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Improving Staff Knowledge of Perioperative Regulated-Waste Management
Improving Staff Knowledge of Perioperative Regulated-Waste Management KRISTEN PERREGO, BSN, RN, CNOR
ABSTRACT The mismanagement of regulated waste is a costly issue for many health care facilities. Our facility undertook a quality improvement project to determine whether increasing staff members’ knowledge of regulated-waste management would reduce its mismanagement in the surgical setting. I designed a mandatory online learning module for all perioperative staff members and obtained consent from participants to use their test scores. I also designed pre- and posteducation audits to identify the total mass of regulated waste produced in the department and to categorize which items were nonregulated according to facility standards. Personnel achieved a 41% reduction in the total mass of regulated waste sampled and a 77% reduction in nonregulated item mass. The results of the audits determined that perioperative staff members are more likely to improve compliance with the disposal of regulated waste after increasing their knowledge base. AORN J 105 (January 2017) 85-91. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.11.005 Key words: regulated waste, waste management, education, waste disposal, waste audit.
T
he mishandling of the trash generated in a perioperative department increases the disposal cost of regulated waste, which is more expensive to dispose of than nonregulated waste.1 The cost for disposing of regulated waste can range from five to eight times that of nonregulated waste.1 Regulated waste is defined by the Occupational Safety and Health Administration as liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.1(p1) Personnel at our facility in Dover, Delaware, were incorrectly disposing of some items (eg, disposable packaging, nonsoiled
gowns) in our perioperative department’s waste stream. In some situations, OR staff members were using regulated trash receptacles for all waste created after the surgical incision occurred. Conrardy et al reported that the recommended standard for the percentage of regulated medical waste in health care facilities is 15% or less of overall waste; however, researchers have found that many facilities dispose of up to 70% of waste as regulated medical waste.2(p711) Knowing how costly excess regulated-waste disposal can be to a facility’s budget and the environment, I hypothesized that proper waste management could be significantly improved through education. In an attempt to determine current staff member compliance with regulated-waste management and disposal, I developed a quality improvement project involving nine OR suites in which staff members performed approximately 600 surgical
http://dx.doi.org/10.1016/j.aorn.2016.11.005 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 85
Perrego
January 2017, Vol. 105, No. 1
Figure 1. Audit tool used to stratify collected data and track overall staff member compliance per sample taken. procedures per month. A total of 66 perioperative employees participated in this education and audit process. I created a simple, unit-based interventional audit to determine what percentage of the regulated waste produced was noncompliant with Occupational Safety and Health Administration disposal recommendations and the facility’s policies and procedures. I created an online educational module to help staff members define regulated waste and determine which items belong in the regulated-waste containers. To enact the necessary practice changes, I based the educational module on Kurt Lewin’s change model, in which an educator must first unfreeze existing knowledge, change the mindset of staff members by providing new knowledge, and then refreeze the new knowledge through establishing new standard practices.3 By following this framework, I had the opportunity to assist staff members in learning how to streamline waste management. The goal of this project was to identify whether education on the topic of regulated-waste disposal was effective in creating a change in regulated-waste management.
LITERATURE REVIEW I performed a brief literature search for documented evidence of other strategies to reduce mismanagement of waste. Key words included regulated waste, waste in the operating room, regulated waste and reduction, OR, and waste management to search in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. This search yielded several quality articles identifying the classification of regulated waste, but it produced little research related to how education may 86 j AORN Journal
improve the regulated-waste management process. Many of the articles discussed how improved management of regulated waste is cost-effective for the facility and better for the environment.4-6 Mosquera et al7 discussed how hospitalwide education can improve the correct segregation of waste and lead to savings for the facility. Mosquera et al7 performed a descriptive analysis of the waste before and after their educational intervention and found that the management of waste was improved after training.
