Document ID: EPA-HQ-OW-2004-0032-0721
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-04-27T04:00Z

Draft,
4/
12/
05;
subject
to
change
Page
1
of
17
Hospitals
Introduction
40
CFR
Part
460,
promulgated
in
1976,
applies
to
effluent
discharges
to
surface
water
from
hospitals
with
greater
than
1,000
occupied
beds.
In
1989,
EPA
published
a
Preliminary
Data
Summary
(
PDS)
for
the
Hospitals
Point
Source
Category.
EPA's
Office
of
Enforcement
and
Compliance
Assistance
(
OECA)
developed
a
draft
Healthcare
Sector
Notebook
in
2004.
OECA
plans
to
publish
the
draft
Sector
Notebook
in
2005.

Industry
Profile
Hospitals
include
facilities
in
SIC
codes
8062,
General
Medical
and
Surgical
Hospitals,
8069,
Specialty
Hospitals,
Except
Psychiatric
(
children's
hospitals),
and
8063,
Psychiatric
Hospitals.
The
1987
SIC
Code
Manual
defines
these
SIC
codes
as
follows:

8062
General
Medical
and
Surgical
Hospitals
­
Establishments
primarily
engaged
in
providing
general
medical
and
surgical
services
and
other
hospital
services.
Specialty
hospitals
are
classified
in
Industries
8063
and
8069.
This
SIC
code
includes
only
General
Medical
and
Surgical
Hospitals

8063
Psychiatric
Hospitals
­
Establishments
primarily
engaged
in
providing
diagnostic
medical
services
and
inpatient
treatment
for
the
mentally
ill.
Establishments,
known
as
hospitals,
primarily
engaged
in
providing
health
care
for
the
mentally
retarded
are
classified
in
Industry
8051.
This
SIC
code
includes:
Mental
hospitals,
except
for
the
mentally
retarded
and
Psychiatric
hospitals.

8069
Specialty
Hospitals,
Except
Psychiatric
­
Establishments
primarily
engaged
in
providing
diagnostic
services,
treatment,
and
other
hospital
services
for
specialized
categories
of
patients,
except
mental.
Psychiatric
hospitals
are
classified
in
Industry
8063.
This
SIC
code
includes:
Alcoholism
rehabilitation
hospitals;
Cancer
hospitals;
Children's
hospitals;
Chronic
disease
hospitals;
Drug
addiction
rehabilitation
hospitals;
Eye,
ear,
nose,
and
throat
hospitals:
in­
patient;
Hospitals,
specialty:
except
psychiatric;
Maternity
hospitals;
Orthopedic
hospitals;
Rehabilitation
hospitals:
drug
addiction
and
alcoholism;
and
Tuberculosis
and
other
respiratory
illness
hospitals.
Draft,
4/
12/
05;
subject
to
change
Page
2
of
17
Table
3­
1.
Census
Data
SIC
Code
NAICS
Code
Number
of
Facilities
in
1997
Number
of
Facilities
in
2002
8062:
General
Medical
and
Surgical
Hospitals
622110:
General
Medical
and
Surgical
Hospitals
5,487
5,404
8063:
Psychiatric
Hospitals
622210:
Psychiatric
and
Substance
Abuse
Hospitals
801
605
8069:
Other
Specialty
622310:
Specialty
(
Except
Psychiatric
and
Substance
Abuse)
Hospitals
397
316
Total
6,685
6,325
EPA's
1989
PDS
states
that,
using
1985
data,
97
percent
of
the
hospitals
are
indirect
dischargers.
This
was
an
increase
from
1975,
when
92
percent
of
hospitals
were
indirect
dischargers.

Table
3­
2
shows
the
facility
counts
available
from
the
2000
TRI
and
PCS
databases.
Using
2002
U.
S.
Census
and
2000
PCS
data,
34
of
6,325
hospitals
are
direct
dischargers,
and
99.5
percent
of
hospitals
are
indirect
dischargers.
Note:
hospitals
are
exempt
from
TRI
reporting
unless
they
are
federal
facilities.

Table
3­
2.
2000
TRI
and
PCS
Facility
Counts
SIC
Code
Number
of
Facilities
Reporting
to
2000
TRI
Number
of
Facilities
Reporting
to
PCS
2000
Direct
Indirect
Both
No
Discharge
Reported
Direct
(
Major/
Minor)

8062
0
0
0
1
2
20
8063
0
0
1
0
1
7
8069
0
0
0
0
0
4
Total
0
0
1
1
3
31
Wastewater
Characteristics
Wastewater
Quantity
EPA
located
wastewater
volume
data
from
the
1989
PDS,
textbooks,
TRI,
and
PCS.
Table
3­
3
summarizes
the
wastewater
flow
data
from
the
PDS
and
textbooks.
Draft,
4/
12/
05;
subject
to
change
Page
3
of
17
Table
3­
3.
Typical
Wastewater
Flow
Rates
from
Hospitals
Type
of
Establishment
Wastewater
Flow
Range
(
gal/
day
per
unit)
Unit
Textbook
Source
Hospital
242
Bed
1989
PDS*

