- Email: [email protected]
Medical waste in the environment: Do anesthesia personnel have a role to play?
ELSEVIER
Medical Waste in the Environment: Do Anesthesia Personnel Have a Role to Play? Michael E. Goldberg, MD, * Denis Vekeman, CRNA,t Marc C. Torjman, MEd,$ Joseph L. Seltzer, MD,§ Teelcie Kynes, RN, BSN” Department
of Anesthesioloa,
Cooper
den, NJ; Department of Anesthesiology, Vital Signs, Inc., Totowa, NJ.
*Professor of Anesthesiology, Robert Wood Johnson Medical Camden tChief Certified Registered Anesthetist, Cooper Hospital Medical Center $Research Associate, Jefferson lege
UMDNJ/ School at NurseUniversity
Medical
Col-
§Professor and Chairman of Anesthesiology, Jefferson Medical College “Director, Division of Shared Solutions, Vital Signs, Inc. Address correspondence to Dr. Goldberg at the Department of Anesthesiology, Cooper Hospital/UMDNJ/Robert Wood Johnson Medical School at Camden, One Cooper Plaza, Camden, NJ 08103, USA. Supported in part Totowa, NJ.
by Vital
Signs, Inc.,
Presented in part at the Annual Meeting of the International Anesthesia Research Society, Orlando, March 5-9, 1994. Received for publication March 8, 1995; revised manuscript accepted for publication November 22, 1995.
Hospital Jefferson
University
Medical
Center,
Medical College, Philadelphia,
Cam-
PA,
Study Objective: To conduct a feasibility study of the mechanics of recycling single-use anesthesia breathing systems and practices of anesthesiologists and nurse-anesthetists in a ttistate region. Study Design: Two-part, open, prospective analysis using preprinted questionnaire and cost/time analysis of labor and materials. Setting: Questionnaire sent to 413 anesthesiology departments in Pennsylvania, New Jersey,,and Delaware, and hospital/recycling facility for evaluation of time and cost. Meas,urements and Main Results: Time to disassemble and sort the breathing circuits, analysis of costs and obtainable income from byproducts of reqcling, and standard survey questionnaire concerning demographic characteristics of respondents and individual department/hospitalpractitioners. Data analysis included analysis of variance and KruskalWallzs tests. Pilot analysis: Sorting of circuits to economic component required ten minutes at an average cost of $1.60. Value of scraps obtainable was $3.44, leaving a gross margin of $1.84 for a box of 18 circuits. Benefit analysis: Extended reduction in the regulated medical waste in our operating room of 16,875 lb, saving $4,387.50 per year. With generation of revenue from scrap, the net gain is $5,994.64 per yr. Questionnaire: Majority (83 %) of dep art ments polled would participate in recycling implemented by suppliers. Most respondents would not consider (58%) recycling unless mandated by law. Conclusion: The program described is cost-effective and environmentally beneficial. Keywords:
Anesthesia;
environment;
medical
waste; recycling.
Introduction Medical waste disposal is an emotional issue, fed by increased environmental awareness, public outcries over the discovery of medical waste in unlikely and unacceptable areas (such as public beaches), lack of knowledge about alternatives in disposal, stringent regulatory mandates, and shrinking landfill capacities. T:he correct and proper refusal of landfill management to handle potentially infectious waste, unless it has been treated, has added to the costs of disposal for hospitals to the extent that regulated medical waste now costs between $0.25 to $0.30 per pound for disposal, compared with $0.016 to $0.03 per pound for
Journal of Clinical Anesthesia 8:475-479, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0952-8180/96/$15.00 PI1 SO952-8180(96)00127-4
disposal of non-regulated, or municipal, waste.im2* These costs add up quickly, as some major facilities are capable of adding up to 15,000 pounds of trash per day (in excess of 2.5 million tons per year) to the landfills, with the operating room (OR) contributing up to one-third of the tota1.3 Rutala et al. claim that U.S. hospitals generate 15 lb of waste per patient per day.4 Compounding the cost issue of disposing of medical waste, the inclination to be “safe, rather than sorry,” in terms of regulatory compliance, has led many hospitals to consider all wastes originating in the OR as regulated medical waste. Proper management of the waste stream to segregate infectious waste from noninfectious waste in the OR may have the single most significant impact on the cost of disposal5 There are many alternatives to the disposal of medical waste. Incineration is capable of reducing the volume of waste to only 10% to 25% its original6 At least one report considers incineration to be the least expensive method to dispose of regulated medical waste but others report that incineration can be costly and unreliable.7,8 Approximately 30% of all hospitals have their own incinerators, but reports of the dangers of their air emissions have dampened their use in some areas of the country.’ Other alternatives to the disposal of medical waste include microwaving,t pulverizing,’ electro-thermal deactiand waste-to-energy fuel.