By Kelly M. Pyrek
The healthcare industry is rife with opportunities to reduce the environmental impact it creates, with the added benefits of institutional financial gain, improved patient outcomes, better staff health and reduced turnover, and community benefit, according to a report from Practice Greenhealth and from the Institute for Innovation in Large Organizations.(1) An increasing number of healthcare institutions are endeavoring to reuse, recycle and repurpose medical supplies and devices to promote better sustainability.
With the healthcare sector accounting for a large part of the U.S. carbon footprint 8 percent, according to a 2009 JAMA study(2) industry involvement in and support of sustainability efforts is no longer a question of why or when, but of how, says Lars Thording, senior director of marketing and public affairs for Ascent Healthcare Solutions. Although a commitment to sustainability is about reducing environmental impact, it is also inexorably tied to the issues of cost and quality care. These are top issues in the burgeoning reform of healthcare. A sustainability measure is not realistic and cannot be effectively implemented if it does not take into account impacts to cost and patient care. Thording continues, A positive sign of progress is that hospital sustainability coordinators and green teams are on the rise. They are helping to guide purchasing decisions and are formulating policies for hospital employees. But a green team isnt enough. Nurses on the hospital floor, surgeons in the OR, administrators and suppliers are all a part of the solution.
Healthcare professionals should be conscious of how healthcare contributes to the waste stream. The hospital industry generates multiple types of waste that can be categorized into 10 waste streams, explains Debra Gillmeister, MBA, a director for Stericycles healthcare service division. Eighty percent are highly regulated, such as regulated medical waste (RMW), pharmaceutical waste and hazardous waste. Each of these must be properly segregated and disposed of to insure that the environment is protected and that laws and regulations are followed. Effective segregation diminishes total waste and the facilities carbon footprint. Gillmeister is a former advisory board member for the American Hospital Associations American Society for Healthcare Environmental Services.
Gillmeister points to the aforementioned JAMA study and notes, The healthcare industry operates 24/7 similar to the airline industry, yet unlike plane schedules that may decrease during off-peak hours, hospital emergency departments and associated trauma services are always open and often at, or over, operating capacity. This factor contributes to the significant energy utilization by hospitals. Fortunately hospital leaders are becoming increasingly aware of their impact on the environment. One example is the number of hospitals starting green teams. Data from more than 800 attendees at Stericycles educational seminars found that 54 percent of hospital respondents have established a green team, with many more facilities planning to establish one.
Gillmeister says that the countrys 5,000-plus hospitals are beginning to understand that 80 percent of their waste streams are highly regulated. While volume and disposal costs vary based on geographic location and facility size, all should focus on appropriately segregating waste streams, she says. Key to appropriate segregation is staying compliant and developing environmentally sustainable practices.
Developing sustainable best practices requires modification of staff behavior, Gillmeister emphasizes, adding, This occurs most frequently through ongoing staff education. Education and supporting processes are one of the most critical elements to effectively managing waste streams, and appropriately segregating all forms of medical waste. With an increased awareness of these waste streams, many hospitals are making strides towards a coordinated management by implementing a facility-wide green approach, including the formation of green teams. In 2009, Practice Greenhealth (PGH) surveyed 1,550 hospitals (473 were PGH members who are committed to sustainable, eco-friendly practices), 67 percent created a team or committee for environmental sustainability planning.(3)
In general, Gillmeister says that healthcare-related green efforts could include:
-- Garnering senior management support and initiating an interdisciplinary team
-- Eliminating solid waste that can be recycled such as glass, cans, boxes, paper, etc.
-- Assuring that the hospital formulary has been characterized so that hazardous and non-hazardous pharmaceuticals can be kept out of the environment
-- Appropriately segregating and disposing of pharmaceutical waste
-- Use of reusable container systems for sharps and pharmaceutical waste, not single use disposable containers
As greening efforts evolve, reusable containers reduce landfill waste and dramatically reduce the amount of carbon released into the environment, therefore improving air quality. For long-term water quality, a hospitals green team could implement a comprehensive pharmaceutical waste compliance program that helps keep pharmaceuticals out of the water, Gillmeister adds.
The Operating Room Goes Green
There are several areas in the healthcare institution that lend themselves particularly well to sustainability efforts. One of the most significant is the operating room. A sweeping and prescriptive path to green the nations operating rooms is underway by Practice Greenhealth, a membership and networking organization for institutions in healthcare that have made a commitment to sustainable, eco-friendly practices.
The "Greening the OR Initiative" is examining a range of interventions that will not only reduce the environmental impact of the OR, but also potentially reduce cost, increase quality and improve worker or patient safety. Among the areas for green interventions in the operating room are single-use device (SUD) reprocessing; using reusable gowns, surgical drapes, basins and other reusable products;
fluid waste management systems; lighting and patient thermal comfort; regulated medical waste minimization; substituting reusable hard cases for sterile wrap; recycling medical plastics; green cleaning and disinfection in a surgical setting; and donating unused medical equipment and supplies instead discarding them.
