Waste Management and the Perspective of a Green Hospital-A Systematic Narrative Review

Waste not want not: the story of surgical trash

PURPOSE OF REVIEW

Our escalating reliance on disposable products in the operating room has generated a large amount of waste, cost, and environmental pollution. Heath damages from the pollution caused by the US healthcare industry cause as much harm, as measured by disability-adjusted life years, as total medical errors. Our response to our own environmental impact should be proportional to that harm. Understanding the waste streams we create and the factors that contribute to our large waste generation in the operating room can help us target solutions to our most harmful practices.

RECENT FINDINGS

Recent studies within the field of medical waste in ObGyn have included a systematic review analyzing most effective practices for waste reduction and environmental life cycle analyses of specific medical procedures.

SUMMARY

Operating room waste includes regulated medical waste, pathologic waste/chemotherapy, sharps, general municipal waste, recycling, linens, and anesthetic gases. The most effective way to reduce the environmental impact from medical waste is to reduce our use of disposable supplies in favor of durable reusable materials. Other important interventions include eliminating 'overage' of unused supplies, optimizing use of anesthetic gas, custom pack scale backs, and proper waste segregation. This review of operative waste is intended to aid healthcare facilities in understanding and addressing their own environmental impact.

Public awareness, attitudes, behavior and norms building green hospitals' power

Hospitals function to provide health services to the community, but they have the potential to be contributors to hazardous waste, climate change, and global warming. The concept of green hospitals is now necessary for changing hospital functions developed by various hospitals worldwide. The success of the green hospital concept requires support from the perspective of the surrounding society. The research aims to analyze public awareness, attitudes, behavior, and norms to build the power of green hospitals. This research method is simple linear regression. The research instrument used a questionnaire. The respondents of this research were 400 green hospital users from Indonesia and Taiwan. The data analysis method includes tests for normality, linearity, and heteroscedasticity. Once these three tests are met, a linear regression analysis is conducted to understand the influence and prediction of public awareness, attitudes, behavior, and norms on building the power of green hospitals. The research results show that each aspect of public awareness, attitudes, behavior, and norms significantly positively influence the building of the power of green hospitals. Each additional value of public awareness, attitudes, behavior, and norms is expected to strengthen the image of a green hospital. Maintaining the sustainability of green hospital programs worldwide not only focuses on implementing the green concept but also needs to pay attention to public perception when choosing a hospital. The research contribution is significant to developing more sustainable green hospitals, increasing knowledge about green hospitals, and increasing public interest and perception of green hospitals.

Healthcare Waste Management: connections with sustainable nursing care

OBJECTIVE

To understand the meanings revealed by nurses about sustainable care in its connections with the management of Healthcare Waste in hospital.

METHOD

Qualitative research, whose theoretical and methodological references were, respectively, Complexity Theory and Grounded Theory. Nursing professionals from a public hospital in Rio de Janeiro participated in the study. Data was collected through semi-structured interviews.

RESULTS

The actions-interactions signified by the nursing staff, for the management of Healthcare Waste, revealed an understanding of the socio-environmental responsibility of the rational use of material resources; of the need for permanent education to promote environmental education; of the need to supervise the proper management of waste. The professionals perceive themselves as a driving force for reordering positive changes in this context.

CONCLUSION

The participants signaled implications between knowledge, rational use of materials, waste generation and disposal, health economics and quality of care. From these connections, we can deduce the complex meaning of sustainable hospital nursing care in the context of Healthcare Waste management.

Strategies and tactics to reduce the impact of healthcare on climate change: systematic review

OBJECTIVE

To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions.

DESIGN

Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions.

DATA SOURCES

Eight databases and authoritative reports were searched from inception dates to November 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses).

RESULTS

Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48).

CONCLUSIONS

Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022383719.

Sterile Draping of Operative Microscopes in Breast Free Flaps and Surgical Site Infections

BACKGROUND

Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections.

METHODS

We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact.

RESULTS

Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species . The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO 2 and direct costs by $7.84 per item.

