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AORN Special Committee on Environmental Issues reports environmental survey results
OCTOBER 1994, VOL 60, NO 4
AORN Special Committee on
Environmental Issues reports environmental survey results he fragility of life enhances our concerns about natural resources. Health care, in particular, is under extraordinary environmental and financial pressures as we move toward a new century and the thiid millennium. As a result, clinicians are confronted with complex issues such as infectious waste management, choices between single-use and reusable products, and the growing concern about infection control. Trade-offs and acceptable risks are not new to medicine. Major questions and emotional reactions call upon us to examine and make prudent decisions about delivering the “best medicine” while weighing outcomes for our patients, the cost to society, and the impact on the environment. The OR is a crucial frontier in establishing these balanced choices.
BACKGROUND In 1990, AORN established the Special Committee on Environmental Issues in response to growing Concerns regarding waste management in the OR. One of the Committee’s objectives was to survey OR directors to obtain information on institutional responses to the threat of surgical waste to the environment. The Committee developed a research survey and mailed it to OR directors at 500 hospitals across the United States. One hundred seventyfive directors responded, forming the first benchmark for understanding practices and perceptions on environmental issues facing the OR.
Sixty-two percent of the respondents believed that they had a great deal of influence in departmental environmental policy. At that time, environmental concerns had become a widespread public issue. A 1990 survey of 1,000 consumers reported that 47% were “very concerned” about the environmental impact of the products they purchased; 4 1% described themselves as “somewhat concerned.”’ The AORN survey results show that most hospital waste was disposed of in regulated waste containers (ie, red bags), and 77% of the directors reported that their hospitals were increasing use of singleuse products because of convenience, infection control, and environmental Concerns. At the 1994 AORN Congress, two seminars were held on environmental issues. The Special Committee on Environmental Issues conducted a comprehensive survey to expand its understanding and compare key findings to the 1990 study. Ethicon EndoSurgery, Cincinnati, sponsored and coordinated the project. Project objectives and the questionnaire were developed in cooperation with the Special Committee on Environmental Issues. The principal objective of this research was to understand OR staff members’ perceptions and practices on environmental issues with a focus on R the OR waste stream and R single-use and reusable products. 652 AORN JOURNAL
Health and safety issues also were included in the study due to increasing concerns within the health care community. More than 1,OOO questionnaires were distributed, and 488 were returned. Bruno and Ridgeway Research Associates, Inc, Lawrenceville, NJ, an independent research f i i , tabulated and compiled the results. Table 1 shows the demographics of study participants.
WASTE STREAM Finding the right balance between the safe handling of infectious waste and an efficient waste segregation program has been an ongoing challenge within the medical community. A 1992environmental study conducted by the American Hospital Association reports that 40% of health care facilities were treating more medical waste as regulated (ie, infectious) than is requiredby most ~tates.~ Red bags. According to the 1994 survey conducted by the Special Committee on Environmental Issues, OR personnel made significant efforts to increase the segregation of regulated and nonregulated (ie, noninfectious) waste. In 1990,57% of respondents stated that their facilities segregated waste; in 1994,85% of respondents stated that their facilities segregated waste. Respondents reported that they segregate items prior to surgery (73%), during surgery (71%), and after surgery (63%). Despite this information and the latitude granted by various state and local regulations,
OCTOBER 1994, VOL 60, NO 4
Table 2