Hospital,
medical
125
­
240
Bed
Metcalf
&
Eddy
Hospital,
mental
75
­
140
Bed
Hospital
150
­
250+
Person
Standard
Handbook
of
Environmental
Engineering
*
The
1989
PDS
cites
1976
data
from
the
American
Hospital
Association
(
AHA),
that
approximately
242
gallons
of
wastewater
are
generated
per
bed
per
day
at
hospitals.
The
PDS
also
states
that,
"
based
on
the
latest
information,
this
figure
has
not
changed."

From
the
Center
for
Medicare
and
Medicaid
Services
(
CMS)
web
site,
the
number
of
hospital
beds
in
2000
was
983,628.
Using
the
data
in
Table
3,
hospitals
discharge
an
estimated
120
to
240
MGD
of
wastewater,
or
43,800
to
87,600
MGY.

Based
on
a
survey
of
26
Florida
hospitals,
conducted
by
the
Southwest
Florida
Water
Management
District
(
SWFWMD),
hospitals
use
an
average
of
139,214
gallons
per
day
(
GPD)
of
water.
Table
3­
4
shows
the
types
of
water
use.

Table
3­
4.
Types
of
Hospital
Water
Use
Types
of
Water
Uses
Average
Water
Use
(%
of
total)

Cooling
53
Domestic
24
Cleaning
10
Kitchen
5
Process
4
Other
4
TOTALS
100%

139,214
gpd
Source:
ICI
Conservation
in
the
Tri­
County
Area
of
the
SWFWMD.
SWFWMD,
November
1997.

Table
3­
5
summarizes
the
2000
PCS
data
available
for
flow.
Draft,
4/
12/
05;
subject
to
change
1U.
S.
Department
of
Defense,
1998.
Handbook
Nondomestic
Wastewater
Control
and
Pretreatment
Design
Criteria,
MIL­
HDBK­
1005/
17,
http://
www.
afcesa.
af.
mil/
ces/
cesc/
wastewater/
1005_
17.
PDF,
October
30,
1998.

Page
4
of
17
Table
3­
5.
2000
PCS
Data
Available
for
Flow
SIC
Code
Flow,
MGY
8062
Max
3,150
Min
0.27
Median
18.7
8063
Max
12,300
Min
0.34
Median
24.8
8069
Max
15.8
Min
2.77
Median
12.9
Raw
Wastewater
Quality
Hospital
wastewater
is
expected
to
contain
normal
sanitary
wastewater
contaminants
plus
cleaning
agents,
germicides,
acids,
and
chemicals
associated
with
laboratory
and
health
care
services.
The
various
medical
industry
wastewaters
include
wastewaters
from
clinical
laboratories,
research
laboratories,
medical
waste
incinerators
equipped
with
fume
scrubbers,
vehicle
maintenance
facilities,
and
hospital
laundries.
Silver
may
be
present
in
the
combined
hospital
wastewater
as
a
result
of
X­
ray
processing,
1
This
unit
operation
is
described
in
more
detail
in
the
Laboratories
II,
Medical/
Dental
and
Photoprocessing
profiles.
Wastewater
produced
by
hospitals
and
by
hospital­
related
industries
originates
from
many
sources.

The
1989
PDS
states
that
EPA
sampled
four
hospitals
to
better
characterize
the
contents
of
hospital
wastewater,
and
determine
if
hospitals
should
be
selected
for
further
study.
Criteria
for
selection
for
further
study
included
the
presence
of
unexpected
chemicals
or
chemical
concentrations
above
wastewater
treatability
levels.
Analysis
included
over
400
toxic
and
hazardous
pollutants.
Based
on
sampling
results,
neither
criteria
were
met,
although
five
pollutants
were
detected
at
levels
higher
than
expected
for
non­
industrial
wastewater.
These
pollutants
were
silver,
phenols,
barium,
acetone,
and
mercury.

