General Guidelines

Training and Communications

• Develop a broad-based communications program throughout your facility to increase the general level of awareness to mercury's danger.
• Make sure that mercury's potentially adverse effects on the environment and human health are known, and train all personnel to look for ways to prevent mercury pollution.
• Train all personnel to follow a distinct protocol to prevent mercury from being disposed of in sharp containers or with infectious wastes.
• Vest the leadership responsibilities for your program in a person or committee that can act as a central point of contact for all departments.
• Involve your whole community in a voluntary "turn-in" program for mercury thermometers and batteries.

Good Housekeeping and Plant Management

• Make sure that equipment and operating procedures meet all standards for dealing with toxic substances.
• Monitor and maintain the working condition of equipment and learn the chemical ingredients of cleaners and solvents.
• Authorize the purchasing department to seek out mercury alternatives, to insist on mercury disclosures on all products coming into the facility, and to specify the use of recovered mercury in all products that do not yet have mercury-free alternatives.
• Establish adequate disposal routes and operating guidelines for mercury recovery and cleanups.

Audit Your Program and Facility Regularly

Conducting an Internal Mercury Audit

• Obtain management approval, resources, and manpower.
• Communicate audit process and goals to employees. Establish a "no blame" policy and solicit employee input.
• Set up an audit team to collect, interpret, and communicate audit findings.
• Conduct the audit with facility processes in normal operation and during work hours so that questions can be asked of employees.
• Recommend waste reduction and pollution prevention steps in line with the audit findings.

Steps of a Mercury Audit

Phase 1:

Understand the functions in your facility.

Phase one of the mercury audit involves going into the facility and developing a sound understanding of all the functional components and their interrelationships. It is worthwhile at this stage to solicit help from employees who are familiar with the day to day operations of the facility.

Step 1.: List unit functions.

Step 2.: Construct a function flow diagram

Step 3.: Construct a waste flow diagram.

Phase 2.:

Inventory possible sources of mercury.

Phase two of the mercury audit encompasses identifying and managing sources of mercury to best minimize and eliminate mercury waste. A key component of this stage is to insure employees have a strong understanding of mercury management practices in the facility.

Step 4.: Inventory mercury content of raw materials. Keep a quantitative record of mercury. Know how much mercury is in use or stored on the premises, and how much has been spilled, recovered, or discarded.

Step 5.: Identify mercury-containing materials and equipment. Their arrival in the facility, the history of their use, and final destination.

Step 6.: Identify other in-facility sources of potential mercury contamination.

Phase 3.:

Identify discharges and emissions from the facility that could become contaminated with mercury

Step 7.: Identify possible points of environmental release of mercury

Step 8.: Define best management practices to prevent release

Step 9.: Train employees to follow best management practices. Any reductions in use, spill incidents, or mercury recovered should be recorded.

Setting Attainable Goals

• Gradually replace the mercury in your facility with less harmful, nontoxic substitutes.
• Separate the mercury-containing waste from other materials slated for burning in medical waste incinerators and send this mercury to a licensed recycler. Liquid mercury, batteries, chemical compounds, and fluorescent lights are among the many products that can be safely recycled. Contact the recyclers in your area for collection procedures and costs.

Proper handling and disposal of mercury products

Mercury often ends up in the environment because of improper handling and disposal of chemicals that contain mercury. This can be prevented by complying with the following simple rules to ensure careful handling of mercury-containing products.

• Use mercury only in uncarpeted, well-ventilated areas. Provide troughs on smooth-surfaced tables and benches to collect mercury spills. Reserve a room for mercury uses only; restrict traffic in the area.
• Ask workers to remove all watches and other jewelry - especially gold jewelry, since mercury readily combines with gold - and have them wear a mercury vapor respirator and protective clothing: gloves, disposable gowns, and shoe coverings.
• Prohibit smoking, eating, and drinking in areas where mercury is used.
• Train all workers to understand the properties and hazards of mercury and to carry out safe handling procedures and specific policies related to mercury disposal.
• Clean and calibrate all mercury-containing equipment according to the manufacturer's recommended handling procedures and the formal procedures posted by the facility's communications or safety program supervisors.
• Encourage all laboratory workers to read the material safety data sheets provided with each solution to determine not only the contents but also safe handling practices. Laws require sellers of mercury to provide buyers with a material safety data sheet and to have the buyer sign a statement regarding proper use and disposal.
• Clearly label instruments containing mercury.
• Mercury must be stored to avoid contact with chlorine dioxide, nitric acid, nitrates, ethylene oxide, chlorine, and methylazide since violent reactions occur.
• Store in tightly closed containers in a cool, well-ventilated area away from acetylene, ammonia, and nickel.
• Make sure that every laboratory facility has a mercury spill cleanup kit on hand for accidental spills. Having the right equipment on hand will limit the amount of mercury released to the atmosphere.
• Make sure personnel are familiar with the proper cleanup procedures for handling a spill involving mercury.
• Do not place mercury-containing materials in waste receptacles for biohazardous waste because mercury will be released to the atmosphere when the biohazardous waste is incinerated.
• When working with mercury solutions, make sure you are familiar with the laboratory's policies on proper disposal practices for these solutions.
• Follow proper procedures when cleaning or refilling instruments that contain mercury. Instrument cleaning, or refilling should take place in a well-ventilated area and, if possible, over a tray to contain any spills.
• Mercury should be handled in areas without tile flooring or carpeting to facilitate cleanup in the event of a spill. To minimize the risk of an accidental spill, never handle mercury over a sink.

