EXECUTIVE SUMMARY

ORs generate a lot of waste, costing surgery centers more in purchasing and disposal costs than if they followed practical green techniques.

  • ORs can generate up to two-thirds of regulated medical waste.
  • Fluid medical waste and blue wrap are the biggest contributors to the medical waste stream.
  • As much as 30% to 40% of items in custom packs often go to waste.

ORs are major generators of waste, leaving a large energy use footprint. By focusing on practical green techniques, surgery centers can save money and help the environment.

“The operating room is really the elephant in the room because of all the intensity of supply use and energy requirements,” says Julie Moyle, RN, MSN, member engagement manager for Practice Greenhealth of Reston, VA.

ORs also log high rates of air exchange and use many disinfectant chemicals. “Operating rooms can generate up to one-third of total hospital waste and up to two-thirds of regulated medical waste,” Moyle reports, adding regulated medical waste is up to five times more expensive in disposal costs than municipal solid waste.

The CDC says healthcare facilities can take a practical approach to medical waste management by identifying waste that represents sufficient potential risk for causing infection during handling and disposal. These can include microbiology laboratory waste, pathology and anatomy waste, blood and other body fluid specimens, and contaminated sharps instruments.1

The biggest contributors to the medical waste stream are fluid medical waste and blue wrap. This blue wrap, a No. 5 plastic composed of polypropylene, is placed around trays before trays are put on a shelf. After trays are opened, the wrap goes in the trash. The material does not break down in landfills and comprises about 19% of the waste that comes out of the OR.2

Surgery centers can reduce waste and save on supply and disposal costs by taking several pragmatic steps. These include more efficient purchasing, reducing, reusing, reprocessing, repurposing, and recycling.

To start, surgery centers can reduce waste by placing only the most frequently used items in surgical custom packs. Custom packs used in operating rooms often waste 30% to 40% of the items in them. For larger surgical practices, this can translate into hundreds of thousands of dollars a year, says Gail Horvath, MSN, RN, CNOR, senior patient safety analyst and consultant at ECRI.

“My rule of thumb was that whatever you put in those packs had to be used 95% of the time,” Horvath says. “It was amazing what we removed from the packs.”

For example, the packs might include three or four surgical gowns or 20 laparotomy sponges, most of which are not needed. “Go into any operating room in the country and see people wearing surgical gowns as warm-up jackets,” Horvath says. “It sounds like a picayune thing, but it adds up to lots of money.”

A surgery center can reduce this waste by conducting an analysis of custom pack use over a two-week period. “Have staff save everything from the packs that are not used and divide them by procedure,” Horvath suggests.

Surgery centers should constantly adjust custom tray packs to reduce waste, says Don Schreiner, MBA, chief executive officer of OrthoIllinois in Rockford, IL. Schreiner says surgeons can keep preference cards that list the essentials for each procedure. The idea is to keep the list lean and always question whether each item really is essential every time.

Reducing waste in a tray pack is an ongoing process because new technologies or supplies could require adjustments. There also might be tools and parts that were disposable, but now can be refurbished and reused (e.g., high-quality metal blades that could be sharpened after each use and reused).

After data are collected on how much unused custom pack items are thrown out, a surgery center director can use the information to educate staff and help them change their behaviors. “Working with a team and surgeons, I showed them how [the savings] could make their jobs easier,” Horvath says. “I showed them the opportunity cost.”

For example, with these savings, the surgery center could send staff to conferences or purchase equipment. Still, nothing will replace the visual of a pile of waste. “We showed them, and they knew a lot of it was wasted,” Horvath says. “They thought it had to be in the [pack] just in case. Getting out of that mentality was the biggest challenge.”

Items can be listed on a preference card, but kept out of the custom pack. Instead, nonessential items can be placed on a cart, available to use if needed, and then put back into inventory if they are not used.

There are several examples of ORs repurposing supplies during the pandemic’s early months. Some people repurposed blue wrap by turning those into isolation gowns or bags to hold patients’ belongings. Others sterilized single-use N95s once a week, which could extend their lifespan by a month or two.