Since
the
1989
PDS,
many
studies
world
wide
raise
the
question
of
the
fate
of
Draft,
4/
12/
05;
subject
to
change
2Giger,
Walter,
Alfredo
C.
Alder,
Eva
M.
Golet,
Hans­
Peter
E.
Kohler,
Christa
S.
McArdell,
Eva
Molnar,
Hansrudolf
Siegrist,
and
Marc
J.­
F.
Suter.
Occurrence
and
Fate
of
Antibiotics
as
Trace
Contaminants
in
Wastewaters,
Sewage
Sludges,
and
Surface
Waters.
Chimia
57
(
2003)
485
 
491
©
Schweizerische
Chemische
Gesellschaft.
ISSN
0009
 
4293.
Accessible
at
http://
www.
sach.
ch/
doc/
chimia/
sept03/
giger.
pdf.

3Endocrine
Disrupting
Chemicals
(
EDCs)
and
Pharmaceuticals
and
Personal
Care
Products
(
PPCPs)
in
Reclaimed
Water
in
Australia,
Australian
Water
Conservation
and
Reuse
Research
Program,
www.
clw.
csiro.
au/
priorities/
urban/
awcrrp/
stage1files/
AWCRRP_
1H_
Final_
27Apr2004.
pdf,
January
2004.

4Medical
Academic
and
Scientific
Community
Organization,
Inc.,
1997.
End­
of­
pipe
Subcommittee,
Technology
Identification
Subgroup
Report,
http://
www.
masco.
org/
mercury/
techid/
index.
html,
December
1997
Page
5
of
17
pharmaceuticals,
including
antibiotics,
genotoxins,
and
antineoplastics,
in
hospital
and
domestic
wastewater.
In
2003,
the
USGS
published
a
study
of
139
streams,
which
they
tested
for
pharmaceuticals,
hormones,
and
other
organic
wastewater
contaminants
(
OWCs).
At
least
one
OWC
was
detected
in
80%
of
the
streams
sampled,
with
82
of
the
95
analyzed
OWCs
determined
in
this
study
detected
in
at
least
one
sample.
The
antibiotics
erythromycin
and
lincomycin
were
two
of
the
most
commonly
detected
OWCs.
In
addition
to
antibiotics
there
may
be
other
pharmaceuticals
and
personal
care
products
in
the
untreated
effluent
including
potential
endocrine
disrupting
chemicals.
2,3
Although
antibiotics
are
excreted
in
urine
from
households,
hospital
toilet
waste
has
a
greater
likelihood
of
containing
antibiotics.

Hospital
may
operate
laundry
facilities
which
typically
process
linens,
gowns
and
lab
coats
that
will
contribute
a
certain
amount
of
organic
material,
fats,
oils
and
grease
(
FOG)
and
an
alternating
range
of
pH
(
alkaline
detergent
followed
by
an
acidic
sanitizer)
to
the
wastestream.
Depending
upon
the
processes
employed,
the
hospital
laundry
wastestream
can
have
elevated
temperatures
and
pH
extremes
and
can
contain
starch,
particulate
(
including
lint),
proteins
(
blood
products),
detergents,
and
oxidizers
(
bleach
or
other
disinfectant).
BOD
and
COD
concentrations
from
laundry
wastewater
are
usually
in
the
normal
range
for
domestic
sewage.
Some
laundry
chemicals
(
sodium
hydroxide
and
bleach)
are
known
to
often
have
significant
levels
of
mercury
contamination.
In
addition,
just
one
broken
mercury
thermometer
can
cause
temporary
high
levels
of
mercury
in
the
laundry
wastewater.
Hospital
laundry
wastewater
flows
can
vary
from
a
few
hundred
gallons
per
day
to
many
thousands
of
gallons
per
day.
4
Treated
Wastewater
Quality
Tables
3­
6
and
3­
7
show
flow
data
available
from
the
2000
TRI
and
PCS.
Tables
3­
8,
3­
9,
and
3­
10
show
the
top
pollutants
reported
to
the
2000
TRI
and
PCS,
based
on
TWPE
and
total
pounds
reported.
Draft,
4/
12/
05;
subject
to
change
Page
6
of
17
Table
3­
6.
Discharges
Reported
to
TRIReleases2000
for
One
Facility*

SIC
Code
Discharge
Status
Pounds
to
Stream
TWPE
8063
D
750
365
8063
I
736
358
Note:
Only
one
facility
reported
water
discharges
to
the
2000
TRI.

Table
3­
7.
Discharges
Reported
to
PCSLoads2000
SIC
Pounds
to
Stream
TWPE
8062
20,458
4.51
8063
4,891
0.36
Table
3­
8.
Top
Pollutant
from
TRIReleases2000
Data*

SIC
Code
Chemical
TWPE
%
of
Total
SIC
TWPE
Pounds
%
of
Total
SIC
Pounds
8063
Chlorine
724
1
1,486
1
*
Note:
Only
one
facility
reported
water
discharges
to
the
2000
TRI.