Selecting alternative mercury-free products

Mercury-free product alternatives are available throughout the medical facility - in housekeeping and engineering, in patient areas, and in clinical laboratories. See that the decision makers in your community are guided by the best available technical, economic, and environmental assessments of mercury products and substitutes.

Encourage your facility to buy products that do not contain mercury. There are several products on the market that can be used as substitutes for mercury. By ordering mercury-free products, hospitals, nursing homes, clinics, and laboratories will encourage manufacturers to provide ecologically sound products. Medical professionals must ultimately balance the advantages of selecting products that contain mercury against the risks that mercury poses to the environment. The following table highlights some alternatives.

Products	Alternatives
Batteries, Defibrillators, Hearing aids, Pacemakers	Lithium, zinc-air, alkaline
Dental amalgams	Gold, ceramics, porcelain and polymers
Electrical equipment	Fiber optics, solid state devices, mechanical switches
Esophageal devices, Cantor tubes, Miller Abbot tubes	Tungsten tubing (tungsten forweight)
Lamps, Fluorescent, High intensity, and Ultraviolet	Ordinary glow lights; low sodium vapor tubes (yellow); opticals, high-energy, long-lasting lights
Sphygmomanometers	Electronic vacuum gage, expansion, aneroid
Thermometers	Electronic (digital), expansion, aneroid

 

Chemicals	Alternatives
Mercury (II) chloride, Zenker's solution, Histological fixatives	Zinc formalin, Freeze drying
Staining solutions and preservatives: Thimerosal, Immu-sal, Carbol-fuchin stain, Gram iodine stain, Phenolic mercuric, Acetate, Alum, Hematoxylin "Solution A"	Replace with a variety of chemical compounds
Mercury (II) oxide	Copper catalyst
Mercury oxide	None identified
Mercury (II) chloride	Magnesium chloride/sulfuric acid
Mercury (II) sulfate	Silver nitrate/potassium, sulfate/chromium-(III) sulfate
Mercury iodide	Phenate method
Mercury nitrate (for corrosion of copper alloys)	Ammonia/copper sulfate
Colorimetric chloride analysis	Ion-selective electrode method

• There is no longer any need to manufacture mercury oxide and silver oxide batteries; the former are 25 to 35 % mercury by weight, the latter are 1 % mercury. Use alkaline, zinc-air, and lithium batteries instead. Collect all batteries containing mercury for special disposal or recycling. Any products that contain batteries should be collected for recycling.
• Dental amalgams do not pose a health risk. However, their disposal is a potential source of mercury to the environment. Separate collection and recycling are recommended along with predetermined operating procedures and spill cleanup measures.
• No effective substitute exists for high energy fluorescent tubes. Effective recycling systems should be in place. U.S. EPA's Green Lights Program is a good source of information about alternative applications in this area.
• Mercury thermometers and manometers should be phased out since good substitutes exist. Old medical instruments should be collected and recycled.
• Mercury's use in chemical analysis can be phased out in many cases, especially in Zenker's solution and histological fixatives. Purchasing contractors and users should ask to see material safety data sheets in all cases. Some substitutes, such as copper, tin, and chromium compounds also have some risk, but less than the risk associated with mercury. The total use of mercury remaining in such products as antiseptics, diuretics, a nd skin preparations is minimal; mercury should not be used in skin lightening soaps and creams.