‘* Both the vation,i’ pyrolysis,ii capital expense involved in using some of the newer technologies and ever-changing federal and state regulations have limited their widespread use in hospitals. Recycling, while more expensive than incineration, is of intense interest to hospitals. Tieszen and Gruenberg have shown that surgical waste can be reduced up to 93% by recovering disposable linen, paper, and recyclable plastic. In their study, disposable products had the greatest effect on this burden. More limited is the use of recyclable elements. We focused on the recyclable class of products in this particular study. Federally funded hospitals are being driven to develop recycling strategies by The Federal ACquisition, Recycling and Waste Prevention Act of 1993. Additionally, nearly half of the states have had legislation pending that mandates recycling rates of up to 50% by 1995. Both single-use and reusable medical products have an impact on our environment. Single-use products add to the burden of our landfills, consume more energy and raw materials to produce, and may add to atmospheric pollu*z2,i3 Reusable products consume tion via incineration. more water than single-use and add pollutants to both the water and air in manufacture and reprocessing.13 As users, by preference, of primarily single-use medical products in our anesthesia department, our primary concern was the impact of single-use products on the environment. Based on this concern we undertook a pilot program, which we describe here, in collaboration with a
medical device manufacturer (Vital Signs, Inc., Totowa, NJ) to recycle anesthesia breathing systems at our hospital. If the mechanics involved in recycling these products were manageable, this medical device manufacturer was prepared to implement a program in which they would take the recovered plastics after disinfection and use as raw material, or procure buyers for, the recovered plastics. A third partner in the feasibility study (Penn Linen Inc., Camden, NJ) was enlisted to disassemble the products, sort them into groups of like plastics, and disinfect the components for distribution to the medical device manufacturer or other buyers. We were also curious, if a recycling program such as this were found to be feasible, as to the interest level of other anesthesiologists in our surrounding area. To this end, we designed a questionnaire to attempt to determine the attitudes and practices of these anesthesiologists regarding recycling in general, and recycling related to medical products specifically.
Materials
and Methods
Recycling Propram During the pilot program, used anesthesia breathing systems (including circuits, masks, gas sampling lines, and breathing bags) were collected after anesthetic procedures by anesthesia technicians and placed in a large, white plastic bag, centrally located in the OR, for subsequent packaging in the standard 3.9 cubic-foot corrugated supply box from the manufacturer. Normally, these circuits are disposed of in red bags and segregated as regulated medical waste, along with all other waste generated during the surgical procedure-a practice that increases the volume, and hence the cost, of medical waste disposal. During the pilot program, if the circuits were grossly contaminated with respiratory secretions, they were simply “red-bagged” and not stored for recycling. Once packaged in the standard corrugated supply boxes, the boxes were placed in the hospital’s shipping department for pick-up by a commercial hospital laundry company during routine laundry pick-ups. They were then transported to their facility for disassembly of the circuit components, sorting into like plastics, and disinfection of the products. This arrangement was worked out as part of our pilot program. Disassembly and sorting was performed at the laundry facility by a laundry worker who was trained in universal precautions and properly attired. The procedure of disassembling and sorting was video-taped with an integral timer, and independently timed with a stop watch by engineering representatives of the medical device manufacturer. The schematic diagram of the process is shown in Figure
1.
Tri-State Questionnaire *Market research data on file at Vital Signs Inc., Totowa, NJ. tSanitec Microwave Disinfection System. Data on file, ABB Sanitec Inc.
476
J. Clin. Anesth., vol. 8, September 1996
A standard survey containing questions concerning the demographic characteristics of respondents and individual departmental and/or hospital practices and atti-
Medical waste: The role of anesthesia personnek Goldberg et al.
1. Cost Analysis of the Disassembly and Sorting Functions for 18 Anesthesia Breathing Circuits
Table
LOW DENSITY POLYETHYLENE
Value CR*
Yield (lb)
BREATHING BAGS
POLYPROPYLENE 1
SORTING TAB!(
j
[a
Ethyl vinyl acetate Latex (bags) Polyvinyl chloride Polypropylene Polycarbonate Low density polyethylene
4.39 2.66
1.01 0.87 0.68
0.63 10.24
HOSPITAL RECYCLED PRODUCT Figure
1. Schematic
ing of breathing
representation circuit by laborer.
of disassembly and sort-
tudes towards recycling was sent to anesthesiology departments at 413 hospitals in Pennsylvania, New Jersey, and Delaware. Also included were specific questions aimed at discovering how opinions on recycling might change if programs were initiated by a manufacturer. Data were analyzed using analysis of variance (ANOVA) and KruskalWallis tests.