CONCLUSIONS

The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.

Sustainable practices in hospital and operating theaters

PURPOSE OF REVIEW

This review aims to provide an update on the results of studies published in the last two years involving the development of sustainable practices in hospital and operating theaters (OT).

RECENT FINDINGS

Recently, many studies evaluated various initiatives to better understand the environmental impact of the OT but also to minimize its environmental impact. Many trials evidenced the positive impact of the instrument's reuse using an appropriate reprocessing procedure. Better waste segregation is associated with a reduction of produced waste and contributes to a significant reduction in CO 2 equivalent emissions. Regarding anaesthetic gas, Desflurane is known to have the worst environmental impact and the majority of the study evidenced that its reduction permits to drastically reduce greenhouse gas emission of the OT.

SUMMARY

Greening the OT necessitates climate-smart actions such as waste reduction, the improvement of reusable instruments, recycling of our waste and better anaesthetic gas management. Within the last two years, many efforts have been made to reduce and better segregate waste produced in the OT and also to better understand the environmental impact of disposable and reusable devices.

The environmental impacts of anesthesia

PURPOSE OF REVIEW

The healthcare sector has a substantial environmental footprint, and the delivery of anesthesia contributes significantly. Inhaled anesthetics themselves are potent greenhouse gases, unused intravenous medication exert toxic effects on the environment, and the increasing reliance on single-use devices has led to an ever-growing amount of solid waste produced in operating rooms. This review discusses many of these environmental impacts and suggests practices to mitigate the environmental footprint of anesthetic practice.

RECENT FINDINGS

The choice of anesthesia maintenance has significant environmental implications, with nitrous oxide and desflurane having the highest carbon footprint of all anesthetic agents. Using low fresh gas flows and supplementing or replacing inhalational agents with propofol leads to a significant reduction in emissions. Many intravenous anesthetic agents pose a risk of environmental toxicity, and efforts should be made to decrease medication waste and ensure appropriate disposal of unused medications to minimize their environmental impacts. Additionally, consideration should be given to replacing single-use devices in the operating rooms with reusable alternatives that are often both environmentally and economically superior. And solid waste generated in the operating room should be segregated thoughtfully, as processing regulated medical waste is a highly energy-intensive process.

SUMMARY

Significant opportunities exist to improve the environmental footprint of anesthesia practice, and with the rapidly worsening climate crisis, the importance of implementing changes is greater than ever.

The "6th R" of sustainability: Repurposing operating room waste for community benefit

BACKGROUND

Operating rooms contribute greatly to hospital waste and greenhouse gas production. Efforts to "green the operating room" have focused on the 5R's of sustainability: reduce, reuse, recycle, rethink, and research. We propose a "6th R" -repurposing- as simple yet effective means of addressing operating room waste.

METHODS

Clean, non-reusable surgical supplies were collected from a satellite facility of a children's hospital during a six-week pilot program. Materials were catalogued and repurposed throughout the community. The potential financial benefits were estimated based upon the value of repurposed goods and savings from reduced waste disposal.

RESULTS

Over 960 items were collected during the 6-week pilot. Materials ranging from plastic trays to surgical towels were donated to organizations throughout the community. Approximate retail value of repurposed items was over $1200. When extrapolated to the entire hospital system, these repurposing efforts could account for over $50,000 in donations and $1300 in operational savings over a calendar year.

CONCLUSIONS

Repurposing unused surgical items provide environmental, societal, and financial benefits, all while promoting more sustainable healthcare systems.

Nursing and waste management in health services: unveiling meanings in the hospital context

OBJECTIVE

To unveil the meanings that nursing professionals attribute to practices related to waste management in health services, within the hospital context.

METHOD

Qualitative research, whose theoretical and methodological references were, respectively, Complexity Theory and Grounded Theory. A total of 30 nursing professionals from a public hospital in Rio de Janeiro participated in the study, between January and August 2022. A semi-structured interview was used for data collection.

