Cheryl Chisholm, CPhT

1

2

Serving 22 counties in Northern Michigan

Patient-centered specialized care

3

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

4

Ignorance Was BlissIgnorance Was Bliss

5

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.

6

PharmEcology site visit on April 13, 2005.◦ Delineated regulations.◦ Outlined risks of noncompliance.◦ Identified waste streams.◦ Identified hazardous pharmaceuticals.◦ Outlined waste hauler criteria.

5

5

We didn’t know how big…We didnWe didn’’t know how bigt know how big……

PharmEcology Site visit April 13, 2005

Delineated regulations

Outlined risks of noncompliance

Identified waste streams

Identified hazardous pharmaceuticals

Outlined waste hauler criteria

7

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.

8

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.

9

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.

10

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?

11

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.

12

We formed a task force consisting of:◦ NMRH (Haz, Safety, Facilities, Pharmacy)◦ City of Petoskey◦ FTC&H◦ KAR Laboratories

13

Erin Szczegielniak

14

15

EngineerConsultant

Municipal Client

SIU

Hospital sent a list:

16

o Antibioticso Pain relieverso Anti-Inflammatories o Steroids/Hormoneso Vitaminso Nutrientso Electrolytes

Alternative disposal is expensive.

“Incinerate everything” is not reasonable.

Priorities:1. WWTP Interference2. Environmental Impact

17

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.

18

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

19

Categorizations:

◦ High: WWTP Interference DO NOT DISCHARGE

◦ Moderate: Environmental Impact LIMIT DISCHARGE

◦ Low: No known impact DISCHARGE AS NEEDED

20

Cheryl Chisholm, CPhT

21

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

22

Disposal Risk High Moderate Low

Compound

Electrolyte A     X

Pharma X X    

Pharma Y   X  

Vitamin B     X

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.

23

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.

24

25

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)

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).

26

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.

27

NMRH has been capturing medications for 3 years.

In 2008, after full implementation, NMRH sent out more than 3.5 tons of pharmaceutical waste.

28

It’s It’s WorthWorth the Effort! the Effort!

29

Cheryl Chisholm cchisholm@northernhealth.org

Sherrie Elliottselliott@charterinternet.com

John Porterjrporter@ftch.comErin Szczegielniak

ehszczegielniak@ftch.com

30