METHODS During December 2014, I procured a total of 45 bags of regulated waste at different times of the day and on various days of the week to obtain a random selection from the scheduled procedures performed in nine OR suites. Staff members marked the regulated-waste bags with date, time, initials, and OR suite number. I used an unvalidated audit tool to stratify the data collected and track overall compliance per sample taken (Figure 1). Our infection prevention specialist, a former perioperative nurse, created and reviewed the audit tool. I measured regulated waste in both pounds and kilograms and sorted the contents of each bag. I wore personal protective equipment including a gown, gloves, mask, and eye protection and used heavy tongs to handle the waste for added protection against accidental exposure to blood or other body fluids. To measure the original mass of the bags, I used a scale that was calibrated by a member of the facility’s clinical engineering department. I measured each bag and then removed items such as protected health information, plastic bottles for saline or sterile water, IV bags, sterile disposal wrappers, prep trays,
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January 2017, Vol. 105, No. 1
and other items that are not considered regulated waste and measured the bags again. Nonregulated items that were not grossly soiled from being in the bags with regulated waste were moved to the nonregulated trash container for disposal. After determining the total mass and percentage of nonregulated waste during this month-long audit, I designed an extensive online educational module that could be completed at the participant’s own pace and made it available to all full-time and part-time staff members in the surgical services department. The goal of the learning module was to educate perioperative staff members regarding the proper management and segregation of waste. The learning module contained both a pretest and a posttest for completion. After participants completed the educational module, I performed another audit in April 2015 using the same tool, methods, and projected sample size.
Participants’ Protection The facility’s Nursing Research Council determined that no institutional review board permission was required to gather data on the components of regulated-waste bags after a surgery has been completed because no patients were involved in this project. The only participants involved with this project were staff members who had their pretest and posttest results compiled. I obtained consent for the collection of pretest and posttest scores from all employees wishing to participate in this project. To ensure that all participants had an opportunity to choose not to participate in the project if they preferred not to share their test results, the initial question on the pretest read as follows: The following educational activity encompasses a pre-test, course, and post-test related to regulated waste management. Do you consent to having your test results collected for a research study to support the determination if increased knowledge of regulated waste management will reduce the overall amount of regulated waste and improve compliance with the disposal of non-contaminated items in the regulated waste bags? Only one employee opted out of the project, and these results are not reflected in the test results data.
Perioperative Regulated-Waste Management
and surgical attendants, participated in the educational module and concurrent audit of regulated waste in the department. All new employees are required to view the presentation. I administered the pretests and posttests in an electronic format using the organization’s online learning system. After the initial pretest, the learners viewed a PowerPoint presentation that defines regulated waste and what is considered eligible for the regulated trash bags in the OR. During the presentation, I explained that the disposal of nonregulated items in the regulated-waste stream is expensive and unnecessary. Staff members had one month to complete the online learning module and take the posttest. I encouraged staff members to err on the side of caution and dispose of any item they had concerns about in a regulated-waste bag. It is the duty of perioperative staff members to correctly handle and remove biohazardous waste in a manner that protects others from exposure. Responsible handling of regulated waste from the time it is generated until its final disposal is the responsibility of all staff members.8 Safety always takes priority over cost savings.
Project Procedures I used the pretest and posttest design to assess the results of the online educational module. Many of the 14 test questions included a selection of drop-down boxes for categories of either regular or regulated waste. The test asked staff members to select the most appropriate disposal method for common items and those items that were considered nonregulated waste. In addition, the test featured questions about the definition of regulated waste and the increased costs associated with the disposal of biohazardous waste. This educational module was used to determine staff members’ pre-education knowledge of the disposal of regulated waste and to perform a review of educational needs. I reviewed the questions that posed the most difficulty for learners to improve overall compliance with regulated-waste standards. The second method for measuring improvement of regulatedwaste disposal was the pre-education and posteducation audit of regulated trash. I performed the audit myself to maintain consistency with measurements, eliminating the potential for inter-rater variations.
