Natasha Menezes

A recent article written by Ingfei Chen, published on the New York Times website discusses the significant garbage issue that is produced by the health care industry. Chen explains that of the many billions of pounds of garbage that is created by hospitals, doctor’s offices, clinics and other health facilities, is a myriad of “unused disposable medical devises and supplies, as well as used, but recyclable, supplies and equipment, from excess syringes and gauze to surgical instruments.”

It appears that this massive waste crisis began because of the increased use of disposables. The increase in the amount of disposable equipment and supplies was born in order to make it easier to keep treatment practices sterile. Getting the health care industry to change its habits, however, is no easy feat. Although there is no one currently keeping track of the amount of medical waste the United States generates, the last estimated amount from the early 1990’s of two million tons a year gives us an idea of just how gross an amount of waste the United States is dealing with.

The health care industry has only just started to come to grips with the amount of waste it produces, and, apparently, its main motivational factor for that is that many hospitals that are suffering monetarily are looking for ways to cut costs.

Chen then introduced Cecilia DeLoach Lynn, who is the Director of Sustainability Education at a non-profit group called Practice Greenhealth. DeLoach Lynn mentioned that there is a huge shift in the attitude of the health care industry in terms of their impact on the environment and the footprint of the industry.

She continued to elaborate that “once upon a time, you had to do a lot of door-knocking to get anybody to pay attention. These days, folks are asking us not whether or not they should by doing it, but how.” At present, there are approximately 1,100 hospitals and 80 companies who are members of Practice Greenhealth.

According to the article, one of the main sources of medical waste is the operating room. The operating room contributes around 20 to 30 percent of the hospital’s waste.

Practice Greenhealth announced in a meeting in May that they will be launching a project called Greening the O.R. This initiative will survey and investigate the best sustainable methods to reduce garbage, energy consumption and indoor air quality problems in the operating room; while at the same time reducing costs and increasing safety.

Chen writes that if the huge amount of disposal of medical supplies and equipment is eradicated, it can lead to massive savings on new purchases, as well as the grand fees that accompany incineration and landfills. A number of health care institutions have begun reducing their use of materials, recycling what they do not use, and donating leftover, but still usable, items to developing countries.

The March edition of Academic Medicine had a commentary by Dr. Martin A. Makary, a gastrointestinal surgeon at Johns Hopkins School of Medicine. Dr. Makary and his colleagues gave some useful advice for medical centres that are looking for ways to be more environmentally friendly. For example, the commentary mentioned that “several reprocessing companies take certain disposables – like orthopaedic drill bits and heart-monitoring catheters – and clean, recalibrate, repackage and re-sterilize them, then sell them back to hospitals and medical suppliers for 40 to 60 percent of the price of new ones.”

Dr. Makary expressed that the movement began for her two years ago when she was performing laparoscopic surgery and looked into the wastebasket in the operating room. Dr. Makary stressed that the wastebasket was full of “perfectly good equipment, much of which was either barely used or never used. The unused devices came from sterilized surgical kits that were opened for the operation; no longer sterile, they got tossed.”

Previously, the majority of medical devices (those made from durable metal, glass or rubber) would be disinfected for a number of reuses. However, in the 1980’s single-use devices took over the industry. One of the reasons for this shift was because of rising fears around the growing H.I.V epidemic and the then feared peril of recycling equipment.

Later it became known that the virus was killed using sterilization techniques, but by that time, using disposable devices and equipment was such a habit that the use kept growing. Dr. Makary stated that he noticed more and more of his surgical tools being replaced by disposables, and that it was a way for the industry to make more money.

Dr. Makary worked with a colleague, Dr. Peter H. Pronovost, and Gifty Kwakye, a graduate student at the time, to investigate for evidence that patients were harmed by the use of recycled devices. They found no evidence of patience being harmed during their research. From the available data, a report was produced by the Government Accountability Office in 2008, stating that there is “no additional health risk from reprocessed disposables.” The researchers at Johns Hopkins concluded that “reprocessing has a reliable safety record of excellence identical to that of new equipment.” Furthermore, Johns Hopkins has an agreement with a reprocessing company to reprocess some of the hospital’s equipment and is looking to expand the list of equipment they recycle.

While recycled devices have gained F.D.A clearance (based on review of additional data to validate the safety and effectiveness of the equipment), the Advanced Medical Technology Association is still questioning the safety of recycled products, data for which the F.D.A does not require. However, the F.D.A mentioned that only a small fraction of the reprocessed devices were exempt from the extra validation data requirement, and that was because they posed a low safety risk. For example, blood pressure cuffs and other pieces of equipment that may be in contact with the skin, but do not actually penetrate it.

Today, a large variety of health care organizations use and support reprocessed equipment and maintain that reprocessing is a safe approach. At present, more than half of the nation’s hospitals send single-use devices to be reprocessed.

A study that was conducted in 2009 by Ascent Healthcare Solutions, one of the major reprocessing companies in the United States, approximated that of its 1,800 hospital clients, 2,650 tons of garbage was diverted from landfills. In particular, the Hospital Corporation of America, which owns 163 hospitals, managed to eradicate 94 tons of waste by adopting the reprocessing strategy.

Dr. Rafael Andrade, a surgeon at the University of Minnesota Medical Centre, emphasized that although recycling is proving helpful and is reducing waste, eventually even reprocessed disposables will have to be thrown away at some point. He stressed that the bigger goal should be to “resume the old practice of relying on permanently reusable equipment. We’re just trying to undo a lot of damage we’ve done.”

Dr. Andrade also mentioned that another way to approach this is to reduce the amount of disposables at the source. For example, restructuring the packaged surgical kits would be a good start. Rather than filling them with instruments that don’t get used, vendors can remove the supplies that never get used from the kits.

Chen illustrates a case where this method was implemented in the kits used for implanting an intravenous port in chemotherapy patients. The kits started out consisting of 44 items. However, the team managed to eliminate 17 items, bringing the kits down to 27 items, and also managed to use reusable gowns and linens rather than disposable ones. The result was that they managed to shave-off a pound of waste and $50 in supply costs per procedure. The various kit restructuring prevented 7,792 pounds of waste and saved $104,658.

The surgeons at Rochester General Hospital are following similar procedures with their kits. Their goal is to “work systems out so they don’t have anything to reprocess.” The Chief of Plastic Surgery, Dr. Ralph Pennino, started a non-profit organization in 1989 called InterVol, where all leftover supplies and instruments are donated. Approximately 8,000 pounds of unused supplies and reusable equipment are collected each week by the volunteers from various health care facilities in the region. The collection is then shipped to clinics in more than two dozen countries. Included in this list of countries receiving the donations are Haiti and Somalia. When the January earthquake occurred in Haiti, InterVol sent two jets with teams of doctors and nurses, along with 8,000 pounds of supplies.

Dr. Pennino highlighted, “anything we collect would have been disposed of, including hospital beds, operating tables, crutches and, in one instance, tens of thousands of brand new hypodermic needles.” Project C.U.R.E is another humanitarian relief organization that does similar work to InterVol. With non-profit organizations like these, there is a massive amount of waste prevention, cost savings and provision of much needed supplies and reusable equipment to countries in need.

Hopefully the realization that the disposable societal behaviour that the industry has become accustomed to, in comparison to the demand of reused equipment and unused supplies in needy countries, will pave the road back to the eventual return to relying on permanently reusable equipment, as proposed by Dr. Andrade.