This article was published in Health Facilities Management Magazine

Posted August 2004

By Beth Burmahl

Selecting A Winning Waste Disposal Technology

Environmental services directors and other health facility professionals who have decided to switch to on-site waste disposal but are still up in the air about which technology will best suit their needs might consider taking a road trip.

That's how Sonny Wyatt, CHESP, director of environmental services for Anderson (S.C.) Area Medical Center, and other staff members settled on the Tempico Rotoclave system when scouting out waste management technology for their 587-bed facility in 1998.

"At the time, there were three main technologies out there being used by health care," says Wyatt. "We took site visits and looked at the microwave system, the autoclave system and the Rotoclave system. We chose the Rotoclave because we felt it had a better steam sterilization process."

An on-site visit was also a selling point for Ed Barr, support services manager, Thomas Jefferson University Hospital, Philadelphia, who eventually settled on Tracy, Calif.-based San-I-Pak's autoclave system after his team saw the technology in action.

"I took some employees out to the site to a new San-I-Pak and said, 'Tell me what you think,' and they gave me feedback," says Barr. "For example, we could have bought an automatic tipper, but the staff came back and said it would be faster to do it manually."

Getting a first-hand look at the equipment will help narrow your choices, but be prepared to wade deeper into the waste management waters if you want to avoid making a costly mistake.

In an industry estimated to be worth $1 billion a year in the United States alone, Barr cautions that there are companies out there who will come up with "new ways to sell you the wheel," which is why you need to do your homework.

Educational opportunity
One excellent educational opportunity will be offered next month at the American Society for Healthcare Environmental Services (ASHES) annual conference in Orlando, Fla., when a panel discussion will be held on three main types of waste management technologies. Barr will speak on autoclaves, Wyatt on the Rotoclave, and Nord Sorensen, COO of Sanitec Industries, Washington, D.C., will discuss the microwaving process.

Additionally, though it doesn't endorse a particular technology, the nonprofit environmental group Health Care Without Harm (HCWH) compared 50 different medical waste treatment technologies in a report issued in August 2001, which is available at www.noharm.org/library/docs/Non-Incineration_Medical_Waste_Treatment_Te_2.pdf.

The report classifies the technology in four categories: heat, chemical, biological systems and radiation.

The bottom line? The technologies that use heat--autoclaves, advanced autoclaves and microwaving--still have the best track record, according to HCWH's Jorge Emmanuel.

Chemical processes such as chlorine and nonchlorine-based systems, biological and radiation systems are still emerging, he says. "But no matter what technology you choose, there has to be a whole system of segregation and minimization in place to be truly effective," says Emmanuel (see sidebar).

Indeed, many experts stress, waste reduction should be your top waste management priority. For instance, HCWH recommends doing a medical waste audit to pinpoint the sources of waste, waste content and rates of generation, which will help determine the type and size of on-site system that is most suitable. The group says the audit may also give information on minimizing waste, handling practices, segregation, regulatory compliance and costs.

Hospitals should also be aware that there are no federal regulations governing medical waste, which is regulated at the state level. Although all states accept autoclave systems for medical waste treatment, some states require some advanced autoclaves to be approved separately.

Hospitals should also check with regulators to find out if certain waste streams (such as chemotherapy or animal or body parts) cannot be treated by nonincineration technologies.

Differences in autoclaves
Autoclaving is an old technology--experts say it predates World War II--and it is still the primary waste management technology used by hospitals today. But not all autoclaves are created equally, Barr cautions.

"Some companies sell inexpensive autoclaves," says Barr. "And, sure, it's cheap, but a lot of labor goes into running them."

Barr's facility is a second generation buyer of the Sani-I-Pak autoclave system, having upgraded after the facility--which generates 10 tons of waste a day--outgrew the first system. He says the system is "expensive but labor-friendly," and that his 650-bed facility has saved an average of six figures a year since making the switch from off-site treatment.

On average, San-I-Pak customers pay 7 to 9 cents a pound to ship regulated medical waste, says Arthur McCoy, senior vice president of the company. He says the equipment--which can range anywhere from $60,000 to $1 million--generally pays for itself in less than two years. The company can also custom-design equipment to suit the hospital, saving construction costs.

Apart from becoming fully automated, McCoy says the biggest advancement to the system in recent years has been the electronic management capabilities it now offers. The PC-based system does its own waste auditing and tracking and creates a waste generation report detailing how much waste comes from which department, among other details.

"What previously took environmental services managers 20 hours a month to compile, the machine is doing automatically," says McCoy.

But every technology has advantages and disadvantages. While HCWH concluded that autoclaves utilize a proven technology with a successful track record and are approved or accepted as an alternative technology in all states, the group added that many autoclaves do not render waste unrecognizable and do not reduce the volume of treated waste unless a shredder or grinder is added.

And if an autoclave doesn't include a way of drying the waste, it will come out heavier (and more costly to ship) because of the condensed steam.

A better mousetrap?
Autoclaves that do have an internal shredding system, called "advanced autoclaves" (the Tempico Rotoclave is one example), may have a rotating drum that tosses and turns waste after spikes tear it from the bags. The process offers uniform sterility because the steam is exposed to all of the waste equally.

"The autoclave offers steam sterilization, but everything is left in the bag and there is no rotation ... it just goes into a sterilizer," says Wyatt. "That's why we chose the Rotoclave."