Table 1 supports discarding the sharp components of laparoscopic instruments in a sharps container. Ranae " of nursina exDerience Nontraumatic components may be OR nursing staff 450'0 discarded in a red bag. OR management Clear bogs. The 1994 survey 31 yo also quantifies the use of clear bags other clinical and in the OR. Eighty-one percent of 24% administrative positions respondents reported that they dis21 average years in practice pose of surgical product packaging and sterilization wrappers in clear bags. Specific attention has been Types of health care given to red bag and clear bag segfacilities rewesented regation in westem states where private hospitals 58% of drapes, 59% of gowns, and 28% network hospitals 90% of product packaging and sterilization wrappers are placed in 23% teaching institutions clear bags. ambulatory surgery Hospital personnel continue to 4% centers dispose of regulated medical 15% waste in various ways. Table 3 other facilities indicates all disposal methods that respondents reported using at their Geogrophic distribution facilities. Total percentages 18% northeast exceed 100% because some facili25% midwest ties use more than one disposal method. Northeastern states pro31 yo south vided the only significant regional 24% west difference; 6 1% of hospitals nationwide use landfills, but only 2O/O international 45% of hospitals in northeastern states use landfills. Size of the institution Recycling. The 1994 survey also 1 1 provides information on recycling average number of ORs practices in the O R this information average number of inpatient 88 was not included in the 1990 survey. DrOCedUreS Der week Although recycling has been a key average number of outpatient element in hospital-wide waste procedures per week 93 management programs for several years, it now is beginning to emerge as a standard practice in the OR. A the 1994 survey results show that small percentage of respondents reported that their ORs sort and most OR waste still is treated as regulated medical waste and disrecycle product packaging (7%) and posed of in red bags or in sharps sterilizationwrappers (6%). containers (Table 2). Although 31 % of respondents reported that SINGLE-USE AND REUSABLE PRODUCTS they dispose of laparoscopic instruments in red bags, the majorA primary objective of the ity (74%) dispose of these instruresearch was to examine the curments in sharps containers. AORN rent use of single-use and reusable
" .
32%
653 AORN JOURNAL
laparoscopic instruments
3 1O/O
IV tubing
59%
gowns
7 2O/O
drapes
79%
blood/bodilyfluids
87%
sponges/dressings
93%
Table 3
third-party waste management
67%
la ndfiII
61 YO
autoclaving
60%
compacting and shredding
49 '/o
chemical processes
40%
irradiation
28%
products within the hospital. The questions asked in the 1994 survey specifically addressed drapes, gowns, basins, and laparoscopic instruments. Survey responses confirm that many hospitals use a combination of single-use and reusable items (Table 4). Both the 1990 and 1994 studies ask respondents whether they had switched from reusable to single-use items or vice versa in the past few years (Figure 1). Drapes, gowns, and basins. The 1994 study reveals the following. The use of single-use drapes peaked during the past four years, while the use of reusable linens (although incrementally smaller than that of single-use drapes) has nearly doubled since 1990.
OCTOBER 1994, VOL 60, NO 4
Table 4 1990
1994
single-use drapes
96%
98%
reusable drapes
19%
36%
single-use gowns
90%
reusable gowns
41 yo
single-use basins
40%
59%
reusable basins
54%
77%
Today, the use of both singleuse and reusable gowns is similar to that of drapes, although the use is distributed more evenly between the two systems. The use of single-use and reusable basins has increased since 1990. The amount of switching from single-use to reusable drapes remained the same (7%) from 1990 to 1994. The rate of conversion from reusables to single-use drapes was significantly higher in 1990 (21%) than in 1994 (10%). In 1994, 18% of respondents reported they had switched from single-use to reusable gowns, and 9% had switched from reusable to single-use gowns. The 1990 study did not address gown use. Switching from single-use to reusable basins increased from 3% in 1990 to 18% in 1994; conversely, the rate of switching from reusable to single-use basins decreased from 2 1% in 1990 to 9% in 1994. Several factors affected hospitals' decisions regarding single-use and reusable drapes, gowns, and basins. Among- those that switched from single-use to reusable drapes,
gowns, and basins, cost and the environment were the two top considerations. Those that switched from reusable to single-use items indicated infection control, convenience, and cost as their most important reasons. Cost was mentioned as a selection criteria for both single-use and reusable products, which suggests that the actual system costs of each may not be clearly understood. It would seem appropriate for all involved parties to evaluate these products on an individual basis. AORN recognizes that both singleuse and reusable products have environmental impacts that need to be considered when making product selections. Laparoscopic instruments. The 1994 study includes laparoscopic instruments as another example of
