Whole-of-hospital approach to waste

AMERICAN hospitals dispose of over 1.8 billion kilograms of waste a year in landfills and commercial incinerators. Health care is the second-largest contributor to landfill after the food industry, and there is no economic or non-economic incentive to change this wasteful practice.

The situation is no better in Australia, where plastics account for a third of hospital waste. Rather than sending the 50 million intravenous fluid bags and PVC tubing sets to landfill, a cost-neutral management solution could include recycling.

The World Health Organization recommends several focus areas for hospitals to get greener: waste reduction, energy efficiency, green building design and water conservation.

It simply distills to the eco-mantra trio of reduce, re-use, recycle.

Buried within the tonnes of a hospital’s waste destined for burial in landfill or incinerated as medical waste are untold numbers of unused disposable surgical instruments, medical devices, dressings and expensive drugs that could be repackaged, resterilised or stored for future use. The community’s enthusiasm to reduce, re-use and recycle newspaper and product packaging, as well as adopting measures to reduce individual carbon footprint, hasn’t quite permeated our hospitals.

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The medical waste problem has been fuelled by a paradigm shift in health care towards single-use disposable medical instruments and equipment that aspires to absolute sterility and minimises cross-infection risk.

This movement was incited by the AIDS epidemic at its zenith in the 1980s, with widely publicised contaminated blood transfusions assuming the blown-out proportions of a fearful contagion.

The sentiment insinuated itself into overzealous demands that the public be protected from potentially infectious hospital patients or health care workers (HCW) with whom they come into contact. At its extreme, surgeons who performed deeply invasive procedures, such as cardiothoracic surgery, were legally required to undergo regular testing for blood-borne viruses or sign declarations that they had remained virus-free.

The infection control ethos of zero-risk patient-to-patient and HCW-to-patient cross-transmission deploying single-use strategy is impossible to achieve and, at the same time, it consumes substantial health care dollars with diminishing return.

In emergency medicine for instance, click-on tourniquets have been replaced by single-use elastic bands that are hard to use and cut into the patient’s skin. My average city emergency department (ED) that sees 120 patients would use 50 of these 10 cm bands a day, resulting in 5 metres of non-reusable waste that will persist for hundreds of years in the landfill.

Equipment packs for suturing and minor procedures come wrapped in sealed thick plastic packaging and receptacle trays, which contain numerous redundant forceps, suture holders, needles, blades, handles, plastic basins, catheters and dressings that are never used and are thrown into medical waste streaming for incineration.

Gowns are disposable, as are oversized drapes and even bed linen. Metal surgical instruments come in large aggregated packs, of which I’d use only one.

Instead of being sent to a hospital sterilising department for autoclaving, they are thrown into sharps bins, transported by contracted waste management companies to high-heat incinerators, and treated as biologically contaminated medical waste.

Unused surgical equipment, dressings and drapes removed from their packaging are condemned as contaminated waste deemed no longer sterile. Medico-legal constraints mean that we no longer collect opened but unused equipment to donate to poor countries.

A straw poll of my surgical colleagues has me being more optimistic.

As operating equipment is expensive to replace, they have been manufactured to be sufficiently robust to undergo repeated sterilisation and be permanently reusable without degraded quality of performance in terms of reliable precision and depth of tissue incision.

There is no credible evidence of blood-borne virus or bacterial infection when such equipment is sterilised to the scrupulously high standards mandated in advanced health systems. Even recycled devices are not known to incur patient harm. Reprocessing medical devices has a reliable safety record of excellence comparable to new equipment, reduces cost by half and generates less harmful waste.

Although instruments for vascular, open heart and deep body cavity surgery are more prone to blood and patient-tissue contamination than equipment used for minor procedures in the ED, they are re-used after stringent sterilisation.

The operating theatre scenario runs against the contention that infection risk associated with re-using sterilised medical equipment in the ED is a quantum worse than rummaging through the trove of single use surgical instruments pre-packed into kits for suturing and minor procedures.

Mass-produced single-use instruments do cost less per unit than labour-intensive sorting and sterilising processes with slow turnaround times. However, hospitals could enhance their ecological credentials by incorporating indirect costs related to waste management and environmental impact into their product–purchase decisions.

This re-orientates hospital policy to ensure they provide healthy, ecologically sound and sustainable environments. Medical waste contributes to the modern hospital’s already energy- and resource-intensive practice, escalating carbon emissions and other pollutants created by waste disposal. Reducing energy use and waste reaps economic benefits.

We need a whole-of-hospital impetus towards not just promoting health, but also providing healthy and safe workplaces, and we need to work towards an environmental sustainability which factors in both budgetary and uncosted environmental concerns.

Favouring slightly higher-cost items that can be re-used rather than disposed of after a single use, asking medical product vendors to pare down equipment packs, and reverting to reusable gowns and linen are some local strategies that could work.

It is crucial that each hospital has a sustainability advocate, who is also a hands-on clinician, to identify interception points through a patient’s journey that are not only inefficient, but that also generate waste.

The ideal would be to identify wasted medical kits in clinical care pathways as they evolve in real time.

In a world of throwaways, making a dent in medical waste is attainable without incurring staff or patient harm. To address ongoing safety concerns associated with reprocessed or recycled instruments and equipment, close regulation and post-marketing surveillance systems for reporting adverse effects need to be implemented.

Joseph Ting is an emergency, pre-hospital and aeromedical physician as well as adjunct associate professor for clinical research methods and pre-hospital care at Queensland University of Technology’s School of Public Health and Social Work and clinical senior lecturer in the Division of Anaesthesiology and Critical Care UQ.