Table
3­
9.
Top
Pollutants
from
PCSLoads2000
by
TWPE
SIC
Parameter
TWPE
%
of
Total
SIC
TWPE
8062
Chlorine,
Total
Residual
4.42
98%

Total
for
SIC
Code
8062
4.51
8063
Nitrogen,
Ammonia
Total
(
As
n)
0.14
38%

8063
Copper,
Total
(
As
Cu)
0.13
37%

8063
Zinc,
Total
(
As
Zn)
0.053
15%

8063
Nitrogen,
Nitrate
Total
(
As
n)
0.034
10%

Total
for
SIC
Code
8063
0.36
Draft,
4/
12/
05;
subject
to
change
Page
7
of
17
Table
3­
10.
Top
Pollutants
from
PCSLoads2000
by
Pounds
SIC
Parameter
Pounds
%
of
Total
SIC
Pounds
8062
Solids,
Total
Dissolved­
180
Deg.
c
5,730.92
28%

8062
Oxygen
Demand,
Chem.
(
Low
Level)
(
COD)
4,960.54
24%

8062
Solids,
Total
Dissolved
4,824.45
24%

8062
Solids,
Total
Suspended
3,081.54
15%

Total
for
SIC
Code
8062
20,458.27
8063
Solids,
Total
Suspended
1,083.09
22%

8063
Bod,
5­
day
(
20
Deg.
C)
639.36
13%

8063
Nitrogen,
Nitrate
Total
(
As
N)
544.63
11%

8063
Oil
&
Grease
Freon
Extr­
Grav
Meth
114.85
2%

8063
Phosphorus,
Total
(
As
P)
94.92
2%

8063
Nitrogen,
Ammonia
Total
(
As
N)
74.24
2%

Total
for
SIC
Code
8063
4,891.19
Tables
3­
11
and
3­
12
list
the
facilities
reporting
to
the
2000
TRI
and
PCS.

Table
3­
11.
List
of
Facilities
in
TRIReleases2000
SIC
Facility
Name
City
State
Discharge
Type
TWPE
8062
U.
S.
VA
Togus
VA
Med/
Regional
Office
Center
Togus
ME
No
Disch
8063
VA
Hudson
Valley
Health
Care
System
Castle
Point
Castle
Point
NY
??

8063
VA
Hudson
Valley
Health
Care
System
Montrose
Camp
Montrose
NY
Direct
365
8063
VA
Hudson
Valley
Health
Care
System
Montrose
Camp
Montrose
NY
Indirect
358
Draft,
4/
12/
05;
subject
to
change
Page
8
of
17
Table
3­
12.
List
of
Facilities
in
PCSLoads2000
SIC
Facility
Name
City
TWPE
NPID
Major/
Minor
8062
Castaner
General
Hospital
Lares
4.4
PR0025283
Major
8062
U.
s.
m.
c.
Development
&
Education
Quantico
0.069
VA0002151
Major
8063
Marlboro
Psychiatric
Hosp
Stp
Marlboro
0.36
NJ0022586
Major
8062
Caritas
Southwood
Hospital
Norfolk
0.364039
MA0102288
Minor
8062
Clara
Maass
Medical
Center
Belleville
6.72E­
02
NJ0032280
Minor
8062
Diagnostic
&
Treatment
Center
Naguabo
194.5359
PR0023183
Minor
8062
Franciscan
Medical
Center
Dayton
OH0127019
Minor
8062
Gibson
General
Hospital
Princeton
IN0056626
Minor
8062
Harbor
Hospital
Center
Baltimore
0
MD0064475
Minor
8062
Huron
Memorial
Hosp
Bad
Axe
7.916473
MI0037508
Minor
8062
Jefferson
Co
Medical
Ctr
Plt
Louisville
1.912969
KY0053783
Minor
8062
Miami
Valley
Hospital
Dayton
OH0115762
Minor
8062
Montana
Behavioral
Health
Inc.
Butte
24.86648
MT0021431
Minor
8062
Morton
Plant
Health
System
Clearwater
5.862706
FL0168831
Minor
8062
Owensboro
Mercy
Health
System
Owensboro
KY0100498
Minor
8062
Quality
Health
Service
of
Pr
Ponce
327.0937
PR0025895
Minor
8062
Red
Bird
Mission
Hospital
Queendale
0.176617
KY0026000
Minor
8062
Ri
Mhrh
Facilities
&
Maint.
Cranston
8.68E­
02
RI0020176
Minor
8062
Rockford
Memorial
Hospital
Rockford
0.572972
IL0073580
Minor
8062
Union
Co
Methodist
Hospital
Morganfield
2.90E­
02
KY0022993
Minor
8062
Usvah
­
Ft
Lyon
(
E)
Fort
Lyon
70.80236
CO0020249
Minor
8062
Veterans
Administration
Medica
Togus
10.07631
ME0000736
Minor
8062
Zambarano
Dr.
U.
E.
Mem.
Hosp.
Wallum
Lake
209.9387
RI0100129
Minor
8063
Brook
Lane
Psychiatric
WWTP
Hagerstown
MD0053198
Minor
8063
Carrier
Foundation
STP
Belle
Mead
0.174901
NJ0023663
Minor
8063
Choate
Mental
Health&
dev
Ctr
Anna
0.205647
IL0070033
Minor
8063
Greystone
Park
Psych
Hospital
Greystone
Park
0.271731
NJ0026689
Minor
8063
Hastings
Regional
Center
Hastings
NE0125016
Minor
8063
Logansport
State
Hospital
Logansport
0
IN0038521
Minor
8063
Muscatatuck
State
Dev.
Center
Butlerville
0.111432
IN0038539
Minor
8069
McDowell
Appalachian
Reg
Hosp
McDowell
6.10E­
02
KY0085791
Minor
Draft,
4/
12/
05;
subject
to
change
SIC
Facility
Name
City
TWPE
NPID
Major/
Minor
Page
9
of
17
8069
No
Princeton
Developmental
Ctr
Skillman
2.108294
NJ0022390
Minor
8069
Nursing
&
Personal
Care
Home
Bruce
2.150472
MS0032051
Minor
8069
Woodward
Resource
Center
Woodward
IA0063916
Minor
On­
Site
Wastewater
Treatment/
Pretreatment
EPA's
1989
PDS
states
that
hospital
wastewater
is
primarily
domestic
in
nature.
Although
some
additional
pollutants
are
added
to
the
wastewater
(
e.
g.,
solvents,
metals,
and
chemical
products),
they
are
generally
treated
at
the
point
of
generation
or
mixed
with
other
wastewaters
and
diluted
prior
to
discharge.
As
a
result,
effluent
concentrations
for
hospitals
are
very
similar
to
domestic
wastewater
without
the
need
for
a
centralized
on­
site
wastewater
treatment
system.
The
PDS
did
not
address
the
concern
of
pharmaceuticals
in
wastewater,
which
is
discussed
in
the
Raw
Wastewater
Section
of
this
report.

