Fraunhofer Institute for Systems and Innovation Research ISI
Fraunhofer Institute for Systems and Innovation Research ISI

Project

Pilot project to reduce the input of X-ray contrast media into the environment (MindER)

Pharmaceuticals enter aquatic environments via wastewater and pose a growing environmental challenge. The MindER projects focus on iodinated X‑ray contrast media (ICM), which are administered in medical diagnostics to visualize organs and vessels and are subsequently excreted largely unchanged in urine. Owing to their physicochemical properties, ICM pass through wastewater treatment plants with limited removal and can reach groundwater.

MindER1 assessed whether large‑scale, decentralized collection of ICM‑contaminated urine is a viable approach. Cost‑effectiveness was evaluated by relating implementation costs to the achievable reduction of pollutant loads in receiving waters.

MindER2 broadened the scope, examining a combined strategy: separation toilets and urinals within healthcare facilities, complemented by the use of mobile urine bags at home.

Building on experience from radiology, the MindERSchwerpunkt project investigates specific workflows in cardiology and urology clinics—areas previously scarcely studied—to derive practical retention options for ICM.

A flyer for the first project (in German) is available here. MindER1 and MindER2 have been successfully completed; the final report (in German) can be accessed here.

 

 

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Iodinated X‑ray contrast media (ICM) are used extensively in medical imaging to visualize internal organs and vessels and are excreted predominantly unchanged in urine. Their high water solubility, chemical stability, high polarity, and low biodegradability lead to limited removal in municipal wastewater treatment plants; even advanced treatment (fourth stage, e.g., ozonation or activated carbon) achieves low elimination for many ICM. Consequently, ICM enter the aquatic environment as micropollutants and have been regularly detected for years in surface waters and, in some cases, drinking water. The compounds most frequently detected at the highest concentrations include amidotrizoate (diatrizoate), iopromide, iopamidol, and iomeprol.

Given rising consumption and these physicochemical properties, further increases in environmental loads are expected. In addition, oxidative processes in wastewater or drinking water treatment (e.g. ozonation) can generate transformation products whose environmental behavior remains insufficiently characterized so far. Unlike therapeutic pharmaceuticals, ICM are designed to be pharmacologically inactive; their ecotoxicity is currently considered relatively low. Nevertheless, precautionary action is warranted considering increasing environmental burdens.

Numerous research and pilot projects have shown that ozonation and activated carbon can be valid fourth‑stage treatment options for a broad range of micropollutants. For ICM, however, removal efficiencies remain limited, making the application of source‑oriented mitigation strategies indispensable. Because per-patient-administration of ICM is relatively infrequent and excretion after administration happens almost completely within a short time, separate collection of urine offers a promising measure to reduce ICM loads in municipal wastewater.

Previous studies focused primarily on hospital settings; capture of ICM in outpatient contexts (physician practices and ambulatory patients) has scarcely been examined. The success of collection systems depends on acceptance and consistent use by staff and patients. Accordingly, the MindER projects included acceptance studies, evidence of the effectiveness of decentralized urine‑collection systems, and economic assessments.

The MindER projects (2016–2020), funded by the Baden‑Württemberg Ministry of the Environment and conducted by Fraunhofer ISI in cooperation with Ulm University Hospital and a radiology practice in Ulm, investigated the applicability and acceptance of urine bags (MindER1) and the potential of urine‑diverting (separation) toilets, which were implemented in the radiology department at Ulm University Hospital (MindER2). These studies indicate that only a portion of ICM emissions originates from radiology; similarly large shares are expected from cardiology, and ICM are also used in urology. Specific departmental workflows—administration, mapping of patients’ post examination pathways, and the resulting retention options—have so far been scarcely examined systematically.

Building on the experience from the MindER projects and the ICM study developed under the Federal Micropollutant Strategy (Round Table on ICM), the MindERSchwerpunkt project prepares targeted measures to reduce ICM emissions from healthcare facilities in Baden‑Württemberg, focusing on particularly affected departments—radiology, cardiology, and urology.

