Mercury Work Group
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APPENDIX A

EXAMPLE STANDARD OPERATING PROCEDURE
Hospital Mercury Reduction

PURPOSE: To enable the Hospital to meet mercury level standards established by federal and state environmental protection agencies and the MWRA, and to meet requirements of the Hospital's Sewer Use Discharge Permit (Permit).

BACKGROUND: Mercury is a hazardous substance under state and federal environmental laws. The Hospital's Permit and MWRA regulations prohibit the discharge of mercury into the sanitary sewer system. Pursuant to its Permit, the Hospital must monitor its discharges into the sewer system for several parameters and substances, including mercury. Among other enforcement actions, the MWRA may assess monetary penalties for discharges that exceed permitted pollutant levels. Once mercury is introduced into a wastewater stream, removing it can be very difficult and expensive. The Hospital, therefore, must attempt to prevent mercury from entering its wastewater stream to protect the public health and avoid penalties.

POLICY STATEMENT: Mercury-containing products and processes will not be used in any manner on the Hospital campus, including within the Hospital buildings and medical office buildings, unless no reasonable alternatives, as determined by Hospital Administration, are available. When use of a mercury-containing product is permitted, measures will be taken to avoid introduction of mercury into the sanitary sewer system.

APPLICABILITY: Compliance with this policy and its procedures is a condition of employment and of clinical privileges and the use of any property on the Hospital campus. The Hospital reserves the right to take any and all actions, including to seek injunctive relief, to prevent violation of this policy by any party.

I.  The Hospital's Departments of Engineering, Environmental Services, Purchasing, Pathology, Radiology, and Safety will work together to identify product(s) or process(es) containing mercury currently in use within the Hospital campus and to identify acceptable alternatives. A list of such products/processes and their alternatives will be presented to the Safety Committee that will arrange for its distribution throughout the Hospital community. The list will be reviewed, updated, and distributed at least once per year.

II.  When mercury-containing products or processes are identified, the manager(s) for the department(s) using such products/processes will develop a plan to include a.) procedures for the prevention of disposal of any mercury into the sanitary sewer system, b.) a schedule for the elimination of the use of these products/processes or, in the alternative, the rationale (including information required below at IV.) for continued use of such products/processes. The manager(s) will present the plan to the Safety Committee for review and approval.

III.  The Safety Committee will review all mercury use plans and may approve the plans as submitted or with modification. Upon approval, the affected departmental manager(s) will implement the plans.

IV.  Managers of departments using mercury products/processes will maintain a readily retrievable log of the mercury-containing products/processes, the approved use(s), the alternatives considered, the reasons such alternatives were deemed unacceptable, and a schedule for reconsideration of available alternatives.

V.  In case of a mercury spill, employees and physicians will follow the procedures of Safety Policy for Handling of Mercury Spills. Managers must report all such spills to the Safety Committee for review.

VI.  All employees and physicians will prevent the disposal of mercury into the sanitary sewer system and will refrain from using mercury-containing products/processes on the Hospital campus unless such use has been approved according to this policy.

VII.  All employees and physicians are encouraged to present suggestions for eliminating mercury-containing products or processes from the Hospital to the Hospital Safety Committee.

REFERENCES:
1. OTA Guide
2. UT Manual
3. EPA Pollution Prevention Guide
4. EPA Hospital Guide
5. Hospital Operations Protocol and Training

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