Pretreatment
at
hospitals
may
consist
of
the
following
technologies:

Solvent
recycling
and
reclamation
(
through
distillation)
for
xylene
and
ethanol;

Dilution
or
decay
of
radioactive
materials;

Silver
recovery
for
X­
ray
wastes;

Acid
neutralization
(
through
use
of
limestone)
in
the
laboratories;

Grease
traps
in
the
cafeteria
and
kitchen;
and

Plaster
recovery
in
the
room
where
casts
are
fitted.

A
majority
of
healthcare
facilities
discharge
wastewater
to
POTWs.
These
facilities
complete
discharge
monitoring
reports
(
DMR)
according
to
their
state,
tribal
and
local
water
discharge
guidelines,
but
there
is
not
a
centralized
data
collection
system
for
the
information.

Hospitals
that
discharge
directly
and
have
greater
than
1,000
occupied
beds
are
covered
by
40
CFR
Part
460.
They
generally
have
on­
site
biological
treatment
in
addition
to
the
pretreatment
listed
above.
The
most
common
type
of
biological
treatment
is
the
trickling
filter.
Other
technologies
in
use
include
activated
sludge
and
aerated
lagoons.

Multimedia
Environmental
Releases
Hospitals
generate
infectious
(
red
bag
or
biohazard)
waste,
hazardous
waste,
solid
waste,
and
volatile
air
emissions.
OSHA
and
RCRA
regulate
the
largest
hospital
waste
stream:
solid
and
hazardous
waste.
OECA's
draft
2004
Healthcare
Sector
Notebook
provides
detailed
information
on
multimedia
releases
from
hospitals.
Draft,
4/
12/
05;
subject
to
change
Page
10
of
17
8
10
12
14
16
1980
1984
1988
1992
1996
2000
Source:
CMS,
Office
of
the
Actuary,
National
Health
Statistics
Group.
Calendar
Years
Percent
of
GDP
Period
of
accelerated
growth
Period
of
stabilization
Industry
Trends
and
Trade
Associations
The
following
is
a
summary
of
information
on
Economic
Trends
from
OECA's
draft
2004
Healthcare
Sector
Notebook
(
Section
6.1).

Healthcare
Expenditures
as
a
Share
of
the
Gross
Domestic
Product
According
to
the
Centers
for
Medicare
and
Medicaid
Services
(
CMS),
the
healthcare
industry
currently
accounts
for
approximately
13
percent
of
the
Gross
Domestic
Product
(
GDP)
of
the
United
States.
By
the
year
2010,
healthcare
expenditures
are
expected
to
increase
to
17
percent
of
the
GDP.
As
shown
in
Figure
6­
1
below,
the
growth
of
spending
has
stabilized
since
1993
because
medical
prices
averaged
only
a
2.9
percent
annual
growth
between
1993
and
1999.
This
growth
is
relatively
minimal
compared
to
the
11.2
percent
average
annual
growth
between
1980
and
1982,
and
the
6
percent
average
annual
growth
between
1982
and
1993.
Another
factor
to
consider
in
this
stabilization
is
the
growth
in
the
complementary
care
industry
(
i.
e.,
nonallopathic
healthcare
services),
which
was
reported
to
be
approximately
42
billion
dollars
in
the
mid
1990'
s.