Results
($)
0.53 0.02 0.13 0.35 0.60
2.33 0.05 0.13 0.30 0.41
0.35
0.22
0.34
3.44
1.60 1.84
Direct labor+ Gross margin
FACE MASKS
Extension
*Includes circuit, mask, gas sampling line, and breathing bag. iPosted scrap prices. IHourly rate of $6.85 + 40% burden for 10 minutes.
that averaged 300,000 pounds per year. Assuming a normal OR regulated medical waste volume of two red bags per OR per day (measured at an average weight of 16.5 pounds per bag), it can be estimated that the OR contributed about 75,000 pounds per year, or 25% of the total. A decrease of 22.5% of the OR regulated medical waste stream would result in a savings of 16,875 pounds of regulated medical waste per year, at a value of $4,387.50 per year. If the scrap material obtained from the recycling effort resulted in a gross margin of $1.84 per 18 circuit systems (which weighted 10.5 lbs), revenues of $1,607.14 could be generated by the recycling program, resulting in a net financial gain of $5,994.64 per year for the hospital. These values represent the costs at the time of this study.
Recycling Propam Prior to starting the recycling program, two red bags per OR per day were required to handle waste. The second bag was removed whether or not it was full. Following the institution of the recycling process, only one red bag was taken from each room each day. Based on the volume of waste in each red bag and on the capacity of the white plastic bag used to contain the anesthesia products, it is estimated that removal of the anesthesia breathing system alone from the regulated medical waste stream in the OR reduced the volume of regulated medical waste by 22.5%. While this value may seem overstated, previous analyses were performed on respiratory tubing in relationship to total hospital burden3 Our pilot program looked specifically at anesthesia tubing in relationship to OR waste; hence, 22.5% is not an overstatement. PILOT PROGRAM ANALYSIS. It took 10 minutes, 0 seconds, on average, to sort one box of 18 circuits into its economic components. The laborer responsible for this received $6.85 per hour with an overhead burden of 40% (Table 1)) resulting in a cost for the 10 minutes of $1.60. The value of the scrap material obtained was $3.44, leaving a gross margin of $1.84 per box of 18 circuits. PILOT BENEFIT ANALYSIS.At our hospital, we were paying $0.26 per pound for disposal of regulated medical waste
Tki-State Questionnaire Of 413 questionnaires mailed, 129 were returned to our department. Most respondents (58%) would not consider recycling medical products unless mandated by law (Figure 2). Yet the majority (91%) indicated that recycling of disposable products was an important issue. Two-thirds of the institutions had not provided educational programs on the environmental impact of various medical practices. Community hospitals, as compared with university and university-affiliated hospitals, recycled significantly less (p < 0.05) and were significantly less aware of the effect of anesthetic gases on the environment (p < 0.05) (Fipre 3). A majority (83%) of the anesthesiology departments polled would participate in a recycling program if implemented by a supplier, as compared with 3.1% who would not. Twenty-one respondents (16.5%) were undecided regarding participation in a supplier-generated program and would need more information.
Discussion Labor costs do not appear to be a prohibitive element involved in the disassembly and sorting processes of recyJ. Clin.
Anesth.,
vol.
8, September 1996
477
Original Contributions
Percent of total respondents 1001
taminated or not, was a needlessly expensive starting point for our department. Should our used products be added to the municipal waste stream, instead of the regulated medical waste stream, we would save approximately $3,300 per year, without recycling. It is apparent however, from this pilot program that recycling of single-use products can be performed in the anesthesia department without increasing hospital costs.
80 J 80 40 -
T.&State Questionnaire
200
Currently recycling (paper, aluminum, plastic)
Recycle medical waste only if mandated
Figure 2. Percentage of hospitals that would or would not consider recycling medical products unless mandated by law.
cling anesthesia breathing systems. However, a complete cost-benefit analysis of a program to recycle anesthesia breathing circuits (or other single-use items used by anesthesia personnel during a procedure) must take into account certain costs that were not analyzed in this pilot study. Hospital pick-up introduces an incremental cost, but can be kept to a minimum by the use of a supply company already servicing the institution. Following the disassembly and sorting process, the material salvaged from the process must be cleaned, ground or pulverized, bundled, sold, and delivered to a purchaser to have an economic value. Each of these transactions would have associated labor costs that were not analyzed in the pilot program. It should be noted that our normal practice of “red-bagging” anesthesia products, whether grossly con-
Percent of respondents 100
85%
1
80
According to the results from our questionnaire, most respondents (anesthesiologists and nurse-anesthetists) expressed concern about environmental pollution, but they would not participate in a recycling program unless mandated legislatively. The survey indicated that leadership from the manufacturing section would facilitate implementation of programs.