RESULTS

The professionals indicate the need for better knowledge about waste management in healthcare services, while revealing their understanding on the importance of this process and of themselves as important elements in impacting the environment and health.

CONCLUSION

The complexity of the meanings attributed to healthcare waste management practices indicates the dialogue between the fragility of nursing professionals' knowledge and their expanded perceptions about the impacts they can have on this reality.

Physicians' duty to climate protection as an expression of their professional identity: a defence from Korsgaard's neo-Kantian moral framework

The medical profession is observing a rising number of calls to action considering the threat that climate change poses to global human health. Theory-led bioethical analyses of the scope and weight of physicians' normative duty towards climate protection and its conflict with individual patient care are currently scarce. This article offers an analysis of the normative issues at stake by using Korsgaard's neo-Kantian moral account of practical identities. We begin by showing the case of physicians' duty to climate protection, before we succinctly introduce Korsgaard's account. We subsequently show how the duty to climate protection can follow from physicians' identity of being a healthcare professional. We structure conflicts between individual patient care and climate protection, and show how a transformation in physicians' professional ethos is possible and what mechanisms could be used for doing so. An important limit of our analysis is that we mainly address the level of individual physicians and their practical identities, leaving out important measures to respond to climate change at the mesolevels and macrolevels of healthcare institutions and systems, respectively.

Environmentally sustainable gastroenterology practice: Review of current state and future goals

OBJECTIVES

The health-care sector contributes 4.6% of global greenhouse gas emissions, with gastroenterology playing a significant role due to the widespread use of gastrointestinal (GI) endoscopy. In this review, we aim to understand the carbon footprint in gastroenterology practice associated with GI endoscopy, conferences and recruitment, identify barriers to change, and recommend mitigating strategies.

METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted to explore the carbon footprint in gastroenterology practice, focusing on endoscopy, inpatient and outpatient settings, and recruitment practices. Recommendations for mitigating the carbon footprint were derived.

RESULTS

This narrative review analyzed 34 articles on the carbon footprint in gastroenterology practice. Carbon footprint of endoscopy in the United States is approximately 85,768 metric tons of CO2 emission annually, equivalent to 9 million gallons of gasoline consumed, or 94 million pounds of coal burned. Each endoscopy generates 2.1 kg of disposable waste (46 L volume), of which 64% of waste goes to the landfill, 28% represents biohazard waste, and 9% is recycled. The per-case manufacturing carbon footprint for single-use devices and reusable devices is 1.37 kg CO2 and 0.0017 kg CO2, respectively. Inpatient and outpatient services contributed through unnecessary procedures, prolonged hospital stays, and excessive use of single-use items. Fellowship recruitment and gastrointestinal conferences added to the footprint, mainly due to air travel and hotel stays.

CONCLUSION

Gastrointestinal endoscopy and practice contribute to the carbon footprint through the use of disposables such as single-use endoscopes and waste generation. To achieve environmental sustainability, measures such as promoting reusable endoscopy equipment over single-use endoscopes, calculating institutional carbon footprints, establishing benchmarking standards, and embracing virtual platforms such as telemedicine and research meetings should be implemented.

Optimal selection of healthcare waste treatment devices using fuzzy-rough approach

The escalating volume of healthcare waste (HCW) generated by healthcare facilities poses a pressing challenge for all nations. Adequate management and disposal of this waste are imperative to mitigate its adverse impact on human lives, wildlife, and the environment. Addressing this issue in Bosnia and Herzegovina involves the establishment of a regional center dedicated to HCW management. In practice, there are various treatments available for HCW management. Therefore, it is necessary to determine the priority for procuring different treatments during the formation of this center. To assess these treatment devices, expert decision-making employed the fuzzy-rough approach. By leveraging extended sustainability criteria, experts initially evaluated the significance of these criteria and subsequently assessed the devices for HCW treatment. Employing the fuzzy-rough LMAW (Logarithm Methodology of Additive Weights), the study determined the importance of criteria, highlighting "Air emissions" and "Annual usage costs" as the most critical factors. Utilizing the fuzzy-rough CoCoSo (the Combined Compromise Solution) method, six devices employing incineration or sterilization for HCW treatment were ranked. The findings indicated that the "Rotary kiln" and "Steam disinfection" emerged as the most favorable devices for HCW treatment based on this research. This conclusion was validated through comparative and sensitivity analyses. This research contributes by proposing a solution to address Bosnia and Herzegovina's HCW challenge through the establishment of a regional center dedicated to HCW management.

