Case Study: R X Waste Disposal

1. Case Study:RX Waste Disposal Cheryl Chisholm, CPhT

3. Our Hospital • Serving 22 counties in Northern Michigan • Patient-centered specialized care

4. Our Hospital • 243-bed, regional referral center located in Petoskey, Michigan • 200 physicians representing nearly all medical and surgical specialties • Full-service care with and emphasis on • Advanced heart/cardiac care • Cancer / Oncology • Orthopaedics • Neuroscience • 1,700 full-time colleagues

5. In 1996 I didn’t know that we had a problem.MDEQ gave warnings and guidance.Thought that everyone else was already doing RX waste. Ignorance Was Bliss

6. There Was An Issue • First: • Simply did what I was told to do by the MDEQ. • Second: • Began to ask questions which had no answers. • Started reading everything on subject as it became available. • Third: • Began to understand. • Realizing we had a problem. • Fourth: • Petitioned for consultant.

7. PharmEcology site visit on April 13, 2005. Delineated regulations. Outlined risks of noncompliance. Identified waste streams. Identified hazardous pharmaceuticals. Outlined waste hauler criteria. We Didn’t Know How Big

8. Do It Group • Formed a team – DIG. • Pertinent areas required. • Nsg, Pharmacy, Haz Mat, Safety, Environmental Services, Clinical Educators, Administration. • Interviewed Waste Vendors. • Everyone played devil’s advocate.

9. Making Progress • Program set up, vendor in place, all recommendations being addressed with the exception of: • Checking with local POTW regarding sewer discharge. • Discovered no one had a list of sewerable items from the City.

10. Getting Ready • Between the Surgery educator and Pharmacy we came up with list of ”potential” items that might go down the drain. • Asked staff who worked with the City to contact them on our behalf. • No action taken, so I asked if anyone cared if I talked to the City myself.

11. Here Comes the City • I was supplied with a name. • Very nervous about contacting City. • Not sure how a “tech” would be viewed. • Would City even talk to me? • Would they use this opportunity to cite us? • Would they understand what I was asking?

12. Not So Bad • Contacted Sherrie Elliott from the City of Petoskey and told her what we were attempting to do. • She had recently attended a seminar on the subject. • If I sent a list, could they tell me if it could go into the sewer? • That was the repeating question: I have “this” in my hand, can I put it down the sewer? • One sheet of medications.

13. The Players • We formed a task force consisting of: • NMRH (Haz, Safety, Facilities, Pharmacy) • City of Petoskey • FTC&H • KAR Laboratories

14. Case Study:The Consultants’ Side Erin Szczegielniak

15. A Partnership Municipal Client Engineer Consultant SIU

16. Focus: Intravenous Bags • Hospital sent a list: • Antibiotics • Pain relievers • Anti-Inflammatories • Steroids/Hormones • Vitamins • Nutrients • Electrolytes

17. Considerations • Alternative disposal is expensive. • “Incinerate everything” is not reasonable. • Priorities: • WWTP Interference • Environmental Impact

18. Review the Research • Few compounds have been studied for their environmental impact. Boxall, A. B. A. (2004) The Environmental Side Effects Of Medication EMBO Reports 5(12): 1110-1116. • Pharmaceuticals detected in surface water monitoring studies. • Specific pharmaceuticals: their effects on different organisms: • Rainbow trout, snails, aquatic plants, bacteria.

19. Sortit Out • Compared known compounds with known effects to IV bag contents. • Categorized contents by chemical structure (not symptom treatment). • Example: Pain killers are not created equal. • Morphine derivatives • Acetaminophen • Ibuprofen

20. What’s good? What’s bad? • Categorizations: • High: WWTP Interference • DO NOT DISCHARGE • Moderate: Environmental Impact • LIMIT DISCHARGE • Low: No known impact • DISCHARGE AS NEEDED

21. Case Study:The Plan in Action Cheryl Chisholm, CPhT

22. The Results Are In 8 Weeks Later: The task force met and produced the chart consisting of High, Moderate, and Low risk discharges.

23. How It Works Quarterly meetings with the City: • Any additional medications to analyze? • If so, they are sent to FTC&H and the results are back in a month. • FTC&H maintains information.

24. Updating Program • New medications are run through the software program. • Are they Hazardous by USEPA, State, NIOSH, OSHA, HHS, etc. • If yes, they are added to the hazardous drug list, notation on RX label, bar code system. • All medications treated as if hazardous.

25. What We’re Doing • Pharmaceutical Waste Program fully implemented at NMRH. • Keeping up with formulary changes. • Working with Little Traverse Bay Band, Emmet County on Household Medication Disposal. In 4 collection events, 300 lbs of non-controlled drugs and 25 lbs of controlled drugs were collected! (= the weight of 13 cement blocks)

26. What We’re Doing • At least quarterly contact with the City. • Ongoing communication with waste vendor. • Contacted the municipal WWTP of our long-term care facility (different City/County).

27. Identified hazardous pharmaceuticals in formulary. Identified current levels of waste. Interviewed potential waste haulers/site visit. Obtained appropriate containers. Developed appropriate labeling/stickers. Developed a storage area. Met with the City to identify sewarable/ non-sewerable items. Developed process for handling all pharmaceutical waste as hazardous = best management practice, ready for future additions to hazardous list. 22 Meetings Later

28. How Much? • NMRH has been capturing medications for 3 years. • In 2008, after full implementation, NMRH sent out more than 3.5 tons of pharmaceutical waste.

29. Safeguarding our Environment… It’s Worth the Effort!

30. Questions? Cheryl Chisholm cchisholm@northernhealth.org Sherrie Elliott selliott@charterinternet.com John Porter jrporter@ftch.com Erin Szczegielniak ehszczegielniak@ftch.com