It’s something that a patient who is worried about a surgery or recovering from a trauma is unlikely to think about. But behind the scenes, plastic syringes, single-use gowns, sterile packaging, surgical instruments and much more are piling into dumpsters.
While the amount of waste is difficult to quantify, a report from the Ontario Hospital Association estimates hospitals are responsible for at least 1% of non-residential landfill waste.
Hospital waste comes from areas like food, electronic and paper waste, but the biggest source is clinical care. It’s estimated that North American operating rooms alone are responsible for 20%-33% of total hospital waste. And a US study found that a single hysterectomy produced 20 pounds of waste in plastic, packaging, drapes, and so on (bio-waste was not included).
The problem may be getting worse – due to patient safety, cost and convenience, more and more clinical instruments and supplies are being marked as “single use” and thrown out.
South of the border, however, major health organizations are beginning to push the pendulum back, calling for a new approach to hospital procurement that minimizes waste from manufacturing to the disposal of medical supplies. And Canadian hospitals are beginning to pay attention.
The rise of throw-away medical supplies
The use of disposable items in health care is nothing new. IV tubing, for example, has been thrown out since the 1960s because it is near impossible to adequately clean. Disposable surgical drapes have been used for the last 20 years, says Victoria Noguera, director of Perioperative Services and Gynecology at Women’s College Hospital.
But the shift toward disposables is still continuing “with disposable [surgical] instruments being the latest in that trend,” according to Cassandra Thiel, an assistant professor at the School of Medicine and Wagner Graduate School of Public Service of New York University.
According to a Toronto doctor who wishes to remain anonymous, for procedures outside the OR, scissors, suturing equipment and so on used to be resterilized and wrapped in washable linen (which would be used in the procedure). Within the last year, these instruments have all been switched over to the disposable kind. And the surgical trays are now wrapped in plastic, which is also thrown out. “If a piece of equipment breaks, I now have to open a new tray and throw out all the equipment in that tray as well,” she says. “It’s kind of shocking the amount of garbage that’s created.”
In many cases, the move has to do with mandatory rules. Health Canada and Ministry of Health standards “dictate what can be reused and not reused,” explains Susan Reader, executive director of Surgical Services and Allied Health at Rockyview General Hospital in Calgary. Plus, she explains, as infection outbreaks reveal weak spots with supplies that are difficult to sterilize completely, more instruments become legally mandated as single use. “We know that there are supplies used in patient care that, if not managed properly, will spread infections and kill people,” says Reader.
More cost-effective disposable products have also come on to the market because of advances in manufacturing technology. Also, manufacturers may be erring towards more “single use” items to avoid liability when they’re not certain a product can be 100% sterilized. Recently, says Ann Mitchell, clinical director of obstetrics and gynecology at The Ottawa Hospital, breast pump equipment once sterilized by hospitals was suddenly marked as single use, meaning the plastic tubing had to be thrown out after each feed. When hospital leaders questioned the move, the company compromised and marked the equipment as single patient – so that one patient could use the same equipment during the course of her hospital stay.
Disposables can also be cost-driven. They’re sometimes cheaper than buying much more expensive reusable supplies that must be washed and are themselves thrown out with wear and tear. Mitchell says her hospital is saving tens of thousands of dollars a year by moving to disposable fetal monitoring belts, for example.
In many other cases, however, disposables are more expensive in the long run. Yet, the low upfront costs of disposables can make them enticing for procurement managers who are tasked with saving money over a specific time period, explains Fiona Miller, a professor at the Institute of Health Policy, Management and Evaluation, University of Toronto.
Efforts to improve hospitals’ waste production
In the US, several organizations are calling for more environmental products. Earlier this year, four major health care companies and two NGOs launched the Greenhealth Exchange, an organization that will investigate and promote green alternatives.
The “online marketplace” will be open to fee paying members and is expected to be a broker for about 500 validated products, says John Strong, the CEO of Greenhealth Exchange. When it comes to clinical supplies, he explains that leaders want to start with products used in the Neonatal and Pediatric ICUs, as “our youngest patients are the most vulnerable to having health effects from some of the [toxic] chemicals that can be found in plastic products like IV tubing.”
Of course, green products can often be more expensive than more waste-creating alternatives, because they have smaller markets and may use more expensive raw materials. For this reason, members will agree to bulk purchasing items in order to drive down the price, explains Strong. Still, in cases where the environmental benefits are high, companies are willing to pay premiums to meet corporate social responsibility goals.
The Greenhealth Exchange leaders meet with vendors to find out about their manufacturing and shipping practices, calculate waste and carbon emissions, and even sometimes independently investigate the chemicals found in products to ensure non-toxicity, explains Strong. “We look at the entire supply chain,” he says.