Description of Instruments PROJECT DESIGN I used a pretest and posttest design to assess the learning needs of staff members. A total of 66 surgical services employees, consisting of RNs, RN first assistants, surgical technologists,
www.aornjournal.org
To accurately measure the mass of the nonregulated items discovered in the regulated trash bags removed from each OR, I used a portable patient scale. In addition, the facility’s clinical engineering staff checked the device for functionality and AORN Journal j 87
Perrego
January 2017, Vol. 105, No. 1
Table 1. Test Results Before and After Education Regarding Managing Waste Participants (N ¼ 66)
Pretest Percent Correct (Overall 92%)
Posttest Percent Correct (Overall 97%)
100.00
100.00
0.00
Question 2 True or false: It is appropriate to dispose of pathological and microbial waste containing blood or other potentially infectious material in the red bag waste. (False)
93.90
96.97
3.07
Question 3 True or false: Regulated waste is segregated and disposed of separately from regular waste and is weighed for total cost of disposal. (True)
95.45
98.48
3.03
100.00
100.00
0.00
87.88
100.00
12.12
Question 6 True or false: Dressing sponges saturated with blood and serous fluid are not considered regulated waste. (False)
100.00
100.00
0.00
Question 7 True or false: Cardboard should not be placed in red bag waste. (True)
100.00
98.48
1.52
Question 8 True or false: Used Foley catheter drainage bags should be placed in regular waste and are not considered regulated waste. (True)
48.48
84.85
36.37
Question 9 True or false: Blood-soaked laparotomy sponges should be placed in red bag waste. (True)
100.00
100.00
0.00
Question 10 True or false: Used suction manifolds should be placed in regular waste and are not considered regulated waste. (False)
71.21
86.36
15.15
100.00
100.00
0.00
Question 1 True or false: Red bag waste is defined as contaminated items that would release blood or other potentially infectious materials in a liquid or semiliquid state if compressed or rehydrated. (True)
Question 4 True or false: Disposing of regulated red bag waste is more expensive than disposing of regular waste. (True) Question 5 True or false: Yesterday’s OR schedule (ie, protected health information) should be placed in the shred bin and is not considered regulated waste. (True)
Question 11 True or false: Sterile blue wrap from instrument pans should not be placed in red bag waste. (True)
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Percent Improvement (Overall 5%)
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Perioperative Regulated-Waste Management
Table 1. (continued ) Participants (N ¼ 66)
Pretest Percent Correct (Overall 92%)
Posttest Percent Correct (Overall 97%)
Question 12 True or false: Prep sticks should not be placed in red bag waste. (True)
98.48
100.00
1.52
100.00
100.00
0.00
89.39
92.42
3.03
Question 13 True or false: Blue paper filters from instrument pans should be placed in red bag waste. (False) Question 14 True or false: After making an incision, drapes and gowns from the sterile field are to be placed in the regulated red bag waste receptacle whether they are saturated with blood or bodily fluids or not. (False)
Percent Improvement (Overall 5%)
NOTE. The most improvement was seen on questions 5, 8, and 10.
safety before use. The scale measures in both kilogram and pounds and has high degrees of accuracy and repeatability. After I determined the amount of nonregulated waste using the audit tool, I created an online HealthStream educational module and offered it to all perioperative staff members. HealthStream, a learning management system, is our organization’s official tool for offering, maintaining, and reporting all professional and continuing education for employees.
RESULTS After the waste management educational program, staff member compliance with the appropriate disposal of
nonregulated items improved from 33% to 69%. Areas of additional education included compliance regarding the correct disposal of the waste generated by anesthesia professionals. The nonregulated waste produced by the anesthesia staff members during a surgical procedure may include the breathing circuit, airways, endotracheal tubes, suction catheters, oxygen masks and tubing, nasogastric tubes, and tracheostomy tubes, if they are not grossly soiled. These items qualify as regulated waste only if they are visibly and grossly contaminated with blood or other body fluids. Waste generated by anesthesia professionals has continued to be disposed of in the regulated-waste stream even when this precaution is not applicable. Staff members benefitted from education regarding the disposal of Foley drainage bags (36.37% improvement), suction manifolds (15.15% improvement), and OR schedule (12.21% improvement); test scores for these items showed the greatest improvement (Table 1). This finding indicated a need for staff member review of correct disposal procedures for these items. Of the 14 test questions, 7 questions showed improvement, 6 questions held at 100% accuracy, and 1 question showed a decrease in knowledge. In this instance, a staff member originally answered a question correct on the pretest but answered incorrectly afterwards. The incorrect answer may have been a typographical error.
Figure 2. After staff member education, there was more than a 40.68% reduction in total regulated waste.
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The regulated-waste audit showed an improvement in the total amount of regulated waste and the amount of nonregulated items contained in the waste after education. During the original audit of the selected regulated-waste bags, the total AORN Journal j 89
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Table 2. Cost Analysis of Regulated Waste Before and After Education Before Education
After Education
Average mass of regulated waste bag
10.4 lb (472 lb in 45 bags)
6.2 lb (278 lb in 45 bags)
Estimated regulated-waste cost per procedure
$2.65 (1.5 bags per procedure 10.4 lb $0.17)
$1.05 (1 bag per procedure 6.2 $0.17)
Estimated regulated-waste cost per month (600 procedures per month)a
$1,600 (600 procedures 1.5 bags $0.17)
$600 (600 procedures 1 bag $0.17)b
Estimated regulated-waste cost per year
$19,100
$7,200
a b
Estimate provided by projects manager for the department. Red bag manufacturer indicated that double red bagging of regulated waste was not necessary, and we switched to using only one bag.