the single-use and reusable considerations in the OR. Eighty-eight percent of respondents reported that they use a combination of single-use and reusable laparoscopic instruments. Seventy-four percent of respondents reported having increased their use of single-use laparoscopic instruments in the past few years and cited surgeon preference, product features, product quality, and convenience as the top reasons. Fifty percent of respondents said that they have increased their use of reusable laparoscopic instruments because of cost and surgeon preference. The switch to single-use laparoscopic instruments also can be attributed to the increased volume of laparoscopic procedures. The conversion rates of the last two years suggest that many ORs
Figure 1 25%
25%
I
21%
0% I
0% 1990
1990
1994
Single-use to reusable drapes
1994
Reusable to single-use drapes 25%
18%
0%
1
/
0%
1990
1994
Single-use to reusable basins 654 AORN JOURNAL
L 1990
1994
Reusable to single-use basins
OCTOBER 1994, VOL 60, NO 4
will continue to use some combination of single-use and reusable laparoscopic instruments. When choosing laparoscopic instruments, each facility should evaluate the advantages and disadvantages of both systems.
HEALTH AND SAFETY ISSUES Health and safety issues are important to all health care professionals, including the survey respondents. When asked to rank the environmental and health care issues that concern them most, patient protection was chosen as the number one concern by 55% of all respondents. Other issues of concern included staff protection (12%), the volume of infectious waste (8%), and the use of landfills (8%). The survey also investigated specific conditions and practices that affect health and safety. Bloodto-skin contact during perioperative procedures was reported as an infrequent occurrence; 57% of respondents said they “rarely” or “never” experience such contact, and 35% of respondents said that such contact occurs “sometimes.” Eight percent of respondents indicated that blood-to-skin contact occurs “frequently,” primarily on
the hand (83%) and, to a much lesser extent, on the face (34%). Respondents reported that personal protection items are readily available in 94% of ORs. Fiftyseven percent of respondents (especially surgeons and scrub nurses) practice double gloving. According to respondents, orthopedic procedures are the cases most likely to cause either blood-to-skin contact (3 1%) or result in staff members’ double gloving (71%).
MAKING A DIFFERENCE Sound environmental choices in the OR can be made only with a complete understanding of all the facts and circumstances as they relate to individual facilities. The best way for OR staff members to chart a reasoned and progressive response to environmental concerns is by continuing education on the issues. The goal should be to raise the level of awareness and knowledge about all relevant issues, including waste management, new OR practices, hospital policies, and government regulations. It is encouraging to report that 72% of survey respondents already perceive that the role of the perioperative nurse includes practicing
NOTES 1. C Spry et al, “A report on infectious and noninfectious waste disposal and its relation to the overall waste problem,” AORN Journal 53 (April 1991)905-916. 2. Sterling GroupPenn & Schoen telephone survey of 1,000 adults conducted May 1990.
and monitoring environmental initiatives. In addition, 36% believe that their responsibilities as OR nurses include initiating and encouraging recycling and education. With ongoing education and focused personal efforts, OR nurses can continue to advance the OR’Spart in environmental responsibility. The Special Committee on Environmental Issues will serve as a springboard for more individual investigation of what is currently practiced in ORs and what environmental measures can be incorporated in the future. JEANNIE BOTSFORD RN, MS, CNOR CHAIR JANET K. HIXON RN, MA, STAFF CONSULTANT SPECIALCOMMIITEE ON ENVIRONMENTALISSUES The authors acknowledge Michelle Burke, RN, SR John W McDowell, PhD, Janet K Schulf’z, RN, MSN, and Carla J Willis, RN, MS, CNOR, members af the Special Committee on Environmental Issues, fortheir assistance with this amcle, ond they acknowledge Margi Butler and the Stefling Group forfunding the study
SUGGESTED READING “Recommended practices for environmental responsibility in the practice setting,”in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1994) 155-159.
