Tribal Compliance Assistance Center

Background Information

EPA's Profile of the Healthcare Industry (PDF) (155 pp, 1.4MB, About PDF) and the Healthcare Environmental Resource Center Web site provide detailed compliance and pollution prevention information on the healthcare sector. Tribes may also want to obtain information from the Indian Health Service Web site.

Tribes, the federal government (i.e., the Indian Health Service), and a variety of public and private parties operate hospitals and healthcare facilities in Indian country to support the healthcare needs of tribal communities and tribal members. These operations include small hospitals, clinics, physician and dentist offices, diabetes centers, home-based care, alternative medicine, nutritional counseling, pharmacies, dental and orthodontic care, substance abuse treatment, mental health counseling, and preventive care. These operations also include ambulatory healthcare services, nursing and residential care facilities, and social assistance.

Many healthcare activities also result in the generation of waste and air or water pollution. Healthcare operations can contribute to the presence of mercury, dioxin, and other persistent, bioaccumulative toxics (PBTs) in the environment. Healthcare operations also generate a wide variety of hazardous waste, such as chemotherapy and antineoplastic chemicals, mercury, solvents, formaldehyde, photographic chemicals, radionuclides, and waste anesthetic gases. In addition, healthcare providers produce tons of solid waste and may also own or operate hospital/medical/infectious waste incinerators (HMIWI), underground storage tanks, aboveground storage tanks, boilers, air conditioners, motor vehicle fleets, and engage in other activities associated with construction and property management. Pesticides, including but not limited to disinfectants, are also used in healthcare facilities.

Producing an exhaustive list of every healthcare activity that impacts the environment or is regulated would be extremely cumbersome and ultimately would distract the focus from those functions within the healthcare industry that create problem wastes and pollution. That said, EPA's Profile of the Healthcare Industry identifies key functions and activities that are the major sources of waste and pollution within health sector institutions.

After identifying environmental impacts by activity, healthcare facilities can begin to address the major waste streams and emission sources. Healthcare wastes can be categorized as follows:

• Municipal solid waste. The majority of healthcare wastes are produced under circumstances identical to restaurants and food industry facilities, hotels, and office complexes. The industry generates large volumes of solid waste (much of which could be sub-categorized as recyclable waste). A special subcategory of municipal solid waste to be considered is construction and demolition (C&D) debris



• Biohazardous waste. Regulated under the Medical Waste Tracking Act of 1988, this healthcare waste can potentially harbor and transmit infectious diseases. This includes a wide range of materials that are considered contaminated or that pose special risks



• Hazardous waste. To be considered hazardous waste under RCRA, waste must either be listed or characteristic. Listed wastes are specifically named in 40 CFR Part 261. Characteristic wastes are ignitable, reactive, corrosive, or toxic. There are some special waste streams that fall most logically under the heading of "hazardous" because of their unique nature and the risks inherent in each of them. The Profile of the Healthcare Industry refers to them as pharmaceutical waste, commingled waste (e.g., commingled "biohazardous," chemical waste or mixed radioactive waste, and commingled nonhazardous and hazardous wastes), pressurized containers and ignitable compressed gas, and universal waste. In some cases, each of these "special" wastes is RCRA listed or RCRA characteristic wastes, and disposal should follow the RCRA hazardous waste requirements



• Air emissions. At hospitals, air emissions come from boilers, air conditioning and refrigeration, HMIWI (if on site), asbestos, paint booths, ethylene oxide sterilization units, emergency generators, anesthesia, laboratory chemicals, and laboratory fume hoods. HMIWI are used by hospitals, healthcare facilities, and commercial waste disposal companies to burn hospital waste and/or medical/infectious waste. When burned, hospital waste and medical/infectious waste may emit various air pollutants, including hydrochloric acid, dioxin/furan, and toxic metals (i.e., lead, cadmium, mercury)

In each case, healthcare providers may be subject to multiple federal and tribal environmental laws and regulations. Potentially applicable federal laws include: the CAA, CWA, EPCRA, and RCRA. Tribal governments should obtain EPA's Profile of the Healthcare Industry and review a variety of Tribal Profile sections, including those on Construction/Property Maintenance, Waste Management, and Pesticides Management to better assess their regulatory requirements.