Recycling Mercury-containing Products

Although using mercury-free products is the preferred method of source reduction, recycling of mercury is sometimes an alternative. Recycling dental amalgams is very successful and can substantially reduce the amount of mercury that ends up at publicly owned treatment works. Large particles of amalgam can easily be removed using drain traps and screens, but fine dust passes through. Systems are available to treat rinse waters contaminated with old amalgam that is too fine to be caught in traps or on screens. Such systems are currently being evaluated by several U.S. organizations.

Several recycling companies accept mercury-containing waste. The companies differ in the type of mercury waste accepted and the transportation requirements. The mention of these companies does not constitute an endorsement by EPA, nor is this list exhaustive.

Instituting Procedures for Immediate Spill Cleanups

• If possible, evacuate the area after any mercury spill.
  Use a mercury vacuum sweeper to collect all mercury droplets - for smaller spills, aspirate the droplets with a plastic disposable syringe. Adhesive tape strips can also be used to collect mercury droplets. The amount of mercury spilled and the effectiveness and cost of the cleaning equipment should determine how you recover the mercury.
• Dispose of the mercury recovered from the spill in accordance with all federal, state, and local hazardous waste disposal regulations. All metallic mercury should be recycled.
• Use a chemical to coat the mercury droplets or to react with the mercury to form an amalgam. HgX or sulfur compounds will eliminate mercury vaporization and decontaminate the surfaces affected by the spill.
• Insist on area monitoring and include mercury testing in employee physical examinations. Although these steps may not be necessary in the case of very small spills, testing mercury levels from time to time is the only way to ensure environmentally safe levels of mercury vapor after an incident or in high use areas.
• Arrange for professional hazardous waste handlers to manage any large mercury spills and to audit high use areas from time to time.
• Document each mercury spill incident.

Case Studies

St. Mary's Medical Center (Dulluth, Minnesota)

Build Support

St. Mary's Medical Center is a 326-bed hospital located in Duluth, Minnesota. To begin the mercury reduction project, WLSSD staff met with hospital management to ensure their interest and commitment to the project. Once support was assured, an existing team of hospital employees (who had already implemented an excellent solid waste reduction program) worked with WLSSD staff on the project.

Form team

The team was made up of representatives from different areas of the hospital. This was important because of the wide variety of different activities performed in a hospital. Representatives from maintenance and purchasing were particularly important. The maintenance staff has knowledge of the inner workings of the hospital which is especially helpful when conducting monitoring. Toxics reduction projects often require that changes be made in the use of certain products. For this reason, a representative from the purchasing department is essential to the team.

Perform an Assessment

As a first step in the project, the mercury reduction team completed a survey on mercury use provided by WLSSD. The survey disclosed that St. Mary's had already replaced some mercury containing items, such as thermometers and blood pressure cuffs, with alternative electronic devices. In addition, mercuric chloride, a common reagent used in pathology labs, was being captured and handled as hazardous waste instead of being flushed to the wastewater treatment plant.

A wastewater monitoring plan was then developed to try to pinpoint mercury sources within the hospital. Often several discharge points may enter the sanitary sewer system from an older building like a hospital. Meeting with maintenance staff to review old blueprints is essential before beginning a monitoring program. Particularly in facilities that have undergone expansion, the use of dye tablets may be needed to verify source information.

Monitoring results found mercury concentrations varying from 0.3 ppb to 1.2 ppb. The monitoring also identified the days on which mercury concentrations were high, and where it came from in the hospital. In this case, the monitoring results were valuable in educating the reduction team. The team felt they had already solved their mercury problem, and did'nt anticipate additional discharges. Once they saw the numbers, however, a "can do" attitude quickly developed.

Take Action

At this point, the mercury in the wastewater appears to be coming from the hospital laboratories and from the laundry services. Reagents and bleach are the suspected sources. These products are being investigated and where possible, alternatives will be substituted. Historic sources are also under investigation. In older buildings where there has been high mercury use in the past, items such as broken thermometers may have been disposed of down the drain. The mercury accumulates in waste traps and is discharged in small amounts each time water is used. Traps in nursing stations and in the labs are being cleaned as part of the reduction effort.

Document Share Results

WLSSD staff will continue to work with St. Mary's on future reduction efforts. New information about sources of mercury and additional wastewater monitoring results are shared with the team in regular meetings. Reductions in mercury discharge will continue to be documented and shared.

University of Michigan Health System (Ann Arbor, Michigan)

Overview of Pollution Prevention Efforts

Pollution prevention (P2) is an important goal at the University of Michigan and the University of Michigan Health System. We are firmly committed to the waste minimization efforts, energy conservation and the efficient and responsible use of resources. Many departments across campus are involved in these efforts. We believe that by working together, we can enhance the environment in which we live and work.

