Acquiring enough personal protective equipment and supplies to test for and treat COVID-19 in the United States was a major challenge in 2020. With case numbers rising and vaccines rolling out, managing supplies and reducing waste continues as a huge issue this year.

Isolation gowns, gloves, masks, needles, syringes and vials discarded after use: some waste is inevitable, but supply chain leaders are finding ways to reduce quantities, reusing and recycling when possible and adjusting procurement and packaging to help the environment and sometimes their bottom line.

Hospitals generate around 30 pounds of waste per patient per day, said Janet Howard, member engagement director of Practice Greenhealth, a nonprofit environmental stewardship membership organization. The Healthcare Plastics Recycling Council said that amounts to about 14,000 tons of waste daily, a quarter of which is plastic packaging and products. The World Health Organization estimates that about 85% of hospital waste is noninfectious, making the bulk of it easier to dispose and potentially recycle.

Sources of medical waste

While the term PPE entered the general lexicon thanks to COVID-19, it was already a staple of the healthcare system.

Gowns

After gloves, medical gowns are the second most commonly used PPE item in healthcare settings, and currently 80% or more of isolation gowns used in the U.S. are disposable.

Disposable gowns have gotten more expensive and harder to procure with hospitals experiencing surges in case numbers and providers needing frequent gown changes.

"I’m shocked that is a challenge right now. There’s no reason they couldn’t be reusing them," by purchasing launderable gowns, Howard said. "Some infection control departments insist on disposable protective equipment, but there is research and evidence that disposable isn’t necessarily safer than reusable."

With pandemic-related supply chain breakdowns, hospitals already using reusable PPE prior to the pandemic felt more prepared, she said.

UCLA Medical Center started switching to reusable isolation gowns in 2012, diverting almost 300 tons of waste from landfills, and saving more than $1.1 million in purchasing costs in a three-year period. A study published in the American Journal of Infection Control showed that laundered medical gowns were more durable and provided better protection than disposable gowns, even after 75 industrial launderings.

Vials and needles

With vaccines, there are fewer opportunities for recycling, said Howard. Glass vials and needles must be disposed of in a sharps container, though some containers can be disinfected and reused after safely disposing of the contents.

"It’s harder for those in remote areas," Howard said, as those facilities may get less frequent disposal service due to their size or location.

Plastics

Plastics are a big part of the waste stream, including flexible plastics, products with multiple resins, and blue wrap (polypropylene) packaging that holds instruments during and after the sterilization process.

Recycling is only one part of a hospital sustainability program, but it’s high profile, especially to employees. China's 2018 policies to limit or ban imports of certain recyclables brought a lot of recycling programs to a slowdown, if not to a halt, Howard noted.

PPE, medical supplies get another life

Healthcare systems may end up using more reusable items out of necessity during the pandemic, resulting in decreased waste. A global shortage of N95 respirators forced hospitals to look at options other than just requiring staff to reuse the disposable respirators for multiple shifts, leading to new sterilization methods. Hospitals are getting approval from the Centers for Disease Control and Prevention to decontaminate some disposable items, and these methods can potentially be used long term if they reduce waste and are safe, said Howard.

How healthcare organizations allocate supplies for patient and surgical rooms can also impact disposal quantities.

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"If you calculate what you’re spending on disposables, it can be eye opening."

Janet Howard

Member engagement director of Practice Greenhealth

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"Anything taken into a [patient’s] hospital room, if they don’t take it home, goes in the trash," said Elizabeth McLellan, founder and president of Partners for World Health, a nonprofit that collects supplies and equipment from U.S. healthcare organizations and distributes them to developing countries.

Once items are opened in the patient’s room or surgical suite, they can’t be reused in the hospital. Every day her organization collects 10,000 to 20,000 pounds of unused material, not including durable medical equipment, from healthcare facilities in the Northeast. Their collections range from unused exam gloves and wound care supplies to unneeded anesthesia machines.

"The pure medical waste is in the red bags," McLellan said. "Everything else I look at as discarded, but with another life."

Manage inventory, manage waste

Hospitals may have supply chain and procurement protocols that don’t allow products to reenter the supply system. Prior to working with PWH, healthcare organizations might have discarded unused items, but now staff can put them in a recycling bin. The items are clean but not sterile and go to a loading dock for PWH staff to pick up. PWH uses its own autoclave machine to sterilize items as appropriate, repackaging, labeling and dating supplies.