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Hospitals, Healthcare Workers and Emergency Response

Hospitals are vital to the success of any emergency response plan. Ambulance crews and emergency room personnel must know how to transport and treat victims of exposure to hazardous chemicals. Without such knowledge, victims of chemical accidents can contaminate emergency rooms and cause hospitals to close temporarily.

Doctors, nurses, and trained medical professionals can be a valuable resource in emergency planning and response. They can also be an important source of information about risks to the public health in their communities. Some of the ways they can participate in emergency planning include:

• Volunteering to be a health professional representative on the LEPC, or offering to assist the LEPC in its work



• Participating in programs to train medical personnel to deal with emergencies involving chemical hazards



• Screening information submitted under EPCRA to determine if any acute or chronic health effects may be associated with hazardous substances on the reservation

In a more general sense, health professionals may be approached to provide and interpret information on chemicals and their impacts on patients. The law allows health professionals to gain access to chemical identity information, even if it is claimed as trade secret, in three different situations:

• If the chemical identity is needed for the diagnosis and treatment of an exposed person



• If a medical emergency exists in which the chemical identity is needed to aid in diagnosis or treatment



• If a health professional who is a tribal government employee requests a chemical's identity to conduct preventive research studies and to render medical treatment

Except for medical emergencies, a written statement of need and a confidentiality agreement must accompany a health professional's request for a chemical's identity.

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Pollution Prevention and Healthcare

Web sites with resource information for source reduction include the Hospitals for a Healthy Environment (H2E) site and the Sustainable Hospitals project site. H2E is designed to help healthcare facilities enhance work place safety, reduce waste and waste disposal costs and become better environmental stewards and neighbors.

Within the healthcare industry, numerous opportunities exist to prevent pollution. By implementing well-planned pollution prevention strategies, facilities can improve efficiencies, save money, minimize adverse environmental impacts, and create a healthier workplace. Opportunities vary from facility to facility and relate to the volumes and types of activities. The Profile of the Healthcare Industry and the Healthcare Environmental Resource Center Web site provide an understanding of some of the most common pollution prevention opportunities available and highlight some examples of strategies by waste type.

The Healthcare Profile provides pollution prevention information on the following key topics:

• Environmental Management Systems (EMS) and EPA's "Healthcare Guide to Pollution Prevention Implementation through Environmental Management Systems, available at the EPA Region 2 Compliance Healthcare Web site are a comprehensive resource for understanding and developing an EMS specific to a healthcare facility.



• Purchasing/Product Substitution/Source Reduction opportunities exist in many areas within healthcare operations. Environmentally preferable purchasing (EPP) can reduce the waste generated at a facility. The Sustainable Hospitals project is, among other things, designed to support the healthcare industry select products and work practices that reduce occupational and environmental hazards



• Process changes are intentional modifications of activities that reduce pollution and there are abundant opportunities for this in healthcare operations. Some process changes with environmental benefits also have other benefits, such as cost containment or improved service or product quality. Examples of healthcare process changes include switching to digital imaging for radiology processing (reduces silver waste outputs) and improving waste segregation systems (reduces biohazardous waste outputs, increases the likelihood that wastes can be collected and handled in the most appropriate and cost-effective fashion, separating solid waste outputs and recyclable waste outputs)



• Recycling opportunities are widespread throughout most healthcare facilities. Waste volumes can dramatically be reduced if systems are in place to capture recyclable materials such as cardboard, paper, glass and aluminum beverage containers, scrap metals, wood waste, kitchen grease, and selected plastics. Opportunities also exist for reducing hazardous waste through recycling initiatives

The treatments chosen to address health issues also can have environmental impacts and less toxic treatments, where appropriate, can prevent pollution. For example, pharmaceutical use of lindane-containing products was banned in California because residues from these products were contaminating drinking water. Because lindane can be toxic to the brain and other parts of the nervous system, the Centers for Disease Control and Food and Drug Administration permit the use of lindane-containing products for treatment of head lice and scabies with caution and only when treatment with safer alternatives has failed.

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