655 AORN JOURNAL
AORN Special Committee on
Environmental Issues reports environmental survey results he fragility of life enhances our concerns about natural resources. Health care, in particular, is under extraordinary environmental and financial pressures as we move toward a new century and the thiid millennium. As a result, clinicians are confronted with complex issues such as infectious waste management, choices between single-use and reusable products, and the growing concern about infection control. Trade-offs and acceptable risks are not new to medicine. Major questions and emotional reactions call upon us to examine and make prudent decisions about delivering the “best medicine” while weighing outcomes for our patients, the cost to society, and the impact on the environment. The OR is a crucial frontier in establishing these balanced choices.
BACKGROUND In 1990, AORN established the Special Committee on Environmental Issues in response to growing Concerns regarding waste management in the OR. One of the Committee’s objectives was to survey OR directors to obtain information on institutional responses to the threat of surgical waste to the environment. The Committee developed a research survey and mailed it to OR directors at 500 hospitals across the United States. One hundred seventyfive directors responded, forming the first benchmark for understanding practices and perceptions on environmental issues facing the OR.
Sixty-two percent of the respondents believed that they had a great deal of influence in departmental environmental policy. At that time, environmental concerns had become a widespread public issue. A 1990 survey of 1,000 consumers reported that 47% were “very concerned” about the environmental impact of the products they purchased; 4 1% described themselves as “somewhat concerned.”’ The AORN survey results show that most hospital waste was disposed of in regulated waste containers (ie, red bags), and 77% of the directors reported that their hospitals were increasing use of singleuse products because of convenience, infection control, and environmental Concerns. At the 1994 AORN Congress, two seminars were held on environmental issues. The Special Committee on Environmental Issues conducted a comprehensive survey to expand its understanding and compare key findings to the 1990 study. Ethicon EndoSurgery, Cincinnati, sponsored and coordinated the project. Project objectives and the questionnaire were developed in cooperation with the Special Committee on Environmental Issues. The principal objective of this research was to understand OR staff members’ perceptions and practices on environmental issues with a focus on R the OR waste stream and R single-use and reusable products. 652 AORN JOURNAL
Health and safety issues also were included in the study due to increasing concerns within the health care community. More than 1,OOO questionnaires were distributed, and 488 were returned. Bruno and Ridgeway Research Associates, Inc, Lawrenceville, NJ, an independent research f i i , tabulated and compiled the results. Table 1 shows the demographics of study participants.
WASTE STREAM Finding the right balance between the safe handling of infectious waste and an efficient waste segregation program has been an ongoing challenge within the medical community. A 1992environmental study conducted by the American Hospital Association reports that 40% of health care facilities were treating more medical waste as regulated (ie, infectious) than is requiredby most ~tates.~ Red bags. According to the 1994 survey conducted by the Special Committee on Environmental Issues, OR personnel made significant efforts to increase the segregation of regulated and nonregulated (ie, noninfectious) waste. In 1990,57% of respondents stated that their facilities segregated waste; in 1994,85% of respondents stated that their facilities segregated waste. Respondents reported that they segregate items prior to surgery (73%), during surgery (71%), and after surgery (63%). Despite this information and the latitude granted by various state and local regulations,
OCTOBER 1994, VOL 60, NO 4
Table 2
Table 1 supports discarding the sharp components of laparoscopic instruments in a sharps container. Ranae " of nursina exDerience Nontraumatic components may be OR nursing staff 450'0 discarded in a red bag. OR management Clear bogs. The 1994 survey 31 yo also quantifies the use of clear bags other clinical and in the OR. Eighty-one percent of 24% administrative positions respondents reported that they dis21 average years in practice pose of surgical product packaging and sterilization wrappers in clear bags. Specific attention has been Types of health care given to red bag and clear bag segfacilities rewesented regation in westem states where private hospitals 58% of drapes, 59% of gowns, and 28% network hospitals 90% of product packaging and sterilization wrappers are placed in 23% teaching institutions clear bags. ambulatory surgery Hospital personnel continue to 4% centers dispose of regulated medical 15% waste in various ways. Table 3 other facilities indicates all disposal methods that respondents reported using at their Geogrophic distribution facilities. Total percentages 18% northeast exceed 100% because some facili25% midwest ties use more than one disposal