Lægemiddelkortlægning på sygehuse i Region Nordjylland

Danish Management of Hospital Wastewater
Ulf Nielsen
07.04.2014
Agenda
Danish Management of Hospital Wastewater
• Are hospitals important point sources?
• How are the hospitals regulated by Danish authorities and what is
the expected requirements?
• What’s the status of the Danish full scale treatment test?
© DHI
Hospital wastewater
Hospital wastewater consists of a complex mixture of:
• Pharmaceuticals (antibiotics, cytostatics, antiviral drugs, parasitic agents,
contrast media etc.)
• Microorganisms/pathogens (antibiotic resistant bacteria, viruses etc.)
• Laboratory chemicals (dyes etc.)
• Cleaning agents (especially disinfectants)
Hospital
WWTP
Sewer workers
Recipient water body
Combined sewer overflows
Flooding
• Risks to aquatic environments and human health remain unclear. Only approx.
450 of 1100 pharmaceuticals used in DK have been environmentally assessed
Greater Copenhagen Area
• Total population in catchment areas: 2 mill (1.6 mill. to WWTP Lynetten)
Are hospitals
important point
sources?
WWTP Lynetten
Population
Hospitals
Outpatient clinics
WWTP Damhusåen
WWTP SCA
Mapping of pharmaceutical discharges
API consumption at hospitals and in the primary sector
Calculation based on sales data.
Excluding metabolism (100% excretion).
API discharge from
hospital
API discharge from
primary sector
Hospital water consumption
Concentration in hospital
wastewater = PECHospital
Total amount discharged to WWTP
Total water volume discharged to WWTP
Wastewater concentration = PECinlet
WWTP removal taken into account where data is available, otherwise
no removal
is assumed.
Illustration modified
from Daughton
and Ternes, 2000
Treated wastewater concentration = PECoutlet
Environmental risk
Dilution in receiving water body = 2-50
Environmental concentration = PEC
PEC/PNEC
DHI database
• Danish Health Agency (DHA) register number of sold packages,
number of pills/fluids in each packages and amount of actice
substance in each pill/fluid
• DHI get’s the raw data from DHA on hospital and section level for DK
• In the database we connect the consumption of each package and
calculate the consumption of active substances for:
− Each hospital and sections inside the hospital
− The population consumption in the 5 Danish regions
Hospitals- a point source?
Cytostatics
Inpatient
16 % (32 kg)
Outpatient
83 % (164 kg)
Hospitals
1 % ( 1,2 kg)
General public
Data (2012) from Copenhagen catchment area (WWTP Lynetten)
Hospitals- a point source?
Endocrine Therapy
Inpatient
42 % (12 kg)
54 % (15 kg)
Outpatient
Hospitals
4 % ( 1 kg)
General public
Data (2012) from Copenhagen catchment area (WWTP Lynetten)
Hospitals- a point source?
Antibiotics
Inpatient
Outpatient
26 % (1490 kg)
2 % (134 kg)
Hospitals
72 % (4186 kg)
General public
Data (2012) from Copenhagen catchment area (WWTP Lynetten)
Hospitals- a point source?
Pain killers (analgesics)
Inpatient
Outpatient
4 % (1669 kg)
0,2 % (69 kg)
Hospitals
96 % (38787 kg)
General public
Data (2012) from Copenhagen catchment area (WWTP Lynetten)
DK regulation of Hospital Wastewater
• Hospital wastewater is regulated as industrial wastewater
• Hospitals are viewed as industrial point sources
• All industrial discharges to sewer - if different from household wastewater - need a
permit
• Direct discharge to surface water is possible if the wastewater is sufficient treated to
comply with Water Quality Criteria
Minister of Environment and the municipalities
• Letter from the Minister of Environment to the municipalities
in May 2011: ”the municipalities have to issue wastewater
permits for all hospitals” and ”a dialogue on BAT is needed”
• In December 2013 the municipalities have finalised a guideline for
municipal regulation of hospitals with:
− Guidance on prioritization and proportionality
− Pharmaceutical assessments
− Limit values
• All hospitals have to prepare a wastewater technical description,
which is the basis for the wastewater permit
© DHI
Regulatory prioritization of health care institutions in DK
Prioritized point sources:
• Source of > 2% of the total load of specific hazardous
pharmaceuticals supplied to the local WWTP
• Uses cytostatics or contrast media
• > 1000 in- or outpatients per year
• > 500 surgeries per year
Psychiatric institutions
• > 100 beds
Smaller institutions are seen as diffuse sources and are not regulated
(now)
© DHI
Municipal ranking of hospitals/health institutions
Environmental assessment ”method-pieces” to put together the
overall environmetal assessment/ranking ”puzzle”:
• ABC hazardous assessment of pharmaceuticals
• Limit values (LM) for discharge to sewer
• Contribution of antibiotics to the local WWTP
Minor source
Medium source
Major source
A - Highly
hazardous
pharmaceuticals
[kg/yr]
B- Hazardous
pharmaceuticals
[kg/yr]
Sum of exceedance of
LM* in wastewater
(Meas. konc./LM)
Antibiotics
contribution (excl.
penicillins) to WWTP
[%]
< 50
< 300
<5
<5
50 - 100
300 - 500
5 - 20
5 - 20
> 100
> 500
> 20
> 20
ABC environmental assessment of inherent properties
A: Higly hazardous substances.