mass of regulated waste measured 213.6 kg (471.4 lb), with the mass of nonregulated items totaling 131.1 kg (289.86 lb). After employees completed the educational module and training, the total mass of regulated waste measured for the 45 randomly collected bags equaled 126.7 kg (278.7 lb), with the mass of nonregulated items measuring 30.2 kg (66.44 lb). This demonstrates a 40.68% reduction in total regulatedwaste mass (Figure 2) and a 76.96% reduction in nonregulated item mass. At this facility, the finance department reports that it costs $0.04/lb for disposal of nonregulated waste and $0.21/lb for regulated waste. The 45 audited bags represent only a fraction of the number of regulated-waste bags produced in our perioperative department each day. The reduction of mass from the regulated-waste stream represents a cost savings for the organization. Taking into account the cost of the regulated-waste bags themselves in addition to the reduction of regulated waste, this facility was able to save an estimated $11,900 in one year (Table 2).
DISCUSSION Mosquera et al7 noted that increased staff member education improves the management of regulated waste. The outcomes of this project support this conclusion. A demonstrated improvement in staff member knowledge regarding the disposal of regulated waste correlated with a decrease in the amount of nonregulated waste disposed of in regulated-waste bags, creating a cost savings for our institution. The limitations of this project include the use of an original audit measurement tool that was not tested by other facilities. There may be alternative nonregulated items that would be appropriate to include in the audit at different institutions. In addition, the audit sheet did not capture the date of the procedure, making it difficult to track data to particular procedures if the need for tracking should arise. Moreover, it would help to perform a second audit of regulated waste one 90 j AORN Journal
year after the education to see whether behavior change was maintained and to confirm that no additional re-education is required. The results of this project support the hypothesis that additional regulated-waste education for perioperative staff members reduces the amount of nonregulated items placed in the regulated-waste stream. Perioperative nurses can contribute to institutional cost savings by learning about and implementing appropriate regulated-waste disposal. In addition, this educational program can be used for all of this institution’s employees, including those at both campuses and the affiliated medical offices. The management of regulated waste occurs in many of the hospital’s departments, in addition to the perioperative areas. Proper waste segregation relies heavily on the individual. A comprehensive education program would improve compliance with waste disposal protocol and improve the overall environmental footprint of the facility.
CONCLUSION The project discussed in this article is ongoing at our institution and demonstrates that additional staff member education about the correct disposal of waste can reduce the amount of incorrectly discarded items, thereby producing a cost savings. Similar education at other facilities could aid in the protection of employees and others from exposure to regulated waste, waste stream volume reduction, reduced environmental effects, and cost savings. The author recommends future re-education of staff members on nonregulated item disposal procedures to sustain and improve performance.
Editor’s notes: CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA. HealthStream is a copyrighted learning management system from HealthStream, Nashville, TN.
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References 1. Occupational Safety and Health Administration. Toxic and hazardous substances: bloodborne pathogens. 29 CFR x1910.1030(b). https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_ table¼STANDARDS&p_id=10051. Accessed August 9, 2016. 2. Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J. 2010;91(6):711-721. 3. Change theory: Kurt Lewin. Current Nursing. http://currentnursing .com/nursing_theory/change_theory.html. Revised September 12, 2011. Accessed August 9, 2016. 4. Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: simple changes to reduce cost and our carbon footprint. Am Surg. 2013;79(7):666-671. 5. McDermott-Levy R, Fazzini C. Identifying the key personnel in a nurse-initiated hospital waste reduction program. Nurs Adm Q. 2010;34(4):306-310. 6. Lee BK, Ellenbecker MJ, Moure-Ersaso R. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Manag. 2004;24(2):143-151.
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Perioperative Regulated-Waste Management 7. Mosquera M, Andres-Prado MJ, Rodríguez-Caravaca G, Latasa P, Mosquera ME. Evaluation of an education and training intervention to reduce health care waste in a tertiary hospital in Spain. Am J Infect Control. 2014;42(8): 894-897. 8. Fisher MG. Perioperative practitioners. Does waste segregation and disposal within your theatre meet the required legal standard? J Perioper Pract. 2013;23(6):127-128.