Is green behaviors of health professionals related to green practices in the workplace? Multicenter study in Turkey

In this study, it is aimed to examine the relationship between green behaviors of health professionals and green practices in the workplace. The study sample consisted of 174 health professionals from 34 Family Healthcare Centers (FHCs) in Turkey. Number, percent, mean, standard deviation, student's test, Mann - Whitney U test, One Way Anova test, Kruskal-Wallis H test, linear regression analysis were used for statistical analysis. Energy-saving (β: 0.197; 95%CI: 0.040;0.266) and waste reduction practices (β: 0.174; 95%CI: 0.019;0.256) in the workplace were positive associated with environmental sensitivity. Waste reduction practices (β: 0.228; 95%CI: 0.093;0.478) in the workplace were positive associated with environmental participation. Recycling bins (β: 0.181; 95%CI :0.084;0.799) and using solar energy (β: 0.198; 95%CI: 0.030; 0.785) in the workplace were positive associated with technological sensitivity. Health professionals who work in workplaces with energy-saving, waste reduction practices, recycling bins and using solar energy more likely to display green behaviors.

Green hospitals face to climate change: Between sobriety and resilience

Climate change poses a critical challenge to global health, influencing social and environmental determinants such as housing, air and water quality, and food security. This article explores the profound impact of climate change on health, projecting an additional 250,000 annual deaths from various climate-related diseases between 2030 and 2050. Healthcare systems significantly contribute to global carbon emissions. The concept of the "Green Hospital" is introduced as a paradigm shift in healthcare, focusing on optimizing resource efficiency and minimizing environmental impact. This concept encompasses renewable energy integration, natural lighting, sustainable materials, green roofs, and smart building management systems. Several challenges remain major, such as medical waste management, water conservation, chemical use, pollution, and plastic usage in healthcare settings. Moreover, obstacles to green hospital initiatives should be resolved, including system redundancy, regulatory compliance, operational demands, financial constraints, and cultural resistance. Conclusively, an urgent reformation of healthcare systems is needed to align with eco-friendly and sustainable practices, highlighting the necessity to reduce CO2 emissions and manage resources and waste more effectively to meet the evolving health needs of a growing and aging global population.

Roadmaps to green nephrology: a mediterranean point of view

PURPOSE OF REVIEW

Green nephrology is a movement whose aim is to find ways to reduce the environmental impact of kidney care. The question is of particular concern in this field since haemodialysis is one of the major contributors to waste generation, energy use and water consumption in healthcare. Although several ways for improving sustainability have been advocated, they are all context sensitive. This review aims to analyse the interventions that have been proposed to improve the ecologic sustainability and reduce the carbon footprint of nephrology care adapting to specific settings, and taking advantage of local expertise.

RECENT FINDINGS

Green hospitals are becoming a reality in several high-income settings, thanks to new building guidelines, with greater awareness of climate change and users' demands. Water saving is feasible, and is increasingly done, in different ways (improving hardware, reducing and adapting dialysate flows). Recycling noncontaminated plastic waste is feasible, but is still rarely performed. However, ecological transition has been slow even in high-income countries, while in low and middle-income countries lack of resources limit the ability to cope with the planet's urgent needs. Conversely, where man-power cost is low, some time-consuming tasks, such as separation of various components for recycling may be affordable. Theoretically, implementation of all clinical tasks aiming to avoid or retard dialysis, should be a priority.

