It's Not Easy Being Green

Since the advent of steam-powered and coal-powered technology in the 19th century, the socially aware have raised their voices in protest of environmental pollution. Initially considered busybodies, these environmental advocates eventually founded a “green” movement to protect the Earth and its resources. Green – defined as environmentally sound or beneficial – is no longer the alien concept of the 1960s, but is instead the basis for an entire crusade that incorporates environmentally friendly concepts into construction, landscaping, manufacturing, waste disposal and conservation.

Nowadays, being green is often considered common sense. Although adherence to this movement has often split along political party lines, extensive media attention has at least presented the concept to the average person, leaving it up to each individual citizen to make his or her own decision about recycling, conservation and alternative power sources.

Medicine especially has been strongly affected by the green movement; for example, red-bag waste has been reduced and proponents advocate for recycling, reprocessing and reusing as much as possible. However, there are times when reuse may be more costly, wasteful or troublesome than when using single-use products.

Money Matters

An attitude of cost-cutting has pervaded medicine for 20 years now. Reimbursement for medical procedures and medical supplies has dropped, as has reimbursement for the physicians, nurses and other healthcare workers who provide patient care.

Being good to the environment was, in the past, considered an indulgence. It was a side effect, not an outright goal. The focus, instead, was on reuse and reprocessing as a solution to conserve spending. “Environmental stewardship has always seemed like a luxury,” reported the organization Hospitals for a Healthy Environment (H2E) on its Web site.

H2E is a cooperative of the American Hospital Association, the U.S. Environmental Protection Agency, Healthcare Without Harm and the American Nurses Association. Its focus is environmental sustainability in medicine. The organization also focuses on education for healthcare workers about pollution prevention.

Pollution prevention is a tricky concept. Is it better to use water, chemicals and electricity in reprocessing tools and devices? Or is it better to dispose of them in landfills, but preserve water and power, and reduce the amount of chemicals discarded?

One particular focus here is dialyzers, which are the filters that remove toxins and waste during dialysis from the bloodstream before returning the blood to the patient’s body. Single-use dialyzers, obviously, are used only once, then disposed of. Reusable dialyzers, however, are reprocessed as many as 15 times before being discarded.

Many hospitals are oblivious to the amount of waste they generate. But much of it is hazardous and accumulates faster than one might expect. Several specific hazards are particular matters for concern, including mercury, dioxin and other persistent, bioaccumulative and toxic chemicals (PBTs). H2E is focusing on dioxin and mercury as two of the greatest problems. According to the organization, “Dioxin has been linked to reproductive and developmental defects, endometriosis, learning disabilities, endocrine disorders, and cancer.”

Dioxin is created when material with large amounts of chlorine are exposed to extreme temperatures. These temperatures can relate to either manufacturing or incineration. In medicine, dioxins are produced through the burning of trash that includes large amounts of chlorinated plastic, or polyvinyl chloride (PVC). “According to the Health Industry Manufacturers Association, PVC is found in 25 percent of all healthcare products,” H2E reports. Blood bags and tubing, peritoneal dialysis bags, blood lines and catheters are just a few of the common dialysis products that can contribute to this issue.

Solutions

Because costs continue to rise for offsite processing of infectious medical waste, MCM Environmental Technologies Inc., a wholly-owned subsidiary of Caprius Inc., has introduced its SteriMed Systems, a proprietary system for the on-site disposal of infectious medical waste. SteriMed is designed to offer a convenient and economical alternative to the traditional practice of hauling away medical waste and burning it. “The on-site unit simultaneously shreds and disinfects solid and liquid regulated medical waste, reducing volume and making it harmless for disposal as ordinary waste,” said Carlo Kyprios, a press representative for MCM.

The system, which is currently being used in some dialysis centers, is compact to make it appropriate for use in small facilities.

When waste is placed into the system, it is first treated with water and a decontaminating detergent. It is then shredded and reduced to grains of 1 cm to 2.5 cm. It is then transferred to a separator, discharged into a filter bag and rinsed. While the liquid drains into the sewage system, the treated waste can be discarded as normal trash, not as red-bag waste.

Fresenius Medical Care, which offers both dialysis clinics and dialysis products, has also focused on the environment in its practices, particularly in Europe. Following the International Standards Organization quality management system and environmental management system, the company’s efforts result “in a stronger focus on environmental improvement opportunities and cost-saving potentials,” according to its Web site.

Using a ranking of ecological effect, the company can determine the costs per treatment with regard to energy, water and waste. “Compared with the consumption data of the previous year, we have successfully lowered the level of resources processed in each treatment,” Fresenius reported.

The company has also focused on transportation, and reducing the costs related to logistics. It uses a multi-box system, which recycles containers throughout the company, and includes disposables used in German clinics. It also has enhanced a recycling system for packaging, infusion products and plastic bags.