Kristen Perrego, BSN, RN, CNOR, is a clinical educator in the Surgical Services Department at Bayhealth Medical Center, Kent Campus, Dover, DE. Ms Perrego has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 91
ABSTRACT The mismanagement of regulated waste is a costly issue for many health care facilities. Our facility undertook a quality improvement project to determine whether increasing staff members’ knowledge of regulated-waste management would reduce its mismanagement in the surgical setting. I designed a mandatory online learning module for all perioperative staff members and obtained consent from participants to use their test scores. I also designed pre- and posteducation audits to identify the total mass of regulated waste produced in the department and to categorize which items were nonregulated according to facility standards. Personnel achieved a 41% reduction in the total mass of regulated waste sampled and a 77% reduction in nonregulated item mass. The results of the audits determined that perioperative staff members are more likely to improve compliance with the disposal of regulated waste after increasing their knowledge base. AORN J 105 (January 2017) 85-91. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.11.005 Key words: regulated waste, waste management, education, waste disposal, waste audit.
T
he mishandling of the trash generated in a perioperative department increases the disposal cost of regulated waste, which is more expensive to dispose of than nonregulated waste.1 The cost for disposing of regulated waste can range from five to eight times that of nonregulated waste.1 Regulated waste is defined by the Occupational Safety and Health Administration as liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.1(p1) Personnel at our facility in Dover, Delaware, were incorrectly disposing of some items (eg, disposable packaging, nonsoiled
gowns) in our perioperative department’s waste stream. In some situations, OR staff members were using regulated trash receptacles for all waste created after the surgical incision occurred. Conrardy et al reported that the recommended standard for the percentage of regulated medical waste in health care facilities is 15% or less of overall waste; however, researchers have found that many facilities dispose of up to 70% of waste as regulated medical waste.2(p711) Knowing how costly excess regulated-waste disposal can be to a facility’s budget and the environment, I hypothesized that proper waste management could be significantly improved through education. In an attempt to determine current staff member compliance with regulated-waste management and disposal, I developed a quality improvement project involving nine OR suites in which staff members performed approximately 600 surgical
http://dx.doi.org/10.1016/j.aorn.2016.11.005 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 85
Perrego
January 2017, Vol. 105, No. 1
Figure 1. Audit tool used to stratify collected data and track overall staff member compliance per sample taken. procedures per month. A total of 66 perioperative employees participated in this education and audit process. I created a simple, unit-based interventional audit to determine what percentage of the regulated waste produced was noncompliant with Occupational Safety and Health Administration disposal recommendations and the facility’s policies and procedures. I created an online educational module to help staff members define regulated waste and determine which items belong in the regulated-waste containers. To enact the necessary practice changes, I based the educational module on Kurt Lewin’s change model, in which an educator must first unfreeze existing knowledge, change the mindset of staff members by providing new knowledge, and then refreeze the new knowledge through establishing new standard practices.3 By following this framework, I had the opportunity to assist staff members in learning how to streamline waste management. The goal of this project was to identify whether education on the topic of regulated-waste disposal was effective in creating a change in regulated-waste management.
LITERATURE REVIEW I performed a brief literature search for documented evidence of other strategies to reduce mismanagement of waste. Key words included regulated waste, waste in the operating room, regulated waste and reduction, OR, and waste management to search in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. This search yielded several quality articles identifying the classification of regulated waste, but it produced little research related to how education may 86 j AORN Journal
improve the regulated-waste management process. Many of the articles discussed how improved management of regulated waste is cost-effective for the facility and better for the environment.4-6 Mosquera et al7 discussed how hospitalwide education can improve the correct segregation of waste and lead to savings for the facility. Mosquera et al7 performed a descriptive analysis of the waste before and after their educational intervention and found that the management of waste was improved after training.
METHODS During December 2014, I procured a total of 45 bags of regulated waste at different times of the day and on various days of the week to obtain a random selection from the scheduled procedures performed in nine OR suites. Staff members marked the regulated-waste bags with date, time, initials, and OR suite number. I used an unvalidated audit tool to stratify the data collected and track overall compliance per sample taken (Figure 1). Our infection prevention specialist, a former perioperative nurse, created and reviewed the audit tool. I measured regulated waste in both pounds and kilograms and sorted the contents of each bag. I wore personal protective equipment including a gown, gloves, mask, and eye protection and used heavy tongs to handle the waste for added protection against accidental exposure to blood or other body fluids. To measure the original mass of the bags, I used a scale that was calibrated by a member of the facility’s clinical engineering department. I measured each bag and then removed items such as protected health information, plastic bottles for saline or sterile water, IV bags, sterile disposal wrappers, prep trays,
www.aornjournal.org
January 2017, Vol. 105, No. 1
and other items that are not considered regulated waste and measured the bags again. Nonregulated items that were not grossly soiled from being in the bags with regulated waste were moved to the nonregulated trash container for disposal. After determining the total mass and percentage of nonregulated waste during this month-long audit, I designed an extensive online educational module that could be completed at the participant’s own pace and made it available to all full-time and part-time staff members in the surgical services department. The goal of the learning module was to educate perioperative staff members regarding the proper management and segregation of waste. The learning module contained both a pretest and a posttest for completion. After participants completed the educational module, I performed another audit in April 2015 using the same tool, methods, and projected sample size.