The University of Michigan Health System initiated a mercury reduction program to systematically remove mercury-containing equipment from this facilities. This has mitigated the potential for mercury to enter the environment by reducing the possibility of mercury escaping during accidental equipment breakage and traditional disposal methods. As of May 1996, 440 pounds of mercury was removed from blood pressure cuffs, thermometers and other equipment. The mercury collected was recycled.

Evaluating mercury containing reagents from laboratories, changing big specifications requiring mercury free equipment and providing mercury training and education for employees among other efforts are being performed. A fluorescent light tube recycling program has been implemented to avoid the potential release of mercury-containing powder inside the bulbs into the environment. Mercury reduction efforts are monitored by several quality control measures. The mercury reduction goals are evaluated periodically to assure continuos improvement and success.

Efforts are being coordinated cooperatively through the Safety Building and Environmental Management Department and the Department of Occupational Safety and Environmental Health. Some of these effort have been performed in settlement of an enforcement action brought by the Michigan Department of Environmental Quality.

University of Michigan Health System

• 872 beads - adult and pediatric
• Onsite clinics
• 8000 employees
• 37 clinics housed in 25 buildings
• 15 acquired practices
• These numbers are always increasing

History

1992

Discussions began regarding replacement of Hg sphygmomanometers
- Initiated by incidence of Hg spills
- Concerns for exposure potential
- Environmental concerns for Hg in Great Lakes Program

1995

Hospital Hg reduction efforts became a Supplemental Environmental project (SEP) performed in settlement of an enforcement action by the MDNR.

Mercury Identification

• Terrace Brochure
• Hg Pollution Prevention in Michigan
• Discussion with other health care facilities
• Surveys
• Targeted sources
• Review material Services inventory for Hg equipment

Communication

• Written correspondence to specific groups based on identification efforts
• Written correspondence to inform staff about Hg reduction efforts
  - asked for voluntary evaluation of Hg containing equipment & products
• Speaking of Safety Newsletter

Case Studies

• Sphyg fell off wall at the clinic
• Sphyg fell of wall in the cast room
• Blood bank calibration sphygs
• Pathology fixatives

Accomplishments

• 660 total Hg sphygmomanometers were replace with aneroid units
• Approximately 440 lbs Hg sent for recycling
• Eliminate B5 reagent from Pathology
• Eliminated Hg thermometers from Material Services inventory
  - Cost effective
  - More convenient
  - Less hazardous
  
• Eliminated Hg filled esophageal devices
• Using only thimerosol free products
• Pharmacy is not dispensing Hg for Miller-Abbott tubes
• New baby kits do not contain Hg thermometers
• Using only Hg free batteries
• Change language on new equipment acquisitions requiring Hg free if possible
• Eliminated most calibration sphygs
• Recently implemented a fluorescent light tube recycling program
• Some of the project accomplishments were performed in settlement of an enforcement action by the MDNR

Current Efforts/Quality Assurance Measures

• Training the offsite clinics as part of the Hazard Communication Program
• Collecting dental Hg amalgams and disposing as hazardous waste
• Testing incinerator ash prior to disposal to assure compliant Hg levels
• Sampling selected sink traps
• Hazard Surveillance Rounds
• Waste disposal - monitor billing reports
• Collecting "discovered" left over equipment

Future Goals

• Use a substitute for Hg amalgams
• Replace barometer with Hg free alternative
• Collect Hg at the newly acquired locations
• Perform additional Hg sampling
• Conduct feasibility study for Hg containing maintenance equipment replacement

Alpena General Hospital (Alpena, Michigan)

Alpena General began instituting mercury pollution prevention measures approximately eight years ago by adopting a purchasing a policy that eliminated mercury-containing items such as thermometers and sphygmomanometeres. In addition, the institution purchases only mercury-free batteries from suppliers, and items such as thimerosal-free saline solution are being used.

Alpena's laboratory conducted its own study on mercury in solvents to determine where mercury was originating. It was necessary to follow this procedure because manufacturers might not list the solvents' ingredients if the formula is under copyright protection. Material Safety Data Sheets might not list mercury in a solvent if amounts are too small or if the formula is protected. After completing roughly 350 analyses, Alpena contacted their suppliers and requested that mercury-free solvents be supplied. Analyses were completed by examining lab results and testing and cleaning drain traps. This last method is currently used as a spot-check system to isolate any mercury discharges. Wastes generated within the institution are separated, and disposed of according regulations. The institution has a procedure policy on spill prevention and management in case of mercury spills or leakages.