method. Northeastern states pro31 yo south vided the only significant regional 24% west difference; 6 1% of hospitals nationwide use landfills, but only 2O/O international 45% of hospitals in northeastern states use landfills. Size of the institution Recycling. The 1994 survey also 1 1 provides information on recycling average number of ORs practices in the O R this information average number of inpatient 88 was not included in the 1990 survey. DrOCedUreS Der week Although recycling has been a key average number of outpatient element in hospital-wide waste procedures per week 93 management programs for several years, it now is beginning to emerge as a standard practice in the OR. A the 1994 survey results show that small percentage of respondents reported that their ORs sort and most OR waste still is treated as regulated medical waste and disrecycle product packaging (7%) and posed of in red bags or in sharps sterilizationwrappers (6%). containers (Table 2). Although 31 % of respondents reported that SINGLE-USE AND REUSABLE PRODUCTS they dispose of laparoscopic instruments in red bags, the majorA primary objective of the ity (74%) dispose of these instruresearch was to examine the curments in sharps containers. AORN rent use of single-use and reusable
" .
32%
653 AORN JOURNAL
laparoscopic instruments
3 1O/O
IV tubing
59%
gowns
7 2O/O
drapes
79%
blood/bodilyfluids
87%
sponges/dressings
93%
Table 3
third-party waste management
67%
la ndfiII
61 YO
autoclaving
60%
compacting and shredding
49 '/o
chemical processes
40%
irradiation
28%
products within the hospital. The questions asked in the 1994 survey specifically addressed drapes, gowns, basins, and laparoscopic instruments. Survey responses confirm that many hospitals use a combination of single-use and reusable items (Table 4). Both the 1990 and 1994 studies ask respondents whether they had switched from reusable to single-use items or vice versa in the past few years (Figure 1). Drapes, gowns, and basins. The 1994 study reveals the following. The use of single-use drapes peaked during the past four years, while the use of reusable linens (although incrementally smaller than that of single-use drapes) has nearly doubled since 1990.
OCTOBER 1994, VOL 60, NO 4
Table 4 1990
1994
single-use drapes
96%
98%
reusable drapes
19%
36%
single-use gowns
90%
reusable gowns
41 yo
single-use basins
40%
59%
reusable basins
54%
77%
Today, the use of both singleuse and reusable gowns is similar to that of drapes, although the use is distributed more evenly between the two systems. The use of single-use and reusable basins has increased since 1990. The amount of switching from single-use to reusable drapes remained the same (7%) from 1990 to 1994. The rate of conversion from reusables to single-use drapes was significantly higher in 1990 (21%) than in 1994 (10%). In 1994, 18% of respondents reported they had switched from single-use to reusable gowns, and 9% had switched from reusable to single-use gowns. The 1990 study did not address gown use. Switching from single-use to reusable basins increased from 3% in 1990 to 18% in 1994; conversely, the rate of switching from reusable to single-use basins decreased from 2 1% in 1990 to 9% in 1994. Several factors affected hospitals' decisions regarding single-use and reusable drapes, gowns, and basins. Among- those that switched from single-use to reusable drapes,
gowns, and basins, cost and the environment were the two top considerations. Those that switched from reusable to single-use items indicated infection control, convenience, and cost as their most important reasons. Cost was mentioned as a selection criteria for both single-use and reusable products, which suggests that the actual system costs of each may not be clearly understood. It would seem appropriate for all involved parties to evaluate these products on an individual basis. AORN recognizes that both singleuse and reusable products have environmental impacts that need to be considered when making product selections. Laparoscopic instruments. The 1994 study includes laparoscopic instruments as another example of
the single-use and reusable considerations in the OR. Eighty-eight percent of respondents reported that they use a combination of single-use and reusable laparoscopic instruments. Seventy-four percent of respondents reported having increased their use of single-use laparoscopic instruments in the past few years and cited surgeon preference, product features, product quality, and convenience as the top reasons. Fifty percent of respondents said that they have increased their use of reusable laparoscopic instruments because of cost and surgeon preference. The switch to single-use laparoscopic instruments also can be attributed to the increased volume of laparoscopic procedures. The conversion rates of the last two years suggest that many ORs
Figure 1 25%
25%
I
21%
0% I
0% 1990
1990
1994
Single-use to reusable drapes
1994
Reusable to single-use drapes 25%
18%
0%
1
/
0%
1990
1994
Single-use to reusable basins 654 AORN JOURNAL
L 1990
1994
Reusable to single-use basins
OCTOBER 1994, VOL 60, NO 4
will continue to use some combination of single-use and reusable laparoscopic instruments. When choosing laparoscopic instruments, each facility should evaluate the advantages and disadvantages of both systems.