Conclusion The program previously described appears to be economically feasible and would fit the criteria described in the questionnaire as “manufacturer-led” recycling. Beside the potential positive financial impact of recycling single-use products, there are environmental benefits to recycling. For example, incineration, with its potential for environmental pollution, could be avoided. If we simply added our used products to the municipal stream, we would save money, but our action would add to the burden of our landfills. Consideration might be given to reusing singleuse products; however, this can be problematic medicolegally, and the reprocessing costs and potential environmental contamination of the air or water supply should also be considered. With concern over possible transmission of infectious diseases, whether viral or bacterial, reuse without reprocessing might not be an appropriate alternative. As Tieszen and Gruenberg have expressed, efforts are underway to emphasize recycling practices in facilities throughout the country to reduce hospital cost and environmental burden. In a similar fashion, our study shows that focused attention on one product can aid this decrease in cost and burden. A widespread trial of recycling seems to be indicated as a result of this pilot program, with the understanding that the financial data represent a single point in time with respect to the writing and publication of this manuscript.
80 References
40 20 0
No recycling program
Recycling of aluminum and plastics
Figure 3. Percentage of university and community currently recycling various products. 478
J. Clin. Anesth., vol. 8, September 1996
hospitals
1. Afterlife exists, ask your trash. Hospital Purchasing News, Oct. 1990;14(10). 2. Hospital Plastics Characterization and Recycling Feasibility Study. Washington, DC: American Plastics Council, 1994. 3. American Society of Anesthesiologists Newsletter November 1992, Vol 56, No. 11. 4. Rutala WA, Mayhill CC: Medical waste. In&t Control Hasp Epidemid 1992;13:38-49. 5. Tieszen ME, Gruenberg JC: A quantitative, qualitative, and criti-
Medical waste: The role of anesthesia personnel: Goldberg et al.
6. 7. 8. 9.
cal assessment of surgical waste. Surgeons venture through the trash can. JAMA 1992;267:2’765-8. Incinerators touted as inexpensive method to dispose of medical waste. Medical Waste News, June 28, 1994:lOl. A look at medical waste incinerators. Medical WasteIVews, Nov. 15, 1989:105-6. Associators fired up about regional incinerators. Hospital Purchming News, Nov. 1989. Dancer JW: Conquering the growing problem of medical waste. Michigan Hasp 1991;27:4--12.
A Quantitative,
Department
10. Combustion engineering affiliate “zaps” infectious waste. Medical Waste News, May 31, 1989:15.
medical
11. New device disposes of medical waste “electrically.” Stand, July 1, 199495.
Biomed Safety
12. Ross-Flanigan N: At their disposal: new techniques hospital wastes. Detroit Free Press, May, 1991.
to deal with
13. McDovell JN: An Environmental, Economic and Health Comparison of Single Use and Reusable Surgical Drapes and Gowns. Cambridge, MA: Arthur D. Little, Inc., 1993.
Qualitattive, and Critical Assessment of Surgical Waste. Surgeons Venture Through the Trash Can Myles E. Tieszen, MD; James C. Gruenberg, MD
of Surgery, Saginaw Cooperative
Hospitals,
Inc., Saginaw, MI
Abstract OBJECTIVES-To quantitatively and qualitatively evaluate the surgical waste produced from several common surgical procedures, define categories of waste that might be readily separated for alternative disposal practices or substitution, and determine the change in surgical waste output that elimination or alternative handling methods may effect. DESIGN-A case series evaluating the surgical waste from five types of surgical procedures including operations of the back, heart, abdomen, hip and knee, and herniorrhaphies, prospectively identified and allocated at the availability of the investigator. SETTING-A single tertiary community teaching hospital. OUTCOME MEASURES-Weight, volume, and percentage of disposable linen, paper, and plastic plus miscellaneous material from surgical waste with a later subset separating plastics from miscellaneous items to comlpletely identify all categories. RESULTS-Surgical waste weighting 610.5 lb (274.7 kg) and occupying 1’71.6 cu ft (5.1 m3) from 27 cases was examined. Disposable linens accounted for 39% of the weight; paper, 7%; plastic, 26%; and miscellaneous waste, 7%. Disposable linen, paper, and recyclable plastic accounted for ‘73% + ‘7% (mean + SD) by weight and 93% + 4% by volume of total surgical waste. CONCLUSION-Nationally, annual surgical waste from these five procedures weighs 5.1 x lO(7) lb [2.3 x lO(7) kg] and occupies 1.4 x lO(7) cu ft [4.0 x lO(5) m3]. By using reusable linen products and1 engaging in recycling methods currently available and feasible, we estimate that weight reductions of 73% and volume reductions of 93% in surgical waste are possible.