The company is pursuing environmental certification for its North American business, which will improve waste minimization in the United States, Canada and Mexico – including solid, medical and hazardous wastes. By observing costs related to medical waste every quarter, in every dialysis clinic, the company will be better able to plan for recycling and reduction of waste.

Reprocessing: Safe or Not?

The medical instrument industry has disputed the safety of reprocessing for decades. Reprocessing, when done correctly, is safe and effective, the proponents maintain. There are too many risks for instrument damage or incomplete cleaning, the opponents claim. However, one might argue that each side is biased – often, proponents are companies that offer cleaning, reprocessing, or repair services; while opponents are companies that manufacture or distribute products labeled as single-use. Each side has a financial investment in its own position.

In past years, hospitals often reprocessed their own devices, but without the strict guidelines imposed on third-party reprocessors. Once the U.S. Food and Drug Administration required that healthcare facilities follow the same guidelines in 2002, hospitals mainly gave up doing it themselves and relinquished the task to commercial reprocessors who are required by law to observe strict regulations into their reprocessing practices. Bad press related to poor reprocessing was often unfairly attributed to those companies, rather than to unmonitored hospitals.

An article by Jennifer Schraag for Infection Control Today, a sister publication to Renal Business Today, provided an update for 2007 on the debate about reprocessing.

“According to FDA, since 2000, on average, FDA has conducted inspections of reprocessor firms once every two years — a rate it claims is ‘considerably higher’ than the average one inspection in four years for original equipment manufacturers,” she wrote. Not only do reprocessors have to test the devices they reprocess to ensure they are still acceptable for use, but they must also now identify the device as theirs – now that it has been reprocessed -- with an identifying mark on the instrument or the packaging.

The Reprocessing Debate

In early 2007, former Vice President Al Gore shared an Academy Award for the documentary feature “An Inconvenient Truth.” Regardless of how we feel about the man himself, we have seen furor over the movie drive the point home – there is growing evidence that our behavior now will have repercussions in the not-so-distant future.

But is conservation good for the bottom line?

“A couple of things go into the equation of single-use vs. reuse,” said Rice Powell, CEO of Fresenius’ North America products and hospital group. “Obviously, you have to be able — from the standpoint of the clinic — to look at the tradeoffs of buying a new dialyzer every time, or the fact that you can reuse them 10, 15, 20 times. We believe — from our knowledge of the dialyzer and how we produce it — that we are providing better therapy for the patient when they get a fresh dialyzer every time.”

The reason for that, he explains, is that “when we had people reuse, we had to make the dialyzer in a certain fashion in order for it to withstand the fairly harsh chemicals that were used to clean it after every use. Our decision to go to single use was because it was going to be better for the patient. We would be able to make a much better dialyzer to clear more of the poisons out of the system with it being fresh every time.”

But then the economics question came in. Clinics wanted to know, “If I have to buy a new dialyzer every time, how can I afford to do that?” So Fresenius examined clinics, many of which had a reuse room with technicians doing the cleaning. “When they looked at being able to do away with that and use those people in other ways that are more patient value-added, such as helping patients to and from their cars, or taking care of some of their needs, versus being stuck in the back room cleaning dialyzers, people found that economically, this was not nearly as worrisome as they had initially looked at.”

Nowadays, Powell says, the company will produce approximately 35 million dialyzers in a year. “And if we’re producing them and people are buying them, where do they go? What happens with the waste? From the factory standpoint, if for some reason we’re not going to sell some dialyzers, it’s a scrap unit, or if there was a problem with it — the dialyzer is torn up. It consists of fibers that actually do the cleaning of the blood, and a hard plastic outer shell.”

The fiber can be ground up, and is sent to a cement factory in Utah where it is used in the process of making cement, Powell said. Fresenius will grind pieces of waste that are used for the dialyzer’s end caps so they can be used for toy production in China.

From the clinic side, Powell says, they have learned a few things. “We and most of our customers will contract with a waste hauler to take away dialyzers from the facility. Keep in mind that there is a little bit of a restriction for handling a used dialyzer because obviously it’s seen blood. So it will be picked up by the waste hauler, they will rinse it with hot water, they will shred it, and then it goes into a landfill or incinerator to be burned. It varies from state to state, but in general, we find that is the most common practice. The other thing we have learned is that, for people that practice reuse, the hardest thing to deal with is the reuse chemicals, such as formaldehyde or glutaraldehyde. The biggest problem there is that it is difficult to drain in various municipalities. When you make 40 million dialyzers, that’s a lot of plastic, it’s a lot of fiber, but we do feel like we’re treating it in the best way we can and trying to be as friendly to the environment as we possibly can be.”