HEALTH AND SAFETY ISSUES Health and safety issues are important to all health care professionals, including the survey respondents. When asked to rank the environmental and health care issues that concern them most, patient protection was chosen as the number one concern by 55% of all respondents. Other issues of concern included staff protection (12%), the volume of infectious waste (8%), and the use of landfills (8%). The survey also investigated specific conditions and practices that affect health and safety. Bloodto-skin contact during perioperative procedures was reported as an infrequent occurrence; 57% of respondents said they “rarely” or “never” experience such contact, and 35% of respondents said that such contact occurs “sometimes.” Eight percent of respondents indicated that blood-to-skin contact occurs “frequently,” primarily on
the hand (83%) and, to a much lesser extent, on the face (34%). Respondents reported that personal protection items are readily available in 94% of ORs. Fiftyseven percent of respondents (especially surgeons and scrub nurses) practice double gloving. According to respondents, orthopedic procedures are the cases most likely to cause either blood-to-skin contact (3 1%) or result in staff members’ double gloving (71%).
MAKING A DIFFERENCE Sound environmental choices in the OR can be made only with a complete understanding of all the facts and circumstances as they relate to individual facilities. The best way for OR staff members to chart a reasoned and progressive response to environmental concerns is by continuing education on the issues. The goal should be to raise the level of awareness and knowledge about all relevant issues, including waste management, new OR practices, hospital policies, and government regulations. It is encouraging to report that 72% of survey respondents already perceive that the role of the perioperative nurse includes practicing
NOTES 1. C Spry et al, “A report on infectious and noninfectious waste disposal and its relation to the overall waste problem,” AORN Journal 53 (April 1991)905-916. 2. Sterling GroupPenn & Schoen telephone survey of 1,000 adults conducted May 1990.
and monitoring environmental initiatives. In addition, 36% believe that their responsibilities as OR nurses include initiating and encouraging recycling and education. With ongoing education and focused personal efforts, OR nurses can continue to advance the OR’Spart in environmental responsibility. The Special Committee on Environmental Issues will serve as a springboard for more individual investigation of what is currently practiced in ORs and what environmental measures can be incorporated in the future. JEANNIE BOTSFORD RN, MS, CNOR CHAIR JANET K. HIXON RN, MA, STAFF CONSULTANT SPECIALCOMMIITEE ON ENVIRONMENTALISSUES The authors acknowledge Michelle Burke, RN, SR John W McDowell, PhD, Janet K Schulf’z, RN, MSN, and Carla J Willis, RN, MS, CNOR, members af the Special Committee on Environmental Issues, fortheir assistance with this amcle, ond they acknowledge Margi Butler and the Stefling Group forfunding the study
SUGGESTED READING “Recommended practices for environmental responsibility in the practice setting,”in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1994) 155-159.
655 AORN JOURNAL