A wa­ter­shed mo­ment

Five N.Y. fa­cil­i­ties agree to stop dump­ing drug waste

Modern Healthcare - - The Week In Healthcare - Gregg Blesch

Now that the pub­lic is be­com­ing aware and alarmed that much of the na­tion’s tap wa­ter is laced with trace amounts of phar­ma­ceu­ti­cals, hos­pi­tals and other health­care fa­cil­i­ties may be in­creas­ingly find­ing them­selves an­swer­ing for it.

Last week, New York At­tor­ney Gen­eral An­drew Cuomo an­nounced his of­fice reached set­tle­ment agree­ments with two crit­i­cal-ac­cess hos­pi­tals and three nurs­ing homes al­leged to have been dump­ing un­used phar­ma­ceu­ti­cals down drains and toi­lets and caus­ing the chem­i­cals to flow into the reser­voirs and lakes that make up the wa­ter­shed pro­vid­ing wa­ter to 9 mil­lion res­i­dents of New York City and sur­round­ing coun­ties.

“It’s not a new is­sue for health­care pro­fes­sions,” said Cyn­thia Reilly, di­rec­tor of the prac­tice de­vel­op­ment divi­sion of the Amer­i­can So­ci­ety of Health-Sys­tem Phar­ma­cists. The as­so­ci­a­tion first crafted guide­lines for proper dis­posal in the 1970s, which is when Congress passed a law to po­lice a wide ar­ray of in­dus­trial waste, the Re­source Con­ser­va­tion and Re­cov­ery Act.

“What’s new is some of the pub­lic scru­tiny of it,” Reilly said. “It’s not just phar­ma­cies that are in­volved in this—it’s also nurs­ing, en­vi­ron­men­tal ser­vices and, most im­por­tantly, the in­sti­tu­tion’s C-suite needs to un­der­stand that this is a sig­nif­i­cant is­sue and re­sources are needed to help man­age it.”

The drugs in our wa­ter don’t all come from health­care fa­cil­i­ties, a fact con­sis­tently noted by sci­en­tists who have stud­ied the mat­ter and the U.S. En­vi­ron­men­tal Pro­tec­tion Agency. Much of the stuff is ex­creted by the peo­ple who take phar­ma­ceu­ti­cals. Other sources in­clude runoff from farm­land, where live­stock is treated with an­tibi­otics and other drugs, and phar­ma­ceu­ti­cal man­u­fac­tur­ers.

The EPA in 2006 em­barked upon an ef­fort to bet­ter un­der­stand the role of hos­pi­tals and nurs­ing homes. A com­pre­hen­sive sur­vey was planned and then scrapped af­ter the agency de­ter­mined its pre­lim­i­nary data col­lec­tion and com­mu­ni­ca­tion with the in­dus­try was enough to be­gin de­vel­op­ing best prac­tices for the in­dus­try.

Ad­vances in an­a­lyt­i­cal meth­ods have al­lowed re­searchers to de­tect lower con­cen­tra­tions of chem­i­cals in wa­ter, ac­cord­ing to the EPA’s Septem­ber 2009 in­terim re­port, and the U.S. Ge­o­log­i­cal Sur­vey de­tected phar­ma­ceu­ti­cal com­pounds in 80% of 139 streams tested in 1999 and 2000.

Cuomo’s of­fice is in the midst of what it de­scribes as a broad and on­go­ing in­ves­ti­ga­tion into the dis­posal prac­tices of health­care fa­cil­i­ties within New York City’s wa­ter­shed. Ac­cord­ing to the five set­tle­ments an­nounced last week, Cuomo’s of­fice sent let­ters in Jan­uary 2009 re­quest­ing in­for­ma­tion from 15 hos­pi­tals, nurs­ing homes and as­sisted-liv­ing fa­cil­i­ties.