Dialyzer Reuse

Wayne Carlson, director of clinical services for Minntech Renal Systems, said, “In the past, the debate of singleuse vs. multiple-use of hemodialyzers centered on the ‘two E’s:’ efficacy and economics. After more than 20 years of discussion of the efficacy of dialyzer reprocessing, evidence indicates that the multiple use of dialyzers is not a determining factor of morbidity and mortality. Although numerous studies over the years have indicated a mortality advantage for both single use as well as dialyzer reuse, the body of research produced over the last 20 years indicates that dialyzer reprocessing is a morbidity- and mortality-neutral activity.”

And, he added, the economics of the debate have often been skewed by the inclusion of inappropriate costs. “The entire cost of the water system for a dialysis facility is not an appropriate cost, while the cost of producing the water necessary to reprocess dialyzers is an appropriate cost,” he said. “The total personnel cost of the person responsible for reprocessing dialyzers may not be appropriate if the duties of that individual include non-reuse activities (i.e., stocking shelves, holding access sites, cleaning and setting-up dialysis stations). The literature indicates that the savings realized by reprocessing dialyzers is related to scale; both the price of single- and multi-use dialyzers and the cost of dialyzer reprocessing will be less for a large provider than for a small center. In general, it will cost a medium-sized center (75 patients) between $4.75 and $5.25 to supply a reprocessed dialyzer (this includes the cost of all reprocessing supplies, equipment and personnel and the dialyzer). The savings enjoyed by the center will be dependent on the efficiency of reprocessing and the cost of dialyzers.

“A third ‘E’ is being discussed in the dialyzer reprocessing debate: The ‘environmental impact’ of disposable dialyzers,” Carlson said. “Does the waste generated during the manufacture of a dialyzer, the packaging waste generated during each treatment, and the disposal of the petroleum-based biohazardous waste after each treatment offset the increased water consumption and environmental impact of the discharge of reprocessing agents into the waste stream?”

It is important for every center to determine where the greatest savings exist, and also which option affects the environment least. This can differ based on the facility’s size or location, staffing numbers and also how many patients it serves.

Remember, when calculating your own center’s costs for single-use vs. reuse, it is important to include all of the appropriate costs, but not to include those that are inappropriate or too broad by definition. First, when calculating the cost of reprocessing, include only the costs attributable to the reprocessing activity, not the center’s entire water use bill. Second, calculate the staffing appropriately – do not count staffing hours that are used for something other than reprocessing. Third, ensure that all appropriate product costs are included – this includes extra personal protective equipment, such as gloves, masks and eye protection that are used during reprocessing. It also includes the cost of reprocessing chemicals, and the cost of disposing of those chemicals into the waste stream, as well as the cost of the dialyzers when they are disposed of after their final use. For single-use, calculate not only the cost of the product (dialyzers), but also any shipping fees associated with product ordering, as well as red-bag waste costs or disposal fees for using local landfills.

And use an accurate representation of how many patients are moving through the dialysis center. You may wish to go back for a full year’s worth of records to determine the center’s average patient load, or review current patient lists to determine how often each client enters the facility for treatment.

Hemodialyzers are made from petroleum products such as plastic and petroleum resins, which do not break down over time. For the time being, manufacturers are exploring alternate materials, but none are FDA approved, so centers cannot plan around a future hemodialyzer that will break down within a year or two; they must make their decisions about reprocessing based on what is available in the current market.

Green Cleaning

Another aspect of being environmentally friendly is using green cleaning products. Older products might release hazardous chemicals into the atmosphere – affecting not just the cleaning employee but also other employees throughout the facility. Earth-friendly, people-friendly products have been in the works for years, and many households have replaced their hazardous house cleaning products with vinegar, lemon juice, and baking soda, for example.

Not all of these simple solutions will work in medicine, but still, items are available that are safer to use. They even function as part of a “healing environment” by “1) reducing stress on the building’s occupants, 2) improving safety, and 3) contributing to improved ecological health,” according to H2E.

H2E quotes a frightening statistic – “An estimated 35 percent of conventional cleaning products can cause blindness, severe skin damage, or damage to organs through the skin.” Not only that, but such an injury can cost the employer an average of $625 in both lost time and related medical expenses for the injured employee.

In addition, some of these products’ ingredients can damage the environment, animals and plants. And they can also cause long-term healthcare issues in employees, such as asthma, cancer and reproductive damage. Cleaning staff members, H2E reports, have twice the rate of asthma compared to any other profession.

By going green when you clean, you may extend the life span of your facility’s floors, walls, and surfaces; you can also improve worker health in both the long term and short term.

Regardless of which road you choose, the bottom line is the client to whom you are providing dialysis. “What’s best for the patient is always first and foremost,” Carlson said. All other considerations are secondary. RBT