Alpena provides an ongoing educational and advisement program with those departments directly involved in mercury pollution prevention, such as advising the nursing department to check for materials that may contain mercury like thimerosal-containing saline solution. The plant superintendent has the responsibility of seeing that all mercury pollution prevention measures are being instituted, as well as cleaning the drain traps and testing for mercury residues.

Butterworth Hospital (Grand Rapids, Michigan)

Hospital:  529 beds

Goal:  Eliminate 300 lbs of elemental mercury

Contact:  Dan Stickles (616) 391-1801

Butterworth Hospital recently hired a local environmental consultant to devise a disposal plan for mercury that will be safe and economical for the entire hospital. In addition, Stock Environmental will develop a spill response plan that is in accordance with the Occupational Safety and Health Administration and the Joint Commission for the Accreditation of Health care Institutions, as well as offer training on spill response, prevention and management. Educational materials about mercury, specifically the Terrene Institute brochure produced by the Health Care Sector Subgroup, have been distributed to all hospital departments, administrative personnel, and regional facilities.

Butterworth Hospital has made a commitment to reach mercury-free status, and is attempting to reach that goal by instituting a purchasing department policy stating unless there is no suitable, mercury-free alternative, no mercury-containing devices are to be purchased. This list includes thermometers, sphygmomameters, esophageal dilators and batteries. Administrative approval has been given to replace all sphygmomameters currently in use with anaeroid devices, which will speed the transition to mercury-free status. In addition, Butterworth Hospital has made a commitment to discontinue sending mercury-containing devices overseas in their humanitarian products, and is currently in the process of discontinuing sending mercury thermometers home with new mothers in the obstetrics department.

Last year two new buildings that are part of Butterworth Hospital opened. Administrative groups managing these buildings have committed them to be mercury-free. Applying the Butterworth Hospital purchasing policy concerning mercury has been difficult with office space being rented to private doctors. The challenge now lies with making the buildings 100% mercury free, in both public and private doctor facilities. The purchasing policies implemented at Butterworth has allowed the facility to explore options of recycling mercury at mercury refining centers, and look to minimize hazardous waste disposal costs. For example, fluorescent tubes are now being recycled using a mobile collection unit.

Genesys Health System (Flint, Michigan)

Group of 4 hospitals, 750 physicians

A formal policy that replaces mercury-containing thermometers and sphygmomameters with electrical devices where medically acceptable and feasible has been instituted by Genesys Health System, as well as a purchasing policy that allows only mercury-free items to be purchased. Also in effect is a goal to eliminate clinical lab procedures that contain mercury. Currently, the health system laboratory removes mercury from the waste stream by precipitating and filtering out the material. The wastes are then separated and mercury waste recycle by reusing the material on site, or sending it to a mercury recovering company.

Genesys Health System has devised programs to train its employees on spill response and spill prevention and management that properly clean up mercury spills in accordance with applicable regulations, as well as to evaluate fluorescent tubing. An Environmental Control Advisory Committee within Genesys has formed an Environmental Control Policy stressing reduction of waste into the environment. The committee has also provided education materials concerning mercury pollution prevention to staff people.

Henry Ford Hospital (Detroit, Michigan)

Perhaps one of the most important aspects Henry Ford stresses in environmental matters, including mercury pollution prevention, is education. Educational at the clinical, administrative, and emergency planning levels focus on being environmentally responsible while at the same time meeting the community health needs. The alternatives to mercury-containing items must be clinically viable in order to be used, and a product that is not environmentally sound will not be purchased. First-response teams are able to minimize patient discomfort and maximize their care, tuning into the emotional element of pollution prevention.

Thermometers and esophageal dilators containing mercury have been or are being replaced with mercury-free alternatives. Blood pressure cuffs that contain mercury are in the process of being replaced with aneroid devices. While there are still devices that contain mercury located and used at the hospital, the safe storage of these devices is an important consideration for Henry Ford.

Henry Ford's laboratory does not release any chemicals down its drains, thereby minimizing chemical on their laboratory sites, buying only the necessary amounts of chemicals needed for their procedures. Henry Ford has removed their old drains and catch points and replaced them with up-to-date systems. The sediment within the pipes are cleaned systematically, and the sludge is treated as hazardous waste.