Figure
6­
1:
National
Healthcare
Expenditures
as
a
Share
of
the
GPD
Source:
June
2002
Centers
for
Medicare
and
Medicaid
Services
Report.
Draft,
4/
12/
05;
subject
to
change
Page
11
of
17
Healthcare
Spending
In
calendar
year
2000,
the
United
States
spent
$
1.3
trillion
on
healthcare
(
NAICS
code
62).
Most
of
this
money
was
split
between
hospital
care
(
32
percent)
and
physician
and
clinical
services
(
22
percent).

As
shown
in
Figure
6­
2
below,
prescription
drugs
accounted
for
9
percent
of
the
total
healthcare
spending
in
2000.
According
to
the
CMS,
between
1990
and
2000,
prescription
drug
spending
increased
by
more
than
3
percent
while
the
amount
of
money
spent
at
hospitals
decreased
by
4.8
percent.
Draft,
4/
12/
05;
subject
to
change
Page
12
of
17
Other
Spending
24%

Nursing
Home
Care
7%
Prescription
Drugs
9%
Program
Administration
and
Net
Cost
6%
Hospital
Care
32%

Physician
and
Clinical
Services
22%

Note:
Other
spending
includes
dentist
services,
other
professional
services,
home
health,
durable
medical
products,
over­
the­
counter
medicines
and
sundries,
public
health,
research
and
construction.

Source:
CMS,
Office
of
the
Actuary,
National
Health
Statistics
Group.
Total
Health
Spending
=
$
1.3
Trillion
*
Figure
6­
2:
The
Nation's
Health
Dollar,
CY
2000
Source:
June
2002
Centers
for
Medicare
and
Medicaid
Services
Report.

Inpatient
Care
Versus
Outpatient
Care
The
implementation
of
Medicare
prospective
payment
systems
and
the
increased
enrollment
into
various
managed
care
programs,
has
been
a
contributing
factor
in
the
decreased
length
of
patient
hospital
stays
since
1980.
According
to
the
CMS,
in
1980,
the
average
length
of
a
hospital
stay
was
between
7
and
8
days.
In
1999,
it
was
approximately
2
to
3
days.
These
factors,
along
with
advances
in
technology
and
pharmaceuticals
available
to
treat
diseases,
have
also
led
to
a
decline
in
the
number
of
inpatient
hospital
procedures.
As
shown
in
Figure
6­
3
below,
inpatient
care
accounted
for
87
percent
of
hospital
procedures
in
1980.
In
2000,
that
number
was
down
to
63
percent.
Draft,
4/
12/
05;
subject
to
change
Page
13
of
17
87
76
63
13
24
37
0
20
40
60
80
100
1980
1990
2000
Inpatient
Outpatient
Note:
Community
hospitals
are
all
non­
federal,
short­
term
general,
and
special
hospitals
whose
activities
are
available
to
the
public.

Source:
CMS,
Office
of
the
Actuary,
National
Health
Statistics
Group.
Percent
Figure
6­
3:
Community
Hospital
Expenditures:
Inpatient
and
Outpatient
Shares
for
All
Payers
Source:
June
2002
Centers
for
Medicare
and
Medicaid
Services
Report.
Draft,
4/
12/
05;
subject
to
change
Page
14
of
17
Pollution
Prevention
In
1998,
EPA
entered
into
a
MOU
with
the
American
Hospital
Association
which
calls
for:
(
1)
virtually
eliminating
mercury­
containing
waste
by
2005;
(
2)
reducing
the
overall
volume
of
all
environmental
releases
by
33
percent
by
2005
and
by
50
percent
by
2010;
and
(
3)
identifying
hazardous
substances
for
pollution
prevention
and
waste
reduction
opportunities,
including
hazardous
chemicals
and
persistent,
bioaccumulative,
and
toxic
pollutants.
The
H@
E
effort
educates
health
care
professionals
about
pollution
prevention
opportunities
in
hospitals
and
health
care
systems.
Through
activities,
such
as
the
development
of
best
practices,
model
plans
for
total
waste
management,
resource
directories,
and
case
studies,
the
project
hopes
to
provide
hospitals
and
health
care
systems
with
enhanced
tools
for
minimizing
the
volumes
of
waste
generated
and
the
use
of
persistent,
bioaccumulative,
and
toxic
chemicals.
Such
reductions
are
beneficial
to
the
environment
and
health
of
our
communities.
Furthermore,
improved
waste
management
practices
will
reduce
the
waste
disposal
costs
incurred
by
the
health
care
industry.
For
more
information
see
the
web
site
for
Hospitals
for
a
Healthy
Environment
(
H2E)
at
http://
www.
h2e­
online.
org/
and
http://
www.
hercenter.
org/