Reprinted
from JAMA 1992;267:26’75-8.
J. Clin. Anesth., vol. 8, September 1996
479
Medical Waste in the Environment: Do Anesthesia Personnel Have a Role to Play? Michael E. Goldberg, MD, * Denis Vekeman, CRNA,t Marc C. Torjman, MEd,$ Joseph L. Seltzer, MD,§ Teelcie Kynes, RN, BSN” Department
of Anesthesioloa,
Cooper
den, NJ; Department of Anesthesiology, Vital Signs, Inc., Totowa, NJ.
*Professor of Anesthesiology, Robert Wood Johnson Medical Camden tChief Certified Registered Anesthetist, Cooper Hospital Medical Center $Research Associate, Jefferson lege
UMDNJ/ School at NurseUniversity
Medical
Col-
§Professor and Chairman of Anesthesiology, Jefferson Medical College “Director, Division of Shared Solutions, Vital Signs, Inc. Address correspondence to Dr. Goldberg at the Department of Anesthesiology, Cooper Hospital/UMDNJ/Robert Wood Johnson Medical School at Camden, One Cooper Plaza, Camden, NJ 08103, USA. Supported in part Totowa, NJ.
by Vital
Signs, Inc.,
Presented in part at the Annual Meeting of the International Anesthesia Research Society, Orlando, March 5-9, 1994. Received for publication March 8, 1995; revised manuscript accepted for publication November 22, 1995.
Hospital Jefferson
University
Medical
Center,
Medical College, Philadelphia,
Cam-
PA,
Study Objective: To conduct a feasibility study of the mechanics of recycling single-use anesthesia breathing systems and practices of anesthesiologists and nurse-anesthetists in a ttistate region. Study Design: Two-part, open, prospective analysis using preprinted questionnaire and cost/time analysis of labor and materials. Setting: Questionnaire sent to 413 anesthesiology departments in Pennsylvania, New Jersey,,and Delaware, and hospital/recycling facility for evaluation of time and cost. Meas,urements and Main Results: Time to disassemble and sort the breathing circuits, analysis of costs and obtainable income from byproducts of reqcling, and standard survey questionnaire concerning demographic characteristics of respondents and individual department/hospitalpractitioners. Data analysis included analysis of variance and KruskalWallzs tests. Pilot analysis: Sorting of circuits to economic component required ten minutes at an average cost of $1.60. Value of scraps obtainable was $3.44, leaving a gross margin of $1.84 for a box of 18 circuits. Benefit analysis: Extended reduction in the regulated medical waste in our operating room of 16,875 lb, saving $4,387.50 per year. With generation of revenue from scrap, the net gain is $5,994.64 per yr. Questionnaire: Majority (83 %) of dep art ments polled would participate in recycling implemented by suppliers. Most respondents would not consider (58%) recycling unless mandated by law. Conclusion: The program described is cost-effective and environmentally beneficial. Keywords:
Anesthesia;
environment;
medical
waste; recycling.
Introduction Medical waste disposal is an emotional issue, fed by increased environmental awareness, public outcries over the discovery of medical waste in unlikely and unacceptable areas (such as public beaches), lack of knowledge about alternatives in disposal, stringent regulatory mandates, and shrinking landfill capacities. T:he correct and proper refusal of landfill management to handle potentially infectious waste, unless it has been treated, has added to the costs of disposal for hospitals to the extent that regulated medical waste now costs between $0.25 to $0.30 per pound for disposal, compared with $0.016 to $0.03 per pound for
Journal of Clinical Anesthesia 8:475-479, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0952-8180/96/$15.00 PI1 SO952-8180(96)00127-4
disposal of non-regulated, or municipal, waste.im2* These costs add up quickly, as some major facilities are capable of adding up to 15,000 pounds of trash per day (in excess of 2.5 million tons per year) to the landfills, with the operating room (OR) contributing up to one-third of the tota1.3 Rutala et al. claim that U.S. hospitals generate 15 lb of waste per patient per day.4 Compounding the cost issue of disposing of medical waste, the inclination to be “safe, rather than sorry,” in terms of regulatory compliance, has led many hospitals to consider all wastes originating in the OR as regulated medical waste. Proper management of the waste stream to segregate infectious waste from noninfectious waste in the OR may have the single most significant impact on the cost of disposal5 There are many alternatives to the disposal of medical waste. Incineration is capable of reducing the volume of waste to only 10% to 25% its original6 At least one report considers incineration to be the least expensive method to dispose of regulated medical waste but others report that incineration can be costly and unreliable.7,8 Approximately 30% of all hospitals have their own incinerators, but reports of the dangers of their air emissions have dampened their use in some areas of the country.’ Other alternatives to the disposal of medical waste include microwaving,t pulverizing,’ electro-thermal deactiand waste-to-energy fuel.