Ascent has been working with Practice Greenhealth and other stakeholders from major hospital systems, manufacturers, government agencies, and hospital staff to help the healthcare industry reduce the environmental footprint of our nations hospitals, and in particular their operating rooms, Thording says. The outcome will be a series of Greening the OR best practices guidance documents, including case studies and implementation recommendations. Reducing the environmental footprint of operating rooms is going to require both large and small changes. The Greening the OR best practices guidance Documents will address these 12 categories with specific recommendations for infrastructure changes, as well as more basic policy changes and educational efforts that aim to shift how OR staff think about the environmental impact of their daily actions. Reprocessing programs, for example, dont require major infrastructure change in order to implement.
For most hospitals, the benefits of going green in the operating room are considerable: reductions in energy and water use, a reduction in staff exposure to toxic chemicals, increased patient and staff safety, and a much-reduced impact on the environment, says Bob Jarboe, executive vice president of business development for Practice Greenhealth.
According to Practice Greenhealth, Operating rooms are some of the most resource-intensive and waste generating places in a hospital, generating between 20 and 30 percent of a facilitys waste. Much of that waste is disposed of as regulated medical waste, which costs 10 to 15 times more in disposal fees than regular waste. Half of budgets for operating rooms are generally spent on supplies that are thrown out, being used once or not at all during procedures, even though re-use may be an option. Likewise, it is a significant cost-center for materials, devices and supplies.
The most basic ways to reduce medical waste stream are through conservation and re-use, Thording says. Looking at how resources in general are used responsibly is a dedication that leads directly to the selection of resource strategies that are about re-use and reduction of unnecessary costs. Reprocessing has an obvious impact in some of the most waste-intensive areas of the hospital: the OR, EP Labs, and wherever non-invasive devices are used.
Thording says that reprocessing of medical devices has a strong sustainability component to it. Evaluating your facilitys responsible medical device strategies is an impactful way to reduce your medical waste stream, he says. Purchasing reprocessed SUDs offers immediate environmental benefit and cost savings with no capital investment. Reprocessing programs are currently employed by more than 50 percent of U.S. hospitals, and more than half of the U.S. News & World Report Honor Roll hospitals. They have become proven solutions for addressing medical, economic and environmental responsibilities without compromising safety or efficacy. A commentary from Johns Hopkins in Academic Medicine(4) recommends reprocessing as a means for curbing costs while reducing their environmental footprint.
Thording continues, Reprocessing allows hospitals to deploy more of their scarce resources to enhance patient care through quality initiatives. Each hospital can decide where to re-direct their cost savings based on its greatest needs, which could include hiring staff or purchasing equipment. For some hospitals, cost savings from reprocessing can make the difference between hiring and firing a nurse. In addition to direct cost-savings, some hospitals are experiencing an unexpected benefit from purchasing reprocessed devices. They are using the lower-cost devices as leverage when negotiating the price of single-use devices with original equipment manufacturers (OEMs). The environmental benefits are intuitive: by putting a reprocessing program in place, hospitals are not just recycling the materials, but also buying those devices back and re-using them, thus keeping those devices out of landfills. In addition, hospitals can expect to pay about 50 percent less for a reprocessed medical device versus what they would pay for the same device labeled as single-use. Administrators understand that theyre not only saving 50 percent of the purchase cost for each device, but theyre also saving money that would be spent on special handling and waste management of that device were it discarded into the waste stream without further re-use.
Thording adds that reprocessing is one of the most significant ways that operating rooms can reduce their environmental footprint. And while many sustainability initiatives can be costly, reprocessing is a unique solution that simultaneously saves money while improving environmental responsibility, he says. In 2009, Ascent helped its healthcare partners reduce overall disposable waste by 5.3 million pounds.
Greening Environmental Services
Another area that affords a significant opportunity for change is environmental services.
A study done in 2007 indicated that U.S. hospitals generate 6,600 tons of waste per day and that up to 85 percent of that is normal commercial waste such as paper, cardboard, metal, glass, plastic etc., says Dan Silk, vice president of environmental sustainability at Georgia-Pacific Professional. However, there are many ways that healthcare professionals can minimize the environmental impacts of waste coming from their facilities. This includes applying the EPAs hierarchy of reduce, reuse, recycle especially by using less through source reduction and returning more by recycling waste products where applicable.
According to Practice Greenhealth, environmental services professionals frequently have responsibility for the management of regulated medical waste, solid waste and recycling, pest management, and most importantly, cleaning and disinfection processes for surfaces and floors, in collaboration with infection prevention and control. Healthcare institutions create large amounts of waste that fall into a variety of categories, including regulated medical waste, liquid waste and sharps, solid waste, recycling, hazardous waste, pharmaceutical waste and organic waste.
"The purpose of following a waste hierarchy is to generate the maximum benefits from products and systems while creating the minimum amount of waste," Silk adds. "Addressing the 85 percent of hospital waste that is 'normal' commercial waste, is a huge step. Georgia-Pacific Professionals enMotion towel systems reduce waste by a minimum of 25 percent, based on Georgia-Pacifics own research. But that source reduction story has another benefit. Research shows that automated touchless towel dispensing systems installed in hospitals represented to 82 percent of the patients and visitors that the hospital cared about preventing the spread of germs."