The
web
site
for
Sustainable
Hospitals,
http://
www.
sustainable
hospitals.
org/
provides
technical
support
to
the
healthcare
industry
for
selecting
products
and
work
practices
that
reduce
occupational
and
environmental
hazards,
maintain
quality
patient
care,
and
contain
costs.
This
site
focuses
on
mercury­
free
products
and
other
pollution
prevention
opportunities.

The
web
site
for
the
American
Society
for
Healthcare
Environmental
Services
(
ASHES),
http://
www.
ashes.
org/,
provides
information
on
environmental
excellence
and
advances
in
healthcare
environmental
services,
textile
care
professions
and
related
disciplines.

There
are
also
a
variety
of
resources
on
water
conservation
available
to
the
healthcare
industry.
Many
of
these
resources
are
presented
on
the
Hospitals
for
a
Healthy
Environment
web
page
for
water
conservation
fact
sheets
(
http://
198.151.15.185/
tools/
waterfct.
htm).
Several
of
these
resources
are
described
below
in
additional
detail:

The
document
titled
"
Water
Conservation
Checklist:
Hospitals/
Medical
Facilities;
Every
Drop
Counts!"
published
by
the
North
Carolina
Department
of
Environment
and
Natural
Resources
Division
of
Pollution
Prevention
and
Environmental
Assistance
contains
a
list
of
water
use
areas
throughout
a
hospital
and
ways
to
reduce
water
consumption
in
each
of
those
areas.
This
document
can
be
found
at:
http://
www.
p2pays.
org/
ref/
23/
22006.
pdf.

Based
on
this
document
water
use
in
hospitals
can
be
reduced
considerably
as
shown
in
the
following
table
(
also
discussed
in
Section
2):
Draft,
4/
12/
05;
subject
to
change
Page
15
of
17
Types
of
Water
Uses
Average
Water
Use
(%
of
total)
Potential
Savings
(%
of
total)

Cooling
53
32
Domestic
24
10
Cleaning
10
9
Kitchen
5
­­

Process
4
­­

Other
4
­­

TOTALS
100%
51%

139,214
gpd
71,000
gpd
Source:
ICI
Conservation
in
the
Tri­
County
Area
of
the
Southwest
Florida
Water
Management
District
(
SWFWMD).
SWFWMD,
November
1997.

The
New
Hampshire
Department
of
Environmental
Services
developed
an
environmental
fact
sheet
titled
"
Water
Efficiency
Practices
for
Health
Care
Facilities"
which
also
presents
practices
by
water
use
area.
This
document
can
be
found
at:
http://
www.
des.
state.
nh.
us/
factsheets/
ws/
ws­
26­
14.
htm

Southwest
Florida
Water
Management
District
(
SWFWMD)
also
has
a
similar
factsheet
titled
"
Water
Conservation
@
Work:
Hospitals."
This
document
can
be
found
at:
http://
www.
swfwmd.
state.
fl.
us/
watercon/
waterwork/
checkhospital.
htm.

Healthcare
Purchasing
News
has
developed
a
Self
Study
Series
to
evaluate
environmentally
preferable
products.
One
item
in
this
series
discusses
microfiber
mops
which
use
less
water
than
conventional
cotton
mops.
The
article
discusses
the
economic,
environmental,
employee,
and
patient
benefits
of
using
microfiber
mops.
This
document
can
be
found
at:
http://
198.151.15.185/
pubs/
ShouldYouMicrofiber.
pdf

The
University
of
Wisconsin
Cooperative
Extension
developed
a
hospital
waste
reduction
checklist
which
includes
strategies
for
reducing
wastewater
discharges.
These
strategies
include
substitution
of
less
toxic
materials,
procedures
for
moving
or
cleaning
sewer
lines,
traps,
or
sumps,
and
chemical
storage
and
disposal
options.
This
document
can
be
found
at:
http://
www.
uwex.
edu/
shwec/
Pubs/
pdf/
425­
9602.
pdf.

The
Medical
Academic
and
Scientific
Community
Organization
prepared
a
pretreatment
manual
for
use
by
hospitals
to
help
solve
a
sewer
discharge
Draft,
4/
12/
05;
subject
to
change
5Williams,
Guy,
1997.
Mercury
Pollution
Prevention
in
Healthcare,
http://
www.
newmoa.
org/
prevention/
topichub/
22/
Mercury_
Pollution_
Prevention_
in_
Healthcare_
NWF.
htm.

