1This
preliminary
Plan
was
signed
by
EPA's
Assistant
Administrator
for
Water
on
December
23,
2003.
It
is
expected
to
be
published
in
the
Federal
Register
on
December
31,
2003.

2See
"
Description
and
Results
of
EPA
Methodology
to
Synthesize
Screening
Level
Results
for
the
Effluent
Guidelines
Program
Plan
for
2004/
2005,"
DCN
548,
Section
3.0.

Page
1
of
4
Memorandum
From:
Carey
A.
Johnston,
P.
E.
USEPA/
OW/
OST
ph:
(
202)
566
1014
johnston.
carey@
epa.
gov
To:
Public
Record
for
the
Effluent
Guidelines
Program
Plan
for
2004/
2005
DCN
XXX,
Section
2.2.3
EPA
Docket
Number
OW­
2003­
0074
(
www.
epa.
gov/
edockets/)

Date:
December
30,
2003
Re:
Factor
2
Screening
Level
Information
on
the
Healthcare
Industry
Overview
Under
the
Clean
Water
Act
(
CWA),
EPA
establishes
technology­
based
national
regulations,
termed
"
effluent
guidelines,"
to
reduce
pollutant
discharges
from
industrial
facilities
to
waters
of
the
United
States.
Section
304(
m)
of
the
Clean
Water
Act
(
CWA)
requires
EPA
to
publish
an
Effluent
Guidelines
Program
Plan
every
two
years.
CWA
Section
304(
m)(
1)(
A)
also
requires
EPA
to
establish
a
schedule
for
the
annual
review
and
revision
of
all
existing
effluent
guidelines.
Additionally,
CWA
Section
304(
m)(
1)(
B)
requires
EPA
to
identify
categories
of
point
sources
discharging
toxic
or
non­
conventional
pollutants
for
which
EPA
has
not
published
effluent
guidelines.

The
preliminary
Effluent
Guidelines
Program
Plan
for
2004/
20051
described
the
four
factors
EPA
considered
during
its
screening­
level
analyses.
Factor
2
(
Technology
Advances
and
Process
Changes)
considers
applicable
and
demonstrated
technologies,
process
changes,
or
pollution
prevention
alternatives
that
can
effectively
reduce
the
pollutants
remaining
in
an
industry
category's
wastewater
and
thereby
substantially
reduce
any
identified
risk
to
human
health
or
the
environment
associated
with
those
pollutants.
This
memo
summarizes
the
Factor
2
screening
level
information
gathered
on
the
healthcare
industry.
Sectors
of
this
industry
were
identified
in
EPA's
outreach
activities,
however,
this
industry
was
not
identified
for
further
data
collection
in
the
current
effluent
guidelines
planning
cycle.
2
Page
2
of
4
Health
Services
Industry
The
health
services
industry
is
one
of
the
many
service
industries
that
have
recently
experienced
a
large
percent
increase
in
revenue
and
value
of
receipts.
Unlike
many
other
services
industry,
the
health
services
industry
discharges
wastewaters
that
many
contain
a
variety
of
pollutants
such
as
pathogenic
microorganisms,
radioactive
elements,
and
other
toxic
chemicals
much
as
mercury.
The
health
services
industry
(
SIC
80)
consists
of
the
following
eight
segments:
1)
hospitals,
2)
nursing
and
personal
care
facilities,
3)
offices
and
clinics
of
physicians,
4)
home
health
care
services,
5)
offices
and
clinics
of
dentists,
6)
offices
and
clinics
of
other
practitioners,
7)
health
and
allied
services,
and
8)
medical
and
dental
laboratories.
However,
hospitals
are
the
only
segment
of
the
health
services
industry
currently
subject
to
any
effluent
limitations
guidelines
(
ELGs).
Direct
discharges
from
hospitals
are
currently
subject
to
the
requirements
of
the
ELG
for
the
Hospital
Point
Source
Category
(
40
CFR
460)
established
in
1976.
Most
hospitals
discharge
to
POTWs
and
are
not
subject
to
these
effluent
guidelines.

Hospitals
generate
wastewater
from
food
service
operations,
cleaning
of
exam
and
surgical
suits,
equipment
sterilization,
laundries,
sanitary
waste
(
toilets,
sinks,
and
showers),
medical
laboratories,
cooling
towers,
and
heating
systems
(
boiler
blow­
down).
Approximately
242
gallons
of
wastewater
are
generated
per
bed
per
day
in
the
average
hospital.
Wastewater
from
hospitals
is
characterized
by
BOD
5
(
50
to
400
mg/
L),
chemical
oxygen
demand
(
150
to
800
mg/
L),
total
suspended
solids
(
60
to
200
mg/
L),
and
total
organic
carbon
(
50
to
300
mg/
L).

The
current
BPT
effluent
limits
for
hospitals
are
based
on
biological
treatment
with
sludge
handling
facilities.
BAT
effluent
limits
are
based
on
multimedia
filtration
following
biological
treatment
to
remove
residual
solids.
Regulated
pollutants
include
BOD
5,
TSS,
and
pH.
Sampling
data
from
hospitals
with
treatment
systems
indicate
BOD
5
and
TSS
removals
are
approximately
93
percent
and
86
percent,
respectively.

