0259 www.mse-ta.com NCE Concepts, Ltd. (TurboClean Thermal Processor) 2150 Chennault Carrollton, TX 75006 (214) 991-4090 (214) 991-9334 (Fax) Plasma Pyrolysis Systems, Inc. Box 158 Stuyvesant Falls, NY 12174 (518) 828-4684 (518) 822-0132 (Fax) PMA Services (MedClean-M) 22347 La Palma Avenue, Suite 106 Yorba Linda, CA 92687 (714) 692-8533 (714) 692-5478 (Fax) C-5
Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Positive Impact Waste Solutions, Inc. (MMT 3000) 4110 Rice Dryer Boulevard Pearland, TX 77581 (281) 412-9991 Premier Medical Technology, Inc. 9800 Northwest Freeway, Suite 302 Houston, TX 77092 (713) 680-8833 (713) 683-8820 (Fax) Roatan Medical Technologies (Redloc Microwave) P.O. Box 227377 Dallas, TX 75222-7377 (972) 647-4033 (972) 647-4454 (Fax) Safety Disposal System, Inc. (EnviroSafe) 3890 NW 132nd Street Opa Locka, FL 33054 (800) 828-0692 www.medwaste.net San-I-Pak, Inc. P.O. Box 1183 Tracy, CA 95378-1183 (209) 836-2310 (209) 836-2336 www.sanipak.com Sanitec, Inc. 26 Fairfield Place West Caldwell, NJ 07470 (800) 551-9897 or (978) 227-8855 (617) 942-7114 (Fax) www.etven.com/sanitec/index.html SciCan, Inc. (TAPS Processor) 2002 Smallman Street Pittsburgh, PA 15222 (800) 572-1221 www.sciscan.com
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Sierra Industries, Inc./RE Baker 1021 South Linwood Avenue Santa Ana, CA 92705 (800) 437-9763 or (714) 560-9333 (714) 560-9339 (Fax) www.sierraindustries.com SPS Medical Equipment Corporation (Needle-Eater) 450 West First Avenue Roselle, NJ 07203 (800) 978-8006 Startech Environmental Corporation 79 Old Ridgefield Road Wilton, CT 06897 (203) 762-2499 (203) 761-0839 (Fax) Sterile Technology Industries, Inc. (Chem-Clav) 1155 Phoenixville Park, Unit 105 West Chester, PA 19380 (610) 436-9980 (610) 436-9986 (Fax) SteriLogic Waste Systems, Inc. (Hydroclave) P.O. Box 84 Kempton, PA 19529 (610) 756-3003 (610) 756-3004 (Fax) STERIS Corporation (EcoCycle 10) 5960 Heisley Road Mentor, OH 44060 (800) 548-4873 (440) 639-4450 (Fax) www.steris.com Svedala Industries, Inc. 350 Railroad Street Danville, PA 17821-2046 (570) 275-3050 (570) 275-6789 (Fax)
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Tempico, Inc. (Rotoclave) P.O. Box 428, 251 Hwy 21 N Madisonville, LA 70447-0428 (800) 728-9006 or (504) 845-0800 (504) 845-4411 (Fax) www.tempico.com ToxGon Corporation 631 S. 96th Street Seattle, WA 98108 (206) 762-5583 (206) 763-9331 (Fax) Tuttnauer USA Co., Ltd. 33 Comac Loop, Equi-Park Ronkonkoma, NY 11779 (800) 624-5836 or (516) 737-4850 (516) 737-0720 (Fax) www.tuttnauer.com Unitel Technologies 411 Business Center Drive, Suite 111 Mt. Prospect, IL 60056 (847) 297-2265 University of Miami E-Beam Medical Waste Treatment Facility Laboratories for Pollution Control Technologies P.O. Box 248294 Coral Gables, FL 33124 (305) 284-2423 or 284-2908 (305) 284-2321 or 284-2885 (Fax) Vance IDS 7381 114TH Ave. N, Suite 402 A Largo, FL 33773 (800) 273-1780 or (727) 548-9572 (727) 549-8097 (Fax) www.vanceids.com
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Alternative Medical Waste Treatment Tehcnologies: Vendor Addresses and Phone Numbers
Vanish Technologies, Inc. 194 Forbes Road Braintree, MA 02184 (781) 356-2211 (781) 356-2211 (Fax) World Environmental Services Corporation/WESCO (Condor Medical Waste Treatment System) 114 14th Street, Suite B & C Ramona, CA 92065 (760) 789-6496 Waste Reduction by Waste Reduction, Inc. (WR2 Tissue Digestor) 212 Pinewoods Avenue Troy, NY 12180-7244 (518) 273-0292
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