MindER1 aimed to determine whether large-scale, decentralized collection of urine containing iodinated X‑ray contrast media (ICM) is a sensible approach. Cost‑effectiveness was assessed by relating implementation costs to the achievable reduction of pollutant loads in receiving waters.

ICM are administered exclusively in healthcare settings and are excreted by patients largely unchanged within 24 hours, predominantly via urine. These characteristics make ICM well suited to decentralized urine collection to prevent emissions to aquatic environments. Among available options, MindER1 investigated collection using urine bags.

The project addressed both hospitals and outpatient radiology practices, which have distinctly different populations of patients. Consequently, approaches and expected capture rates differed, and information materials for medical staff and patients had to be individually adjusted. The integration of the general public was an integral part of the work—both to underscore the project’s relevance and to support public discourse and awareness regarding problematic substances.

The project consisted of three phases: Phase 1 established the foundations; Phases 2 and 3 covered implementation of measures, data collection, evaluation of results, and derivation of recommendations. Across all key steps, the consideration of stakeholder‑specific perspectives was essential (collection concept, information materials, training, and surveys were designed, implemented, and evaluated for each target group).

MindER2 examined capture via urine‑diverting (separation) toilets and urinals, combined with urine bags. Multiple toilet technologies were assessed for practicality—for patients and for the required logistics. As in MindER1, communication with staff and patients was individually adjusted, and involvement of the public remained a core element. The project was implemented at Ulm University Hospital, where prior engagement through MindER1 enabled immediate continuity and use of previous experience.

Using these insights from previous projects, MindERSchwerpunkt intends to develop tailored concepts for radiology, cardiology, and urology. Work routines, patients’ post-examination pathways, and resulting substance flows will be analyzed to derive department‑specific measures. To ensure transferability, the project will distinguish between site‑specific and examination‑specific processes applicable across hospitals. Collaboration with Ulm University Hospital will continue.

Core elements of the project:

  1. Identification of ICM‑relevant examinations in radiology, cardiology, and urology.
  2. Determination of products used and consumption volumes.
  3. Identification of departmental work routines.
  4. Identification of examination routines.
  5. Documentation of already structurally captured urine volumes (e.g., bedpans, catheters).
  6. Mapping of patients’ post‑examination pathways and locations.
  7. Development of tailored concepts to minimize emissions.

Throughout the project, several workshops will be conducted with participating clinics. The goal is to derive concrete concepts for Ulm University Hospital and general recommendations for radiology, cardiology, and urology.

 

MindER1 results

From a psychological perspective, acceptance of new concepts is shaped by factors such as perceived relative advantage over current practice, perceived ease or difficulty of use, and compatibility with individual needs and requirements of the user (patients and staff). Results of MindER1 indicate that decentralized collection using urine bags can be adopted by approximately 20–30% of patients. A key recommendation is to combine low‑barrier measures to optimize the effectiveness of mitigation strategies.

MindER2 results

In cooperation with Ulm University Hospital, MindER2 examined the combined use of urine bags and urine‑diverting (separation) toilets to reduce inputs of iodinated X‑ray contrast media (ICM) to wastewater. Retrofitting or installing separation toilets to retain and separately dispose of ICM‑contaminated urine appears feasible and, depending on local conditions, effective.

Recommended measures in ascending order of effort:

  • Information and continuing education for medical staff
  • Inclusion of a module on pharmaceuticals in the environment in medical degree programs and nursing schools
  • Routine provision of urine bags accompanied by a brief information leaflet
  • Simple, quickly accessible on‑site information beyond leaflets (e.g., posters, signage)
  • Clearly signposted toilets enabling separate urine collection on site
  • Wider deployment of separation toilets