Bronson Methodist Hospital (Kalamazoo, Michigan)

Capacity: 414 beds

Educating the staff at Bronson Methodist Hospital, including the proper use of mercury-containing devices, eliminates breakages, and the proper procedures to follow in case of a breakage, has helped to decrease mercury from its system. In addition, instituting a purchasing policy to ban the purchase of mercury-containing items, if an alternative exists, has been formalized. A company that purchases the mercury-containing devices from the hospital has been located. Batteries that contain mercury are in the process of being phase out and replaced with mercury-free batteries. Sphygmomanometers containing mercury are being replaced with aneroid devices throughout the facility.

Bronson is also working in conjunction with Kalamazoo's waste-water department to remain below their mercury discharge detection limit of 0.5 parts per billion, and to further decrease their concentration to 0.3 parts per billion. The hospital has monitored its systems, located areas to clean up, and has since decreased its emissions significantly.

Bronson's work in mercury was recognized by Kalamazoo with the first annual Industry Excellence Award for having the best mercury minimization results of all the significant industrial users discharging to the Reclamation Plant.

Quest Diagnostics, Incorporated (Wyoming, Michigan)

Contact:   Neil Findley, (616) 538-6700

Quest Diagnostics Incorporated has instituted a wide range of mercury pollution prevention measures to meet the city's strict water guidelines of 0.5 ppb. Initially, Quest Diagnostics isolated manufacturer contributions of mercury within its waste water system by testing its list of reagents for mercury content. Manufacturer might not list mercury in their Material Safety Data Sheets because the amount is so small; therefore Quest Diagnostics did not know the sources of mercury until test results were finalized. Once the sources where determined, a formally mercury reduction policy to continually decrease mercury in its effluent, as well as evaluating mercury content of the reagents it purchases, was instituted. If the vendor cannot provide mercury-free reagents, Quest Diagnostics will locate a vendor that does or, where possible, change methodologies to processes that do not involve mercury; if the purchase of mercury-free reagents is not possible, waste is segregated. This policy was submitted by the laboratory to the city, and is updated quarterly with the report sent to Wyoming semiannually.

In addition, Quest Diagnostics separates their wastes and packages them to send to the correct hazardous waste facility. Test spickets are inserted into 100% of all laboratory drains to regularly test the material being released. If the tests are above the limits, the drain traps are replaced, the material is handled as hazardous waste, and investigation begins as to the source of the contamination.

The staff and employees of Quest Diagnostics Incorporated service 3,000 patients per day. Regular updates on mercury reduction are shared with employees at quarterly meetings. This keeps them informed of the actions and policies of the laboratory. Employees are given the required Occupational Safety and Health training, additional training in bloodborne pathogens, and are broken up into ?risk groups in relation to where they work and the chemicals that are handled. A formal chemical-hygiene plan is also in effect for Quest Diagnostics Incorporated.

Mercury Management at Mayo Clinic

Contact Person: David H. Senjem
Environmental Safety Coordinator
(2/13/97)

Mayo's management of mercury in the medical environment has evolved over time. Historically, elemental mercury from thermometers, blood pressure units, research apparatus, and other devices was referred to Mayo's Pulmonary Laboratory for cleaning, redistillation, reuse, or sale. Mercury batteries were first collected for referral to a California-based reprocessing center in 1978. A strong emphasis has existed since the mid-1970's on collecting and commercially disposing of mercury-containing laboratory wastes through Mayo's hazardous waste program. Specialized mercury vacuum cleaners were first purchased in the 1970's to ensure than mercury spills were effectively and safely managed.

In more recent years, institutional interest in mercury management has led to even more aggressive actions. Mercury thermometers have been removed from Mayo's 1500 outpatient examination rooms and replaced with electronic devices. Similarly, mercury thermometers and sygnometers were removed and replaced with electronic devices in all hospital areas. Mayo's Pulmonary Function Laboratory discontinued the use of large quantities of mercury associated with their Haldane/VanSlyke devices in favor of electronic instrumentation. Laboratory test procedures have been re-evaluated for mercury use with an emphasis on substitution, whenever possible, and strict attention to disposal management when substitution is not possible. Used mercury-containing fluorescent light bulbs are, of course, collected and disposed of through a commercial vendor who recovers and recycles mercury.

Efforts continue to further investigate and reduce the presence of mercury in the Mayo environment. Examples of such efforts include the incorporation of heavy metal analysis in certain product purchases and similar evaluations in certain large components of Mayo's incinerated waste stream. Additionally, we have strived through continuing educational efforts to sensitize staff on avoidance of the use of mercury or mercury-containing materials, whenever possible, and especially when alternative choices are available.