‘* Both the vation,i’ pyrolysis,ii capital expense involved in using some of the newer technologies and ever-changing federal and state regulations have limited their widespread use in hospitals. Recycling, while more expensive than incineration, is of intense interest to hospitals. Tieszen and Gruenberg have shown that surgical waste can be reduced up to 93% by recovering disposable linen, paper, and recyclable plastic. In their study, disposable products had the greatest effect on this burden. More limited is the use of recyclable elements. We focused on the recyclable class of products in this particular study. Federally funded hospitals are being driven to develop recycling strategies by The Federal ACquisition, Recycling and Waste Prevention Act of 1993. Additionally, nearly half of the states have had legislation pending that mandates recycling rates of up to 50% by 1995. Both single-use and reusable medical products have an impact on our environment. Single-use products add to the burden of our landfills, consume more energy and raw materials to produce, and may add to atmospheric pollu*z2,i3 Reusable products consume tion via incineration. more water than single-use and add pollutants to both the water and air in manufacture and reprocessing.13 As users, by preference, of primarily single-use medical products in our anesthesia department, our primary concern was the impact of single-use products on the environment. Based on this concern we undertook a pilot program, which we describe here, in collaboration with a
medical device manufacturer (Vital Signs, Inc., Totowa, NJ) to recycle anesthesia breathing systems at our hospital. If the mechanics involved in recycling these products were manageable, this medical device manufacturer was prepared to implement a program in which they would take the recovered plastics after disinfection and use as raw material, or procure buyers for, the recovered plastics. A third partner in the feasibility study (Penn Linen Inc., Camden, NJ) was enlisted to disassemble the products, sort them into groups of like plastics, and disinfect the components for distribution to the medical device manufacturer or other buyers. We were also curious, if a recycling program such as this were found to be feasible, as to the interest level of other anesthesiologists in our surrounding area. To this end, we designed a questionnaire to attempt to determine the attitudes and practices of these anesthesiologists regarding recycling in general, and recycling related to medical products specifically.
Materials
and Methods
Recycling Propram During the pilot program, used anesthesia breathing systems (including circuits, masks, gas sampling lines, and breathing bags) were collected after anesthetic procedures by anesthesia technicians and placed in a large, white plastic bag, centrally located in the OR, for subsequent packaging in the standard 3.9 cubic-foot corrugated supply box from the manufacturer. Normally, these circuits are disposed of in red bags and segregated as regulated medical waste, along with all other waste generated during the surgical procedure-a practice that increases the volume, and hence the cost, of medical waste disposal. During the pilot program, if the circuits were grossly contaminated with respiratory secretions, they were simply “red-bagged” and not stored for recycling. Once packaged in the standard corrugated supply boxes, the boxes were placed in the hospital’s shipping department for pick-up by a commercial hospital laundry company during routine laundry pick-ups. They were then transported to their facility for disassembly of the circuit components, sorting into like plastics, and disinfection of the products. This arrangement was worked out as part of our pilot program. Disassembly and sorting was performed at the laundry facility by a laundry worker who was trained in universal precautions and properly attired. The procedure of disassembling and sorting was video-taped with an integral timer, and independently timed with a stop watch by engineering representatives of the medical device manufacturer. The schematic diagram of the process is shown in Figure
1.
Tri-State Questionnaire *Market research data on file at Vital Signs Inc., Totowa, NJ. tSanitec Microwave Disinfection System. Data on file, ABB Sanitec Inc.
476
J. Clin. Anesth., vol. 8, September 1996
A standard survey containing questions concerning the demographic characteristics of respondents and individual departmental and/or hospital practices and atti-
Medical waste: The role of anesthesia personnek Goldberg et al.
1. Cost Analysis of the Disassembly and Sorting Functions for 18 Anesthesia Breathing Circuits
Table
LOW DENSITY POLYETHYLENE
Value CR*
Yield (lb)
BREATHING BAGS
POLYPROPYLENE 1
SORTING TAB!(
j
[a
Ethyl vinyl acetate Latex (bags) Polyvinyl chloride Polypropylene Polycarbonate Low density polyethylene
4.39 2.66
1.01 0.87 0.68
0.63 10.24
HOSPITAL RECYCLED PRODUCT Figure
1. Schematic
ing of breathing
representation circuit by laborer.
of disassembly and sort-
tudes towards recycling was sent to anesthesiology departments at 413 hospitals in Pennsylvania, New Jersey, and Delaware. Also included were specific questions aimed at discovering how opinions on recycling might change if programs were initiated by a manufacturer. Data were analyzed using analysis of variance (ANOVA) and KruskalWallis tests.