Publications

Presentations and conference contributions

  • Niederste-Hollenberg, J., Schuler, J., Cassier-Woidasky, A.-C. (2021): Restmüll oder Waschbecken? - Problembewusstsein bei der Entsorgung von Arzneistoffen in Krankenhäusern; SUK 2012, Spurenstoffe und Krankheitserreger im Wasserkreislauf.
  • Beer, M.; Kraus, E.; Schuler, J.; Zhou, S.; Niederste Hollenberg, J. (2020): Analyse der Akzeptanz von Maßnahmen in einer Universitätsradiologie zur Minderung des Eintrags jodhaltiger Röntgenkontrastmittel in die Umwelt; Röntgenkongress der dt. Röntgengesellschaft "RöKo 05/2020 digital" - Vortrag in der Highlightsitzung am Eröffnungstag (21.05.2020).
  • Beer, M.; Kraus, E.; Schuler, J.; Zhou, S.; Niederste Hollenberg, J. (2020): Analysis of the acceptance of measures in a radiology department to reduce the introduction of iodine-containing contrast media into the environment; Radiologie-Weltkongress RSNA 11/2020 - submitted.
  • Schuler, J.; Eckartz, K.; Niederste-Hollenberg, J. (2018): Little Persuaders - reducing x-ray contrast agents in water cycles with psychological techniques for behavioural change; BEHAVE 2018; 5th European Conference on Behaviour and Energy Efficiency; Zurich, 6-7 September 2018, submitted.
  • Eckartz, K.; Schuler, J.; Niederste-Hollenberg, J. (2018): Keeping it off the circle - approaches to reduce the emission of x-ray contrast agents to the environment. Conference paper. CleanMed Europe 2018 10th to 12th of October 2018, Nijmegen, submitted.
  • Hillenbrand, T. (2018): Integrierte Ansätze zur Minderung der Spurenstoffbelastungen der Gewässer: Aktuelle Entwicklungen. Dialogforum Spurenstoffe im Hessischen Ried, 4. September 2018, Darmstadt.
  • Niederste-Hollenberg, J.;  Eckartz, K.; Hillenbrand, T.; Peters, A. (2017): Pilotprojekt zur Minderung des Eintrags von Röntgenkontrastmitteln in die Umwelt. Vortrag zum 5. Workshop Arzneimittelwirkstoffe in der aquatischen Umwelt am 17. Februar 2017 im Umweltministerium in Stuttgart.
  • Niederste-Hollenberg, J.; Tettenborn, F; Hillenbrand, T.; Eckartz, K.; Peters, A. (2017): Gewässerbelastung durch Arzneistoffe – Ansätze zur Reduzierung in 2 Pilotprojekten; DWA Landesverbandstagung 2017 Baden-Württemberg; 12./13. Oktober 2017/Kongresszentrum Schwabenlandhalle Fellbach; Hrsg. DWA-Landesverband Baden-Württemberg; ISBN 978-3-88721-496-8, www.dwa-bw.de.
  • Hillenbrand, T. (2017): Spurenstoffe in unseren Gewässern – wo kommen sie her und was können wir dagegen tun? BDEW, DVGW: 26. Werkleitertagung Wasser, 23./24. November 2017, Brehna.
  • Hillenbrand, T. (2017): Strategien und Maßnahmen zur Verminderung des Eintrags von Spurenstoffen in die Gewässer. Symposium "Spurenstoffe in den Gewässern des Hessischen Rieds und Strategien der Eliminierung". Hessisches Landesamt für Naturschutz, Umwelt und Geologie. Frankfurt, 16. März, 2017.
  • Hillenbrand, T. (2016): Röntgenkontrastmittel: Einträge in die Umwelt und Ansätze zur Emissionsminderung. 2. Kongress Spurenstoffe in der aquatischen Umwelt 2016. Deutsche Vereinigung für Wasserwirtschaft, Abwasser und Abfall -DWA-, Landesverband Baden-Württemberg, 13. - 14. Juni 2016, Ulm.

Duration

  • MindER1: January 2015 until June 2016
  • MindER2: August 2017 until December 2019
  • MindERSchwerpunkt: September 2025 until January 2027

Client

  • Funded by the State of Baden-Württemberg: Ministry of the Environment, Climate Protection and the Energy Sector of Baden-Württemberg