Participants’ Protection The facility’s Nursing Research Council determined that no institutional review board permission was required to gather data on the components of regulated-waste bags after a surgery has been completed because no patients were involved in this project. The only participants involved with this project were staff members who had their pretest and posttest results compiled. I obtained consent for the collection of pretest and posttest scores from all employees wishing to participate in this project. To ensure that all participants had an opportunity to choose not to participate in the project if they preferred not to share their test results, the initial question on the pretest read as follows: The following educational activity encompasses a pre-test, course, and post-test related to regulated waste management. Do you consent to having your test results collected for a research study to support the determination if increased knowledge of regulated waste management will reduce the overall amount of regulated waste and improve compliance with the disposal of non-contaminated items in the regulated waste bags? Only one employee opted out of the project, and these results are not reflected in the test results data.
Perioperative Regulated-Waste Management
and surgical attendants, participated in the educational module and concurrent audit of regulated waste in the department. All new employees are required to view the presentation. I administered the pretests and posttests in an electronic format using the organization’s online learning system. After the initial pretest, the learners viewed a PowerPoint presentation that defines regulated waste and what is considered eligible for the regulated trash bags in the OR. During the presentation, I explained that the disposal of nonregulated items in the regulated-waste stream is expensive and unnecessary. Staff members had one month to complete the online learning module and take the posttest. I encouraged staff members to err on the side of caution and dispose of any item they had concerns about in a regulated-waste bag. It is the duty of perioperative staff members to correctly handle and remove biohazardous waste in a manner that protects others from exposure. Responsible handling of regulated waste from the time it is generated until its final disposal is the responsibility of all staff members.8 Safety always takes priority over cost savings.
Project Procedures I used the pretest and posttest design to assess the results of the online educational module. Many of the 14 test questions included a selection of drop-down boxes for categories of either regular or regulated waste. The test asked staff members to select the most appropriate disposal method for common items and those items that were considered nonregulated waste. In addition, the test featured questions about the definition of regulated waste and the increased costs associated with the disposal of biohazardous waste. This educational module was used to determine staff members’ pre-education knowledge of the disposal of regulated waste and to perform a review of educational needs. I reviewed the questions that posed the most difficulty for learners to improve overall compliance with regulated-waste standards. The second method for measuring improvement of regulatedwaste disposal was the pre-education and posteducation audit of regulated trash. I performed the audit myself to maintain consistency with measurements, eliminating the potential for inter-rater variations.