The environmental services department also must engage in sustainable practices such as reassessing the ways in which healthcare environments are cleaned and disinfected, moving to the use of green cleaning products and materials where possible, and initiating utilization of green cleaning equipment and processes. It involves developing and implementing policies that support these practices, and continuously evaluating your progress. Green cleaning has become an integral part of efficient, effective, and environmentally sustainable operations in healthcare facilities.
Implications for Infection Prevention and Control
One of the most notable ways that healthcare institutions can practice sustainability is to examine their practices relating to sharps disposal.
For example, Gillmeister says that one Stericycle Bio Systems reusable container prevents 600 disposable containers from going to the landfill. Thousands of hospitals using the Stericycle Sharps Management System have been able to keep almost 85 million disposable containers out of landfills since 1986, she says.(5) From the total waste volume, the average hospital experiences approximately 25 percent total sharps waste. Sharps disposal has various waste elements, some of which include needles, syringes, lancets and the sharps container. Of these three waste elements, hospitals can impact the volume of sharps disposal by utilizing a reusable container with a proactive system that, according to recent feedback by APIC attendees, decreases the number of needlesticks.
At this years national APIC meeting, Stericycle conducted a survey that showed a decline in needlesticks. Rose Marie Prou, an infection control practitioner from Carney Hospital in Boston, notes, Since we have implemented the Stericycle program we saw about a 22 percent (needlestick) reduction in the first six months. After the first year, we had a 31 percent reduction in needlesticks from all of our units.
There is a huge opportunity to link sustainability and infection control to the use of sharps containers and reusable pharmaceutical waste containers, Gillmeister says. There are 2.36 million estimated sharps containers of all types in hospitals at any one given time. Experts predict that 30 percent of these containers are reusable.(6) When reusable containers are proactively changed, this practice better protects staff, patients and visitors. The benefits are numerous when one considers reduction in risk and needlesticks; cost avoidance and savings; clinical best practices, safety and the environment.
Gillmeister points to a 2009 telephone survey conducted with 52 infection preventionists from hospitals across the country (licensed bed capacity ranged from 69 to 2,000-plus). The survey examined the influence of reusable sharps containers on sharps injury rates and medical waste management. One hundred percent of respondents indicated a significant decline in disposal needlesticks with 77 percent averaging 0-1/year, and 100 percent of respondents preferred the reusable container for its positive environmental impact. Ninety-one percent of respondents agreed that using reusable containers is a clinical best practice; 85 percent agreed that utilizing a system with a proactive container exchange increased safety outcomes; and 90 percent responded that they would highly recommend. All survey participants prefer reusable containers to disposable ones and saw a decline in needlesticks; 82 percent of participants cited environmental benefits for using reusable containers instead of disposable ones.
In addition to reducing risk and needlesticks, infection preventionist, Sandra Gallegos of St. Mary Corwin Medical Center in Pueblo, Colo. estimates that using BioSystems saves thousands of dollars. Consider that each needle stick incident can cost approximately $5,000 to test and to process a report on an injured staff member, Gallegos says.
There are many opportunities for a healthcare facility to re-use, recycle or re-purpose items. Increasing recycling percentages is a great place for a green team to start, says Gillmeister. Currently, Practice GreenHealths Hospital Partners for Change cite the average:
- Recyclables percentage from total waste is 27 percent (the average high is 35 percent)
- RMW percentage of total waste of these hospitals is approximately 9 percent
- MSW percentage of total waste in 2010 is 56 percent
A Stericycle 2010 healthcare waste stream survey of 200 hospitals identified industry best practices for managing waste. The survey found that the average hospital recycles less than 14 percent of its total waste. A 24-month Stericycle case study of pharmaceutical waste reusable containers tracked the reuse rates for 2,340 containers serviced in a 150-bed hospital. Combined, eight-gallon and 17-gallon reusable containers accounted for 97 percent of the pharmaceutical waste containers used hospital-wide during the study. In comparison, to two of the leading manufacturers of pharmaceutical waste disposable containers, Stericycles reusable containers diverted between 3.4 and 4.7 tons of plastic from disposal, therefore minimizing landfill contributions and reducing hospital disposal costs.
1. The Business Case for Greening the Health Care Sector. Practice Greenhealth. Report prepared by the
Institute for Innovation in Large Organizations. 2008.
2. Chung JW and Meltzer DO. Estimate of the carbon footprint of the U.S. healthcare sector. JAMA. Nov. 11, 2009; 302: 1970 -1972.
3. Practice Greenhealth. 2010 Benchmark Report.
4. Kwakye G, Pronovost PJ and Makary MA. A call to go green in healthcare by reprocessing medical equipment. Academic Med. 85(3):398-400. March 2010.
6. Garcia R and Olmsted R. An epidemiologic perspective for the infection control professional: Reusable sharps container. Stericycle white paper. 2010.