Other
pollutants
possible
in
hospital
waste
include
solvents,
radioisotopes,
and
body
fluids
(
considered
to
be
infectious).
Solvents
include
alcohols,
acetone,
xylenes,
formalin,
some
halogenated
compounds,
and
toluene.
The
continued
increase
in
the
use
of
pharmaceuticals
may
also
affect
the
composition
of
wastewater
from
health
service
facilities.
Drugs
such
as
antibiotics,
anti­
depressants,
birth
control
pills,
seizure
medication,
cancer
treatment,
pain
killers,
tranquilizers,
and
cholesterol­
lowering
compounds
have
been
detected
in
varied
water
sources.
These
drugs
can
pass
through
conventional
sewage
treatment
facilities
intact,
and
end
up
in
waterways,
lakes,
and
even
aquifers.
For
example,
data
from
Tucson,
Arizona
show
approximately
3.4
mg/
L
of
Ibuprofen
and
6.3
mg/
L
Naproxen
in
effluent
from
the
city's
activated
sludge
treatment
plant.

Medical
procedures
as
well
as
research
utilize
radioactive
dyes.
For
example,
radioactive
sodium
iodide
(
Na
131­
I)
is
a
common
compound
used
in
medical
treatment
for
thyroid
disease.
About
750,000
diagnostic
thyroid
scans
are
performed
each
year
in
the
United
States.
Each
procedure
utilizes
about
0.01­
0.1
millicuries
of
I­
131.
Patients
who
have
been
injected
with
the
3See
http://
www.
nrc.
gov/
reading­
rm/
doc­
collections/
cfr/
part020/
part020­
2003.
html.

Page
3
of
4
iodine
will
eventually
excrete
the
material
in
their
urine
or
feces
mostly
while
in
the
hospital.
Radioactive
discharges
from
a
hospital
to
a
POTW
may
result
in
radioactive
particles
suspended
in
effluent
and
entrapped
in
sewage
sludge.
These
discharges
are
regulated
by
the
U.
S.
Nuclear
Regulatory
Commission.
3
Recent
studies
have
shown
a
variety
of
pathogenic
pollutants
present
in
hospital
wastewater,
including
bacteria,
fungi,
and
viruses.
Ozonation
has
been
shown
to
be
a
suitable
treatment
process
for
the
control
of
such
pollutants
prior
to
the
discharge
of
wastewater
from
a
hospital.

Internationally,
high
concentrations
of
AOX
(
halogenated
organic
compounds
adsorbable
on
activated
carbon)
have
been
detected
in
hospital
wastewater.
In
Germany,
iodized
X­
ray
contrast
media
used
for
medical
applications
have
been
linked
to
these
high
concentrations.
Photochemical
oxidation
with
hydrogen
peroxide
was
investigated
as
a
method
to
reduce
concentrations
of
AOX.
Studies
demonstrate
that
complete
removal
of
the
organically
bonded
iodine
and
partial
mineralization
is
feasible.
The
degradation
in
the
UV
reactor
was
enhanced
by
adding
hydrogen
peroxide
and
by
using
a
bubble
column
to
remove
the
formed
elemental
iodine
from
the
solution
by
stripping.

The
disposal
of
mercury,
a
persistent
bioaccumlative
toxin,
is
a
problem
for
many
health
care
facilities.
Mercury
can
accumulate
in
waste
traps
and
be
discharged
in
small
amounts
each
time
water
is
used.
Many
hospitals
have
already
taken
steps
to
reduce
or
eliminate
mercury
use.
There
are
many
mercury­
free
products
(
e.
g.,
thermometers,
sphygmomanometers)
that
can
be
used
in
place
of
the
conventional
mercury­
containing
products.
Mercury
may
also
originate
in
laboratory
reagents
and
laundry
bleach.
Hospitals
have
begun
testing
these
products
and
reagents
to
quantify
the
mercury
content
and
investigate
product
substitution
to
reduce
mercury
use.

The
dental
industry,
which
uses
mercury
amalgam
fillings,
has
also
been
receiving
pressure
to
reduce
their
use
of
mercury
and
develop
effective
techniques
for
removing
mercury
from
their
liquid
wastewater
streams.
The
larger
particles
of
amalgam
captured
by
the
chair
side
dental
vacuum
system
during
the
placement
or
removal
of
amalgam
fillings
get
caught
in
the
chair
side
trap.
This
trap
is
periodically
cleaned
out
and
any
pieces
of
amalgam
are
recycled.
However,
most
of
the
amalgam
material
vacuumed
up
is
in
smaller
particles
or
slurry,
which
passes
through
the
chair
side
trap
and
enters
the
wastewater
line
which
eventually
leads
to
the
municipal
sewage
system.
There
are
several
different
commercially
available
amalgam
separators
which
can
remove
more
than
99
percent
of
amalgam
from
dental
wastewater
streams;
however,
in
most
states,
dentists
are
not
required
to
use
amalgam
separators.

Composite
resin
fillings
are
becoming
a
popular
alternative
to
conventional
amalgam
fillings.
While
the
number
of
new
amalgam
restorations
being
placed
is
declining,
there
are
still
billions
of
amalgam
restorations
currently
in
place
which
will
eventually
need
to
be
removed.
Page
4
of
4
Consequently,
the
process
of
removing
amalgam
restorations
will
continue
to
serve
as
a
source
of
mercury
discharges
for
many
years
to
come
and
may
necessitate
the
implementation
of
pollution
prevention
techniques
to
control
the
release
of
mercury
from
dental
offices.