Description of Instruments PROJECT DESIGN I used a pretest and posttest design to assess the learning needs of staff members. A total of 66 surgical services employees, consisting of RNs, RN first assistants, surgical technologists,
www.aornjournal.org
To accurately measure the mass of the nonregulated items discovered in the regulated trash bags removed from each OR, I used a portable patient scale. In addition, the facility’s clinical engineering staff checked the device for functionality and AORN Journal j 87
Perrego
January 2017, Vol. 105, No. 1
Table 1. Test Results Before and After Education Regarding Managing Waste Participants (N ¼ 66)
Pretest Percent Correct (Overall 92%)
Posttest Percent Correct (Overall 97%)
100.00
100.00
0.00
Question 2 True or false: It is appropriate to dispose of pathological and microbial waste containing blood or other potentially infectious material in the red bag waste. (False)
93.90
96.97
3.07
Question 3 True or false: Regulated waste is segregated and disposed of separately from regular waste and is weighed for total cost of disposal. (True)
95.45
98.48
3.03
100.00
100.00
0.00
87.88
100.00
12.12
Question 6 True or false: Dressing sponges saturated with blood and serous fluid are not considered regulated waste. (False)
100.00
100.00
0.00
Question 7 True or false: Cardboard should not be placed in red bag waste. (True)
100.00
98.48
1.52
Question 8 True or false: Used Foley catheter drainage bags should be placed in regular waste and are not considered regulated waste. (True)
48.48
84.85
36.37
Question 9 True or false: Blood-soaked laparotomy sponges should be placed in red bag waste. (True)
100.00
100.00
0.00
Question 10 True or false: Used suction manifolds should be placed in regular waste and are not considered regulated waste. (False)
71.21
86.36
15.15
100.00
100.00
0.00
Question 1 True or false: Red bag waste is defined as contaminated items that would release blood or other potentially infectious materials in a liquid or semiliquid state if compressed or rehydrated. (True)
Question 4 True or false: Disposing of regulated red bag waste is more expensive than disposing of regular waste. (True) Question 5 True or false: Yesterday’s OR schedule (ie, protected health information) should be placed in the shred bin and is not considered regulated waste. (True)
Question 11 True or false: Sterile blue wrap from instrument pans should not be placed in red bag waste. (True)
88 j AORN Journal
Percent Improvement (Overall 5%)
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January 2017, Vol. 105, No. 1
Perioperative Regulated-Waste Management
Table 1. (continued ) Participants (N ¼ 66)
Pretest Percent Correct (Overall 92%)
Posttest Percent Correct (Overall 97%)
Question 12 True or false: Prep sticks should not be placed in red bag waste. (True)
98.48
100.00
1.52
100.00
100.00
0.00
89.39
92.42
3.03
Question 13 True or false: Blue paper filters from instrument pans should be placed in red bag waste. (False) Question 14 True or false: After making an incision, drapes and gowns from the sterile field are to be placed in the regulated red bag waste receptacle whether they are saturated with blood or bodily fluids or not. (False)
Percent Improvement (Overall 5%)
NOTE. The most improvement was seen on questions 5, 8, and 10.
safety before use. The scale measures in both kilogram and pounds and has high degrees of accuracy and repeatability. After I determined the amount of nonregulated waste using the audit tool, I created an online HealthStream educational module and offered it to all perioperative staff members. HealthStream, a learning management system, is our organization’s official tool for offering, maintaining, and reporting all professional and continuing education for employees.
RESULTS After the waste management educational program, staff member compliance with the appropriate disposal of
nonregulated items improved from 33% to 69%. Areas of additional education included compliance regarding the correct disposal of the waste generated by anesthesia professionals. The nonregulated waste produced by the anesthesia staff members during a surgical procedure may include the breathing circuit, airways, endotracheal tubes, suction catheters, oxygen masks and tubing, nasogastric tubes, and tracheostomy tubes, if they are not grossly soiled. These items qualify as regulated waste only if they are visibly and grossly contaminated with blood or other body fluids. Waste generated by anesthesia professionals has continued to be disposed of in the regulated-waste stream even when this precaution is not applicable. Staff members benefitted from education regarding the disposal of Foley drainage bags (36.37% improvement), suction manifolds (15.15% improvement), and OR schedule (12.21% improvement); test scores for these items showed the greatest improvement (Table 1). This finding indicated a need for staff member review of correct disposal procedures for these items. Of the 14 test questions, 7 questions showed improvement, 6 questions held at 100% accuracy, and 1 question showed a decrease in knowledge. In this instance, a staff member originally answered a question correct on the pretest but answered incorrectly afterwards. The incorrect answer may have been a typographical error.
Figure 2. After staff member education, there was more than a 40.68% reduction in total regulated waste.
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The regulated-waste audit showed an improvement in the total amount of regulated waste and the amount of nonregulated items contained in the waste after education. During the original audit of the selected regulated-waste bags, the total AORN Journal j 89
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Table 2. Cost Analysis of Regulated Waste Before and After Education Before Education
After Education
Average mass of regulated waste bag
10.4 lb (472 lb in 45 bags)
6.2 lb (278 lb in 45 bags)
Estimated regulated-waste cost per procedure
$2.65 (1.5 bags per procedure 10.4 lb $0.17)
$1.05 (1 bag per procedure 6.2 $0.17)
Estimated regulated-waste cost per month (600 procedures per month)a
$1,600 (600 procedures 1.5 bags $0.17)
$600 (600 procedures 1 bag $0.17)b
Estimated regulated-waste cost per year
$19,100
$7,200
a b
Estimate provided by projects manager for the department. Red bag manufacturer indicated that double red bagging of regulated waste was not necessary, and we switched to using only one bag.