According to Thiel, this “life cycle” analysis is key. “A lot of the raw materials for hospital supplies are coming from all over the world, they’re being shipped to other parts of the world for manufacturing and then the finished products are shipped to the hospitals,” she says. “Usually, the manufacturing of these products has a far bigger environmental impact than the disposal of them.”
In addition, this September, the non-profit Practice Green Health is launching a free “total cost of ownership tool” that will help hospitals understand the long-term costs of disposable versus reusable products. The tool allows hospitals to enter everything from the costs they pay to dispose waste, to how often they’ll need to repurchase disposables, to the costs of water for sterilization. “If you look at just the price tag for the item, disposables seem far cheaper. But by capturing some of the cost to use the product over the long term, you’re making a better informed purchasing decision,” explains Beth Eckl, director of the Environmental Purchasing Program at Practice Greenhealth.
Canada, meanwhile lags behind. “The US is much further ahead on this than we are in Canada,” explains Ed Rubinstein, director of Environmental Compliance, Energy, and Sustainability at the University Health Network (UHN) in Toronto.
But isolated hospitals are making changes. The Children’s Hospital of Eastern Ontario is in the process of moving toward a green purchasing strategy, which it’s developing in partnership with Canadian Coalition for Green Healthcare. (The draft plan is currently available online for other hospitals to utilize.)
UHN has had a green procurement policy in place since 2001, in which procurement staff investigate to see if reusable or more environmentally friendly alternatives are available, according to Rubinstein.
At Toronto Western Hospital, meanwhile, a neurosurgery team led by Dr. Michael Tymianski was able to save hundreds of thousands by making the switch to reusables.
In many cases, however, UHN buys in bulk with a group with other hospitals, and it’s been difficult to get environmental considerations at the forefront of buying decisions, says Rubinstein. “It’s kind of like the tail trying to wag the dog,” he says. While many of his colleagues at other hospitals have expressed interest in environmentally friendly supplies, “there aren’t too many hospitals who have a team like us who look at sustainability, and it’s a difficult thing to do as a side job.”
And even when UHN is buying just for its own organizations, the hospital network doesn’t have the resources to assess complicated environmental impact factors like where a product has been shipped from, chemicals released in the degradation process and much more.
Ways to minimize the impact of disposables
Where disposables are the only safe option, there are ways to reduce their footprint, starting with how they’re packaged. “Sometimes the packaging is quite excessive, an instrument might be packaged in a package in another package,” says Paul Belletrutti, a Calgary-based gastroenterologist. “Then there’s a big thick manual for each one in 100 different languages.” Though it may be difficult for one small organization to convince a manufacturer to change, hospitals can get together to pressure manufacturers to reduce packaging.
The cardboard and plastic packaging – and even the supplies themselves – could also be recycled by hospitals to a much greater degree, according to frontline providers. “There’s so much in a garbage bin that’s not truly garbage,” says Belletrutti. While recycling bins can be available in procedure and operating rooms, due to the need for a quick change-over, often the clean-up crew collects all the waste together, throwing both recyclables and non-recyclables in the garbage, says Belletrutti. (A couple of other providers spoken to for this article said the same thing happens at their hospitals.)
Some hospitals have taken aim at recycling medical supplies and packaging, however. Noguera says about six years ago, staff at Women’s College Hospital brought in a program to ensure that all paper and plastic packaging of medical supplies is recycled. And UHN has a “green team” of more than 600 staff volunteers. They attend training sessions and report back to green leaders in the hospital about how recycling and other waste diversion efforts are working on the ground. The staff members have instigated changes, both small (such as where a bin is placed) and big (such as a new program for recycling certain metals), according to Rubinstein.
UHN also conducts waste audits once a year, in which two to three departments in the hospital are randomly targeted and housekeeping and environmental staff quantify how much recyclable material is ending up in garbage bins, and vice versa. Feedback is provided to the unit, and if poor waste management is found, the environmental team works with the unit’s leaders to improve waste diversion through education sessions, new signage and recruiting green team volunteers in the unit. Then, another audit is done months later to see if there’s been improvement.
Still, Miller points out that it remains voluntary for hospitals to implement green disposal and/or procurement programs. In her view, the best way to reduce waste coming from operating rooms and patient wards is to financially incentivize change. Provincial and local governments can increase the costs of waste for hospitals and reward hospitals that can demonstrate landfill reduction, for example, she says.
She also thinks hospitals should be encouraged to buy more socially responsibly, given that many health supplies are produced around the globe by people working in dangerous conditions for poverty-level wages. “The health, environmental and social costs of the production of these consumables is something that doesn’t get costed,” she says.