SUMMARY

There is no single roadmap for achieving green nephrology. Each setting should start from those feasible interventions most in line with its specific needs and priorities.

Reusable laryngoscope blades: a more eco-responsible and cost-effective alternative

INTRODUCTION

Consumption of single-use medical devices has increased considerably, contributing to the excessive wastage produced during surgical procedures. The present study aimed to describe a methodology to assess the transition from single-use blades (SUB) to reusable laryngoscope blades (RUB) and to assess the ecological and economic impact of the switch.

METHODS

The ecological analysis was based on the life cycle assessment method. Based on 30 operating rooms in a single tertiary university hospital, the economic analysis compared the usual SUB supplier with four RUB suppliers considering different costs: blade purchasing and depreciation, reprocessing, logistics and waste management.

RESULTS

In 2021, 17,200 intubations were performed requiring about 147 RUBs. Switching from SUB to RUB led to an annual saving of 26.5 tons of CO2eq (global warming impact), equivalent to 120 000 km by car. It avoids the extraction of 6.6 tons Oileq (petroleum) and 579 kg of copper (mineral resources) per year. This action also leads to a land occupation reduction of 626 m2 per year and water savings of 221.6 m3 per year. The average cost per intubation varies from 3.16 [3.15-3.16] for SUB to 2.81 [2.77-2.85] for RUB, representing an average saving of 0.35 per intubation leading to 5783.50 annual gain [5074.00-6192.00]. RUB are preferable from 3 and 86 uses from an ecological and economic viewpoint, respectively.

CONCLUSION

In a model of 17,200 intubations /year, switching SUD to RUB would save 26.5 tons of CO2eq and 6.6 tons of Oileq with 5783.50 annual gain. RUBs are ecologically and cost-effective after 3 and 86 uses, respectively.

Death by compaction in a robotic dumpster

Robotic waste management automation systems are increasingly utilized around the globe as a user-friendly, ecological and hygienic alternative to waste disposal, simultaneously reducing the volume and frequency of waste collection. The present paper aims to report a case of death by compaction in an automated robotic waste management system and review relevant literature on compactor-related fatalities. The unusual fatal accident involved a 37-year-old male citizen who deliberately entered the robotic dumpster to retrieve his accidentally discarded medication. Upon entering the robotic chamber, the compaction system was automatically activated, although all safety measures were in full operation. This paper highlights the lack of standardized reporting on compactor-related mortality, which however is of importance both in terms of its social impact and public safety. These deaths occur rarely, in scattered areas of the globe, associated with various situations (e.g., occupational fatalities, homeless people, infanticide) and trash compactors of different types, technology, age, maintenance quality, warning signage and safety interlocks. In all previously reported fatalities, the technology involved was considerably older (as in conventional waste containers, garbage compaction trucks, chute-fed compactors in buildings, etc.). The case described in the present report is a rare event in both literature and international news coverage as it encompasses a fully automated technology intended for unsupervised, direct use by the public being located in public spaces where all citizens can interact with it. The aim of this report is to raise awareness and improve knowledge about safety parameters so that similar incidents can be avoided in the future.

Promoting the Sustainable Recovery of Hospitality in the Post-Pandemic Era: A Comparative Study to Optimize the Servicescapes

As COVID-19 spread throughout the world, the hospitality and tourism sectors were hard hit as no other industry. For this reason, the UNWTO developed the One Planet Vision as a response to a sustainable recovery of the tourism sector. At present, when people are starting to travel and stay at hotels again, it is important to analyze what their expectations are of hotels to move forward in the post-pandemic era. For instance, empirical research has been developed to examine people's sentiments toward servicescapes, and a comparative study is presented between 2020 and 2022. Findings contribute to the research by identifying new servicescape attributes during a health crisis. These also lead to practical implications by proposing a scale to evaluate customers' perceptions and to increase their wellbeing and resilience. The current research is one of the first studies to collaborate with the One Planet Vision by empirically proposing improvements in the servicescapes of hotels for a responsible recovery.