The waste goes onto a conveyer belt leading to a grinder, which renders the waste unrecognizable, says Craig Boots, director of engineering for Tempico, Hammond, La. "When it comes out of the Rotoclave, it is considered standard waste, which means it can go into a dumpster and be taken to a regular landfill," says Boots.

"That's an advantage because most landfills will not let you dispose of sharps and items of that nature unless they are ground up," says Wyatt.

On average, Rotoclave customers pay 6 to 12 cents a pound to ship the waste, says Boots, who says the technology ranges from $400,000 to $1 million.

Wyatt's facility processes 1.9 million pounds of waste per year, which includes waste from 34 off-site satellite facilities. The Rotoclave, which cost the facility about $600,000, saves 6 cents a pound on treated waste, says Wyatt, who says increasingly strict air quality standards forced the facility to shut down its incinerator.

"The capital expense and the space to house the equipment were factors, but we feel the investment is paying off," says Wyatt. "We built a temporary facility here in the main campus to house it."

In recent years, advanced autoclaves have been developed to offer a number of combinations that allow a facility to custom-fit the technology, so to speak, to suit its needs. Some of the combinations include: steam treatment-mixing-fragmenting/drying/shredding; shredding-steam treatment-mixing/drying; and preshredding/steam treatment mixing.

A drier alternative
Indianapolis-based WR2 and its parent company, Sterile Technology, offer a regulated medical waste processing unit that emits decontaminated waste that is shredded, unrecognizable, dry and ready for the landfill, says Marty Wetzel, vice president, WR2.

"Our process is a continuous feed auger that is steam-heated through a jacket, but it's not a pressure vessel," says Wetzel. "The main advantage is that it treats the waste in such a way that it comes out dry with no odor."

The system preshreds the waste--including sharps, needles, IV bags, etc.--which creates a finer mulch, Wetzel says. "It comes out as confetti-type mulch that can go out as municipal waste."

HCWH cautions that preshredding should not be done before disinfection to protect workers from exposure to pathogens released in the air by the mechanical process (except when shredding or grinding is part of a closed system designed in such a way that the air stream from the process is disinfected before being released).

The technology ranges in size from 300 to 600 pounds per hour and in cost from $320,000 to $1 million installed, Wetzel says.

Microwave gaining ground
Microwave technology--a heat/thermal induction-based process--is still not widely used in the health care industry, but is gaining ground. Sanitec, which has been operating in the United States since 1990, has installed 48 systems in the United States, and a total of more than 80 units worldwide--most of them at hospitals.

With microwaving technology, the waste is shredded, dry, unrecognizable and ready for the landfill. It can treat the same types of waste as autoclaves (excluding toxic waste) and some that it can't. In most states, microwave technology is permitted to treat biological, trace chemo and pathological waste, which are not treated by autoclaves.

And if waste streams are properly segregated to prevent hazardous chemicals from being fed into the treatment chamber, the emissions from microwave units are minimal, according to HCWH.

Sorensen, of Sanitec, says, "Microwaves give a very thorough kill of the bacteria. And it's a very clean technology. There are no air emissions, no liquid emissions. And employees never come into contact with the waste."

He says the technology has taken longer to take hold in health care because autoclaves are entrenched in the market and microwaving is relatively new. HCWH also cites its cost as a drawback, but Sorensen says it's hard to give a ballpark figure because microwaving is done as a cooperative venture with hospitals who pay a waste management fee to use the technology, plus a rate per pound.

"The actual cost of disposal depends on the size of the hospital and the volume of waste they are treating," Sorensen says.

But the technology can save facilities money in other ways. Sorensen says the technology can reduce medical waste volume up to 80 percent, which reduces final waste disposal hauling costs, and the Sanitec units can be used by facilities to process Health Insurance Portability and Accountability Act-sensitive medical records. He says a facility can be expected to save 15 to 25 percent in overall costs.

Hotter still?
Other waste disposal options include high-heat thermal technology in which pyrolosis is usually the dominant process. It operates at or above the temperature of an incinerator and can handle the full spectrum of medical waste except for radiological waste and mercury.

But HCWH's Emmanuel says he has told a number of hospitals who have asked him about the process in recent years that he considers the process "problematic" because it creates some of the same pollutants as incineration.

"It has the incineration advantage--you could just burn everything--but then you raise the issue of what are the pollutants you are releasing? Studies have shown that many are the same type of pollutants created by incineration," Emmanuel says.

The system also has a high capital cost related to its throughput capacity, and may especially not be cost-effective for small hospitals.

A very small percentage of the market is taken up by biological processes that use enzymes to decompose organic waste, and the radiation process where electron-beam technology bombards medical waste with radiation, damaging the cells of the microorganisms.

Chlorine or sodium hydroxide chemical systems have a longer track record, but Emmanuel says the method has raised concerns about contaminants being released in the wastewater.

One chemical system that he says does occupy a favorable niche in the market is the alkaline digestion process that is used to convert animal and microbial tissue into a decontaminated solution. The system, the Path-Clav, developed by WR2, uses alkaline hydrolosis at elevated temperatures. "The alkaline digests the organic material so that what is left is a neutral solution that goes into the wastewater," says Emmanuel.

The Path-Clav does not handle the full range of waste streams, but is designed specifically for tissue waste including organs, placentas, body fluids and animal carcasses.

No constants
With varying regulations and changing technology, hospitals don't have many constants they can rely on when selecting a nonincineration system.

But if they consider the most critical factors--type of waste, throughput capacity, regulatory compliance, environmental emissions, reduction of waste volume, reliability and cost among them--facilities will be able to determine which waste management technology best suits their needs.