The two hos­pi­tals that set­tled were 16-bed O’Con­nor Hospi­tal in Delhi, N.Y., and 15-bed Mar­garetville (N.Y.) Hospi­tal. Nei­ther re­turned calls re­quest­ing in­ter­views. In both cases, ac­cord­ing to the set­tle­ments, man­age- ment re­sponded that they did not de­posit any phar­ma­ceu­ti­cals in drains and toi­lets, but those as­ser­tions were con­tra­dicted by in­ter­views with pa­tient-care staff.

Com­mon med­i­cal prod­ucts that are con­sid­ered haz­ardous waste in­clude nitro­glyc­erin, nico­tine and the an­ti­co­ag­u­lant war­farin. Other drugs iden­ti­fied by Cuomo’s of­fice as po­ten­tially dam­ag­ing to the area’s aquatic life were es­tro­gens, Prozac, Ta­mox­ifen and beta block­ers.

The agree­ments with Cuomo in­clude a few thou­sand dol­lars in fines and fees but prin­ci­pally call for the fa­cil­i­ties to cease dis­pos­ing of any phar­ma­ceu­ti­cal prod­ucts in sinks and toi­lets and trans­port all prod­ucts deemed haz­ardous to qual­i­fied waste in­cin­er­a­tors.

The EPA ob­served in a 2008 doc­u­ment that “for many years, a com­mon prac­tice at many health­care fa­cil­i­ties has been to dis­pose of un­used phar­ma­ceu­ti­cals by flush­ing them down the toi­let or pour­ing them down the drain.”

Manag­ing un­used phar­ma­ceu­ti­cals is ex­tremely com­pli­cated, ac­cord­ing to pro­fes­sion­als who strive to do it right. The re­cov­ery con­ser­va­tion law in the EPA’s do­main was writ­ten largely for in­dus­trial plants and doesn’t trans­late eas­ily to health­care, said Janet Brown, di­rec­tor of fa­cil­ity en­gage­ment for Prac­tice Green­health, a mem­ber­ship or­ga­ni­za­tion for health­care or­ga­ni­za­tions work­ing to be good en­vi­ron­men­tal cit­i­zens.

Com­pli­ance re­quires cross-check­ing a for­mu­lary that typ­i­cally in­cludes more than 1,000 med­i­ca­tions against fed­eral lists of chem­i­cals and char­ac­ter­is­tics. “We try to help hos­pi­tals iden­tify ways to make less phar­ma­ceu­ti­cal waste in the first place,” Brown said. “In­stead of just pay­ing those bills to haul haz­ardous waste, let’s look at what you’re gen­er­at­ing.”

Com­pli­ance is fur­ther com­pli­cated by the va­ri­ety of fed­eral and state agen­cies, laws and reg­u­la­tions that have a hand in waste dis­posal, said William Churchill, ex­ec­u­tive di­rec­tor of phar­macy ser­vices at 776-bed Brigham and Women’s Hospi­tal in Bos­ton. Churchill, who has done ed­u­ca­tional pre­sen­ta­tions on the topic, said con­sul­tants can help do the work of clas­si­fy­ing the proper waste stream for each prod­uct used by a hospi­tal. He echoed Reilly’s ob­ser­va­tion, though, that craft­ing and car­ry­ing out an ap­proach must in­volve leaders from sev­eral hospi­tal de­part­ments and a will­ing­ness at the top to in­cur ad­di­tional cost.

Just in the past few years, Churchill said, he has no­ticed sig­nif­i­cantly more at­ten­tion paid to the is­sue by reg­u­la­tors and the me­dia. Col­leagues have shared tales of EPA in­ves­ti­ga­tors show­ing up unan­nounced. “I had never re­ally heard of it six years ago,” he said. “I think there’s a com­bi­na­tion of things that are bub­bling to the sur­face.”

The Cro­ton River is part of the New York City wa­ter­shed al­legedly con­tam­i­nated with phar­ma­ceu­ti­cals flushed by hos­pi­tals and nurs­ing homes.

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