mass of regulated waste measured 213.6 kg (471.4 lb), with the mass of nonregulated items totaling 131.1 kg (289.86 lb). After employees completed the educational module and training, the total mass of regulated waste measured for the 45 randomly collected bags equaled 126.7 kg (278.7 lb), with the mass of nonregulated items measuring 30.2 kg (66.44 lb). This demonstrates a 40.68% reduction in total regulatedwaste mass (Figure 2) and a 76.96% reduction in nonregulated item mass. At this facility, the finance department reports that it costs $0.04/lb for disposal of nonregulated waste and $0.21/lb for regulated waste. The 45 audited bags represent only a fraction of the number of regulated-waste bags produced in our perioperative department each day. The reduction of mass from the regulated-waste stream represents a cost savings for the organization. Taking into account the cost of the regulated-waste bags themselves in addition to the reduction of regulated waste, this facility was able to save an estimated $11,900 in one year (Table 2).
DISCUSSION Mosquera et al7 noted that increased staff member education improves the management of regulated waste. The outcomes of this project support this conclusion. A demonstrated improvement in staff member knowledge regarding the disposal of regulated waste correlated with a decrease in the amount of nonregulated waste disposed of in regulated-waste bags, creating a cost savings for our institution. The limitations of this project include the use of an original audit measurement tool that was not tested by other facilities. There may be alternative nonregulated items that would be appropriate to include in the audit at different institutions. In addition, the audit sheet did not capture the date of the procedure, making it difficult to track data to particular procedures if the need for tracking should arise. Moreover, it would help to perform a second audit of regulated waste one 90 j AORN Journal
year after the education to see whether behavior change was maintained and to confirm that no additional re-education is required. The results of this project support the hypothesis that additional regulated-waste education for perioperative staff members reduces the amount of nonregulated items placed in the regulated-waste stream. Perioperative nurses can contribute to institutional cost savings by learning about and implementing appropriate regulated-waste disposal. In addition, this educational program can be used for all of this institution’s employees, including those at both campuses and the affiliated medical offices. The management of regulated waste occurs in many of the hospital’s departments, in addition to the perioperative areas. Proper waste segregation relies heavily on the individual. A comprehensive education program would improve compliance with waste disposal protocol and improve the overall environmental footprint of the facility.
CONCLUSION The project discussed in this article is ongoing at our institution and demonstrates that additional staff member education about the correct disposal of waste can reduce the amount of incorrectly discarded items, thereby producing a cost savings. Similar education at other facilities could aid in the protection of employees and others from exposure to regulated waste, waste stream volume reduction, reduced environmental effects, and cost savings. The author recommends future re-education of staff members on nonregulated item disposal procedures to sustain and improve performance.
Editor’s notes: CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA. HealthStream is a copyrighted learning management system from HealthStream, Nashville, TN.
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References 1. Occupational Safety and Health Administration. Toxic and hazardous substances: bloodborne pathogens. 29 CFR x1910.1030(b). https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_ table¼STANDARDS&p_id=10051. Accessed August 9, 2016. 2. Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J. 2010;91(6):711-721. 3. Change theory: Kurt Lewin. Current Nursing. http://currentnursing .com/nursing_theory/change_theory.html. Revised September 12, 2011. Accessed August 9, 2016. 4. Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: simple changes to reduce cost and our carbon footprint. Am Surg. 2013;79(7):666-671. 5. McDermott-Levy R, Fazzini C. Identifying the key personnel in a nurse-initiated hospital waste reduction program. Nurs Adm Q. 2010;34(4):306-310. 6. Lee BK, Ellenbecker MJ, Moure-Ersaso R. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Manag. 2004;24(2):143-151.
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Perioperative Regulated-Waste Management 7. Mosquera M, Andres-Prado MJ, Rodríguez-Caravaca G, Latasa P, Mosquera ME. Evaluation of an education and training intervention to reduce health care waste in a tertiary hospital in Spain. Am J Infect Control. 2014;42(8): 894-897. 8. Fisher MG. Perioperative practitioners. Does waste segregation and disposal within your theatre meet the required legal standard? J Perioper Pract. 2013;23(6):127-128.
Kristen Perrego, BSN, RN, CNOR, is a clinical educator in the Surgical Services Department at Bayhealth Medical Center, Kent Campus, Dover, DE. Ms Perrego has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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