Results
($)
0.53 0.02 0.13 0.35 0.60
2.33 0.05 0.13 0.30 0.41
0.35
0.22
0.34
3.44
1.60 1.84
Direct labor+ Gross margin
FACE MASKS
Extension
*Includes circuit, mask, gas sampling line, and breathing bag. iPosted scrap prices. IHourly rate of $6.85 + 40% burden for 10 minutes.
that averaged 300,000 pounds per year. Assuming a normal OR regulated medical waste volume of two red bags per OR per day (measured at an average weight of 16.5 pounds per bag), it can be estimated that the OR contributed about 75,000 pounds per year, or 25% of the total. A decrease of 22.5% of the OR regulated medical waste stream would result in a savings of 16,875 pounds of regulated medical waste per year, at a value of $4,387.50 per year. If the scrap material obtained from the recycling effort resulted in a gross margin of $1.84 per 18 circuit systems (which weighted 10.5 lbs), revenues of $1,607.14 could be generated by the recycling program, resulting in a net financial gain of $5,994.64 per year for the hospital. These values represent the costs at the time of this study.
Recycling Propam Prior to starting the recycling program, two red bags per OR per day were required to handle waste. The second bag was removed whether or not it was full. Following the institution of the recycling process, only one red bag was taken from each room each day. Based on the volume of waste in each red bag and on the capacity of the white plastic bag used to contain the anesthesia products, it is estimated that removal of the anesthesia breathing system alone from the regulated medical waste stream in the OR reduced the volume of regulated medical waste by 22.5%. While this value may seem overstated, previous analyses were performed on respiratory tubing in relationship to total hospital burden3 Our pilot program looked specifically at anesthesia tubing in relationship to OR waste; hence, 22.5% is not an overstatement. PILOT PROGRAM ANALYSIS. It took 10 minutes, 0 seconds, on average, to sort one box of 18 circuits into its economic components. The laborer responsible for this received $6.85 per hour with an overhead burden of 40% (Table 1)) resulting in a cost for the 10 minutes of $1.60. The value of the scrap material obtained was $3.44, leaving a gross margin of $1.84 per box of 18 circuits. PILOT BENEFIT ANALYSIS.At our hospital, we were paying $0.26 per pound for disposal of regulated medical waste
Tki-State Questionnaire Of 413 questionnaires mailed, 129 were returned to our department. Most respondents (58%) would not consider recycling medical products unless mandated by law (Figure 2). Yet the majority (91%) indicated that recycling of disposable products was an important issue. Two-thirds of the institutions had not provided educational programs on the environmental impact of various medical practices. Community hospitals, as compared with university and university-affiliated hospitals, recycled significantly less (p < 0.05) and were significantly less aware of the effect of anesthetic gases on the environment (p < 0.05) (Fipre 3). A majority (83%) of the anesthesiology departments polled would participate in a recycling program if implemented by a supplier, as compared with 3.1% who would not. Twenty-one respondents (16.5%) were undecided regarding participation in a supplier-generated program and would need more information.
Discussion Labor costs do not appear to be a prohibitive element involved in the disassembly and sorting processes of recyJ. Clin.
Anesth.,
vol.
8, September 1996
477
Original Contributions
Percent of total respondents 1001
taminated or not, was a needlessly expensive starting point for our department. Should our used products be added to the municipal waste stream, instead of the regulated medical waste stream, we would save approximately $3,300 per year, without recycling. It is apparent however, from this pilot program that recycling of single-use products can be performed in the anesthesia department without increasing hospital costs.
80 J 80 40 -
T.&State Questionnaire
200
Currently recycling (paper, aluminum, plastic)
Recycle medical waste only if mandated
Figure 2. Percentage of hospitals that would or would not consider recycling medical products unless mandated by law.
cling anesthesia breathing systems. However, a complete cost-benefit analysis of a program to recycle anesthesia breathing circuits (or other single-use items used by anesthesia personnel during a procedure) must take into account certain costs that were not analyzed in this pilot study. Hospital pick-up introduces an incremental cost, but can be kept to a minimum by the use of a supply company already servicing the institution. Following the disassembly and sorting process, the material salvaged from the process must be cleaned, ground or pulverized, bundled, sold, and delivered to a purchaser to have an economic value. Each of these transactions would have associated labor costs that were not analyzed in the pilot program. It should be noted that our normal practice of “red-bagging” anesthesia products, whether grossly con-
Percent of respondents 100
85%
1
80
According to the results from our questionnaire, most respondents (anesthesiologists and nurse-anesthetists) expressed concern about environmental pollution, but they would not participate in a recycling program unless mandated legislatively. The survey indicated that leadership from the manufacturing section would facilitate implementation of programs.