When a surgery center cannot find a repurposed use for discarded supplies, they could donate the material to nonprofit organizations, such as medical missions. “Blue wrap could be made into sleeping mats [or] ponchos to keep it out of the waste stream,” Moyle offers.

The COVID-19 pandemic has ushered in, at least temporarily, a return to reusable supplies. “There was a push prior to the pandemic to do single-use items because it’s cheap, quick, easy, and then you dispose of them,” says Kaeleigh Sheehan, member engagement manager and program manager for the Greening the OR Program at Practice Greenhealth. “Those hospitals that before the pandemic were using reusable linens and had more reusable items on hand were not left with quite as much of a shortfall to access linens and products when those shortages came about. Now, we’re looking at hospitals adding in more reusable items on hand.”

Supply chain disruptions continue to challenge hospitals and surgery centers as the pandemic drags on. “That just-in-time, disposable inventory wasn’t all it was cracked up to be in the face of a pandemic,” Moyle observes.

Some of Practice Greenhealth’s sustainability techniques were adopted overnight during the pandemic. “One hospital that was among the first to treat COVID-19 patients in Oregon said they went through more personal protective equipment in February and March 2020 than did their entire multihospital system in all of the previous year,” Moyle reports. “We knew we would not have enough supplies to continue to practice the way we had practiced with disposable PPE. The CDC tried to help with extended-life guidelines on how to process single-use disposables with available technologies.”

OR practices changed as organizations sought to secure their inventory. “People started looking for other options because the supply chain could not be relied upon,” Moyle says. “In some ways, the pandemic has forced us to re-examine our purchasing practices and where we’re getting our supplies from. The pandemic, in some respects, has helped reduce waste. Then, in other aspects, there’s an overreaction where they’re wrapping everything in plastic.”

For surgery centers, some items might not be practical to reuse because of the cost of directing employees to perform additional sterile processing. In other cases, there might be reusable items that can be wiped down and disinfected within a few seconds.

By spring 2021, there might be data on how much waste was generated by ORs during the first year of the COVID-19 pandemic.

“Anecdotally, I was chatting with a [leader at a health system], and they were generating 20,000 pounds of waste of isolation gowns per day during the height of the pandemic,” Moyle says. “Now, they are looking at bringing on board reusable gowns.”

Surgery centers also can improve waste management by eliminating single-use disposable supplies in fluid management systems. For example, Moyle suggests surgery centers could bypass the single-use disposable plastic suction canisters process altogether. Instead, fluid management systems can dispose of fluid medical waste by treating it and discharging it directly into a sanitary sewer, following federal guidelines.1

“This would eliminate disposable suction canisters made of plastic, eliminate the need for a chemical solidifier, and vastly reduce the amount of solidified medical waste going into the regulatory medical waste stream,” Moyle explains. “Fluid waste can make up 40% of the regulated medical waste stream in surgery. The medical waste stream is five times more expensive to dispose of than municipal solid waste.”

There is an upfront capital investment, but the return can be speedy, depending on the surgery center’s procedures and whether they generate high volumes of fluid.

Another area in which surgery centers can save considerable costs is by dialing back their HVAC systems on weekends and at night. Be sure to consult with outside experts first before making these changes. “This is a big opportunity for ambulatory surgery centers,” Sheehan says. “There are standards [that dictate centers] need to have 20 air exchanges per hour when occupied and in use. When unoccupied, these can be set back to as low as six air exchanges per hour.”

Surgery centers also can adjust the temperature to save both energy usage and costs. “Setting computers and equipment on standby or powering them down at the end of the day are small behavioral things that can result in energy savings, and that adds up,” Sheehan explains. “This translates into dollar savings as well, and prolongs the lifespan of those pieces of equipment.”

REFERENCES

  1. Centers for Disease Control and Prevention. Infection control. Background I. Regulated medical waste. Page last reviewed Nov. 5, 2015.
  2. Albert MG, Rothkopf DM. Operating room waste reduction in plastic and hand surgery. Plast Surg (Oakv) 2015;23:235-238.