Unwanted in the sewer system
B: Hazardous substances Should be
reduced to below environmental
quality standards
C: Not problematic substances, when
discharged to sewer
Limit values for discharge to sewer
• 33 pharmaceuticals used at hospitals plus supplementary 7 from psychiatric
institutions – Total: 40 pharmaceuticals
• Derived from PNEC (predicted no effect concentration) - most sensitive water living
organisms
• Only selected substances with robust effect data (assessment factor ≤100 and no
QSAR) is used
• Removal rate in WWTP is taken into account
Antibiotics contribution to municipal WWTP
• Total contribution without penicillins and out-patients
Copenhagen University
Hospital
Consumption: 496 kg/y
Contribution: 28%
WWTP Lynetten
Total catchment:
1.795 kg/y
Ranking of hospitals in the Capital Region of Denmark
Hospital/
Psychiatric
Center
Bornholm
Amager
Psych.
Ballerup
Psych. St.
Hans
No. of
beds
100
120
140
180
Sum of
Highly
Hazardous
exceedance of
hazardous
Catchment/
pharmaceuticals LM* in wasterecipient
pharmaceuticals
water (Meas.
[kg/yr]
[kg/yr]
konc./LM)
Small/
marine
Large/
marine
Large/
marine
Large/
marine
Antibiotics
contribution Classification
(excl.
as point
penicillins)
source
[%]
15
134
58
Medium
source
25
205
2
Minor source
9
33
< 0,1
Minor source
68
50
< 0,1
Minor source
Medium
source
Medium
source
Gentofte
280
Large/marine
52
337
2
Glostrup
310
Large/
marine
50
286
13
670
Small/ fresh
130
989
79
Major source
111
818
27
Major source
147
754
9
Major source
436
1381
28
Major source
181
700
18
Major source
New Northern
Zealand
Hvidovre
New
Bispebjerg
Copenhagen
New Herlev
800
860
1100
1100
Large/
marine
Large/
marine
Large/
marine
Large/
marine
25
104
Best Available Techniques (BAT) and proportionality
Principle: The larger point source - the larger compliance
investments/costs are fair!
Size as point source
Plans for construction/renovation
Size of health institution
Need for investments in BAT
Requirements and actions (BAT) in Capital Region of Denmark
Full-scale treatment at Herlev Hospital
•
•
•
•
Full solution - water, sludge, air
Project from 2012-2015 (start: May 2014)
Total budget including building: 5.8 mill. €
Total estimated running costs
(incl. sludge handling): 1.3 €/m3
MBR technology: Grundfos Biobooster
Polishing technologies: Ultraaqua
Air treatment: Neutralox
Testing and documentation: DHI
Other partners: Herlev Hospital, Business Innovation Fund, Capital Region of Denmark, the
municipalities of Herlev and Copenhagen, Lynettefællesskabet I/S
© DHI
Objectives of full-scale plant
• Direct discharge to the local stream
• Reuse of the treated water (tecnical water, cooling water)
• Payback periode: 6-7 years
• Continuous operation during 1 year to document treatment
efficiency, robustness and operational costs
• Optimization of the combination of MBR and polishing
technologies
• Environmental and health risk assessments, with the aim of
direct discharge to the local stream
• Development of methods for continuous monitoring and control of
operations and effluent water quality
© DHI
Operation of full-scale plant
• Two lines for testing; one with GAC+ ozone, the other with ozone + GAC
• Flow: approx. 150.000 m3/yr (hospital with 900 beds)
Screening
© DHI
MBR
Polishing
Overview of planned full-scale test plant
© DHI
Information brochure Full scale test plant
Just e-mail:
uln@dhigroup.com
© DHI
Agenda
Danish Management of Hospital Wastewater
• Are hospitals important point sources? Yes, for groups of
pharmaceuticals, such as antibiotics and cytostatics
• How are the hospitals regulated by Danish authorities and what is
the expected requirements? By the municipalities as industrial point
sources. Depending on “size” substitutions, selected treatment or
full treatment
• What’s the status of the Danish full scale treatment test? Started up
now (May 2014). Documented performance: February 2014
© DHI
Next steps:
Water efficient hospitals in the Capital Region of Denmark
Major goals:
• Water savings
• Reduced risk of internal waterborne
infections
• Use of secondary quality water
• No negative impact on the aquatic
environment