Page
16
of
17
compliance
problem.
The
manual
outlines
the
elements
of
typical
source
reduction
programs
and
a
wastewater
pretreatment
strategy.
This
document
can
be
found
at:
http://
www.
masco.
org/
mercury/
pretreatment/
index.
html.

EPA's
Small
Business
Ombudsman
developed
a
fact
sheet
for
walk­
in
urgent
care
facilities
and
smaller
hospitals.
The
fact
sheet
explains
some
of
the
best
management
practices
(
BMPs)
related
to
toxic
chemicals
or
hazardous
materials
used
as
part
of
the
diagnostic,
treatment,
and
cleaning
processes
used
in
these
smaller
facilities.
This
document
can
be
found
at:
http://
www.
smallbiz­
enviroweb.
org/
html/
pdf/
BMP_
HealthCare­
4.
pdf.

EPA
Regions
1
and
2
have
on­
going
programs
to
provide
information
to
help
healthcare
facilities
reduce
environmental
impacts
of
their
operations
and
improve
their
understanding
of
and
compliance
with
environmental
regulations.
The
EPA
programs
also
help
facilities
realize
the
cost
savings
and
environmental
benefits
that
can
be
attained
through
improvements
in
recycling,
energy
efficiency
and
water
conservation.
More
information
can
be
found
at:
http://
www.
epa.
gov/
region1/
healthcare/
and
http://
www.
epa.
gov/
region2/
healthcare/.

With
respect
to
controlling
mercury
discharges,
healthcare
facilities
contain
mercury
in
some
medical
equipment
(
e.
g.
pressure
gauges,
thermometers),
laboratory
reagents,
and
common
facility
items
(
e.
g.,
fluorescent
lights,
thermostats,
cleaning
supplies).
Some
hospitals
approached
the
problem
of
mercury
use
within
their
facilities
by
following
some
basic
steps,
including:

Conducting
inventories
to
identify
sources
of
mercury
within
their
facilities;

Making
recommendations
to
existing
hazardous
waste
and
safety
committees
and
the
administration
for
reducing
or
eliminating
these
sources;

Instituting
immediate
steps
for
mercury
reduction;
and,

Devising
long­
term
goals
for
the
virtual
elimination
of
mercury
from
their
facilities.

An
example
of
this
approach
was
documented
at
two
major
Detroit
hospitals
that
instituted
mercury
pollution
prevention
plans.
Wastewater
sampling
was
conducted
to
evaluated
their
performance.
Before
the
mercury
pollution
prevention
program,
mercury
measures
at
these
sites
were
in
the
range
of
0.28
ppb
to
0.96
ppb.
After
the
program
was
instituted,
these
figures
dropped
to
0.09
ppb
to
0.15
ppb.
5
Draft,
4/
12/
05;
subject
to
change
Page
17
of
17
References
Centers
for
Medicare
and
Medicaid
Services
web
page.
http://
www.
cms.
hhs.
gov/
charts/
healthcaresystem/
chapter2.
asp,
accessed
10/
22/
04.

Hospitals
for
a
Healthy
Environment
web
page
for
water
conservation
fact
sheets
(
http://
198.151.15.185/
tools/
waterfct.
htm).

U.
S.
EPA.
Development
Document
for
Interim
Final
Effluent
Limitations,
Guidelines
and
Proposed
New
Source
Performance
Standards
for
the
Hospital
Point
Source
Category.
EPA
440/
1­
76/
060n,
EPA
Office
of
Water
and
Hazardous
Materials,
April
1976.

U.
S.
EPA.
Draft
version
of
Office
of
Compliance
Sector
Notebook
Project:
Profile
of
the
Healthcare
Industry.
EPA/
310­
R­
04­
001,
Office
of
Enforcement
and
Compliance
Assurance,
September
2004.
Publication
expected
in
2005.

U.
S.
EPA.
Preliminary
Data
Summary
for
the
Hospitals
Point
Source
Category.
EPA
440/
1­
89/
060­
n,
EPA
Office
of
Water
Regulations
and
Standards,
September
1989.

U.
S.
Geological
Survey,
Water­
Quality
Data
for
Pharmaceuticals,
Hormones,
and
Other
Organic
Wastewater
Contaminants
in
U.
S.
Streams,
1999­
2000.
Authors:
Kimberlee
K.
Barnes,
Dana
W.
Kolpin,
Michael
T.
Meyer,
E.
Michael
Thurman,
Edward
T.
Furlong,
Steven
D.
Zaugg,
and
Larry
B.
Barber.
Open­
File
Report
02­
94.
Available
at
http://
toxics.
usgs.
gov/
pubs/
OFR­
02­
94/.