Conclusion The program previously described appears to be economically feasible and would fit the criteria described in the questionnaire as “manufacturer-led” recycling. Beside the potential positive financial impact of recycling single-use products, there are environmental benefits to recycling. For example, incineration, with its potential for environmental pollution, could be avoided. If we simply added our used products to the municipal stream, we would save money, but our action would add to the burden of our landfills. Consideration might be given to reusing singleuse products; however, this can be problematic medicolegally, and the reprocessing costs and potential environmental contamination of the air or water supply should also be considered. With concern over possible transmission of infectious diseases, whether viral or bacterial, reuse without reprocessing might not be an appropriate alternative. As Tieszen and Gruenberg have expressed, efforts are underway to emphasize recycling practices in facilities throughout the country to reduce hospital cost and environmental burden. In a similar fashion, our study shows that focused attention on one product can aid this decrease in cost and burden. A widespread trial of recycling seems to be indicated as a result of this pilot program, with the understanding that the financial data represent a single point in time with respect to the writing and publication of this manuscript.
80 References
40 20 0
No recycling program
Recycling of aluminum and plastics
Figure 3. Percentage of university and community currently recycling various products. 478
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hospitals
1. Afterlife exists, ask your trash. Hospital Purchasing News, Oct. 1990;14(10). 2. Hospital Plastics Characterization and Recycling Feasibility Study. Washington, DC: American Plastics Council, 1994. 3. American Society of Anesthesiologists Newsletter November 1992, Vol 56, No. 11. 4. Rutala WA, Mayhill CC: Medical waste. In&t Control Hasp Epidemid 1992;13:38-49. 5. Tieszen ME, Gruenberg JC: A quantitative, qualitative, and criti-
Medical waste: The role of anesthesia personnel: Goldberg et al.
6. 7. 8. 9.
cal assessment of surgical waste. Surgeons venture through the trash can. JAMA 1992;267:2’765-8. Incinerators touted as inexpensive method to dispose of medical waste. Medical Waste News, June 28, 1994:lOl. A look at medical waste incinerators. Medical WasteIVews, Nov. 15, 1989:105-6. Associators fired up about regional incinerators. Hospital Purchming News, Nov. 1989. Dancer JW: Conquering the growing problem of medical waste. Michigan Hasp 1991;27:4--12.
A Quantitative,
Department
10. Combustion engineering affiliate “zaps” infectious waste. Medical Waste News, May 31, 1989:15.
medical
11. New device disposes of medical waste “electrically.” Stand, July 1, 199495.
Biomed Safety
12. Ross-Flanigan N: At their disposal: new techniques hospital wastes. Detroit Free Press, May, 1991.
to deal with
13. McDovell JN: An Environmental, Economic and Health Comparison of Single Use and Reusable Surgical Drapes and Gowns. Cambridge, MA: Arthur D. Little, Inc., 1993.
Qualitattive, and Critical Assessment of Surgical Waste. Surgeons Venture Through the Trash Can Myles E. Tieszen, MD; James C. Gruenberg, MD
of Surgery, Saginaw Cooperative
Hospitals,
Inc., Saginaw, MI
Abstract OBJECTIVES-To quantitatively and qualitatively evaluate the surgical waste produced from several common surgical procedures, define categories of waste that might be readily separated for alternative disposal practices or substitution, and determine the change in surgical waste output that elimination or alternative handling methods may effect. DESIGN-A case series evaluating the surgical waste from five types of surgical procedures including operations of the back, heart, abdomen, hip and knee, and herniorrhaphies, prospectively identified and allocated at the availability of the investigator. SETTING-A single tertiary community teaching hospital. OUTCOME MEASURES-Weight, volume, and percentage of disposable linen, paper, and plastic plus miscellaneous material from surgical waste with a later subset separating plastics from miscellaneous items to comlpletely identify all categories. RESULTS-Surgical waste weighting 610.5 lb (274.7 kg) and occupying 1’71.6 cu ft (5.1 m3) from 27 cases was examined. Disposable linens accounted for 39% of the weight; paper, 7%; plastic, 26%; and miscellaneous waste, 7%. Disposable linen, paper, and recyclable plastic accounted for ‘73% + ‘7% (mean + SD) by weight and 93% + 4% by volume of total surgical waste. CONCLUSION-Nationally, annual surgical waste from these five procedures weighs 5.1 x lO(7) lb [2.3 x lO(7) kg] and occupies 1.4 x lO(7) cu ft [4.0 x lO(5) m3]. By using reusable linen products and1 engaging in recycling methods currently available and feasible, we estimate that weight reductions of 73% and volume reductions of 93% in surgical waste are possible.
Reprinted
from JAMA 1992;267:26’75-8.
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