Operating rooms are a source of supplies that can be repurposed. A study in the Journal of Neurosurgery found an average of $968 in unused and discarded neurosurgery supplies per procedure at University of California, San Francisco, adding up to $2.9 million per year in that department alone.

These supplies often come in surgical packs, which include items typically needed during a procedure. A hysterectomy pack might include six disposable surgical gowns, sterile gloves, plastic bowls, sutures and three sets of 10 sponges. But if most doctors don’t use everything in there, the unused supplies may be tossed.

An option for decreasing unused surgical supplies is to reformulate surgical packs. Hospitals can identify the items and quantities they want in each pack and work with suppliers to reformulate them.

Some of that savings can be used to purchase more environmentally-friendly products. The additional cost for these green products can range from pennies per product to 40% more per product, said Kimberlee Luedee-Chase, cofounder and vice president of marketing at NewGen Surgical, which sells supplies made from agricultural waste material. While that may sound high, hospitals look in context of total spend per pack, she said.

Why not just put the unused items back in the supply closet? "I think it’s challenging for a hospital to set up an entirely different service that would reprocess that stuff," McLellan said.

It would be expensive and require additional staffing and tracking and it could interfere with accreditation standards. That said, some hospitals now use supply closets outside the patient room, so they can just take one piece of gauze or a diaper, instead of a whole package into the patient’s room.

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"The pure medical waste is in the red bags. Everything else I look at as discarded, but with another life."

Elizabeth McLellan

Founder and president of Partners for World Health

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Organizations like the Cleveland Clinic divide waste into 37 different streams, looking for the best way to reuse or recycle if possible. The Clinic estimates its organization produces 6,000 tons of waste per day. It sorts waste by bag color: red for regulated medical waste, orange bags for plastics, blue bags for commingled recyclables, purple bags for clinical plastics and clear bags for unregulated waste.

The Cleveland Clinic’s main campus uses an underground tunnel system, where 100 robotic automated guided vehicles carry the waste bags to their destination, whether to the health system’s autoclave, or to the pickup dock for recycling and medical waste.

Small operational changes for big impact

Hospitals can decontaminate some products like metal emesis basins, but the cost to collect, transport, sterilize and repackage the items may be higher than buying new products, especially if they have patient fluids on them. "It’s not worth the supply chain cost," said Luedee-Chase.

The operating room accounts for up to 35% of all hospital waste generated, said Luedee-Chase, but there are opportunities to reduce waste without changing the current workflow.

"You don’t want to make a massive change to how the perioperative staff do their job as this requires time, training and cost," she said.

Through NewGen Surgical’s "small change, big impact" program, Dignity Health Network swapped out traditional plastic needle counters used in the surgical suite for ones made of plant-based material. While the playing card-size boxes are still disposed of after surgery, Dignity Health eliminated 10 tons of single-use plastic in two years.

The use of blue wrap, made of polypropylene, is common in hospitals for wrapping instruments for sterilization. About 255 million pounds are discarded by the healthcare industry each year, according to Practice Greenhealth.

Previously, hospitals used rigid sterilization containers.

"We’d rather hospitals go back to reusable sterilization containers rather than recycle the blue wrap" Howard said. It’s voluminous and hard to recycle. While it costs money to invest in the containers, "if you calculate what you’re spending on disposables, it can be eye opening," Howard said.

KPIs for measuring and reducing waste

Key performance indicators depend on the healthcare system’s goals. McLellan said PWH provides each hospital with an annual accounting of how many pounds her organization collects, so hospitals can calculate their savings from avoiding disposal fees.

She can also tell hospitals where their durable medical equipment went, as hospitals like to share this in their annual report. "I can tell them 20 beds went to Ethiopia and their anesthesia machine went to Syria," she said.

Luedee-Chase said NewGen Surgical can calculate how many tons of plastic waste per year a customer saves in using a product like plant-based trays, as trays are in many surgical packs. Unlike the traditional surgical polystyrene trays, NewGen Surgical's tray can be recycled with paper products. The organization estimated that one kit manufacturer purchased enough trays to fill seven football fields knee-deep.

Cleveland Clinic charts its waste profile by quarter, breaking waste into three dozen categories, including pulse oximeters, X-ray film, ice packs and batteries. The clinic includes landfill diversion rate tracked yearly as well.

Every healthcare organization should have someone take the lead in sustainability, said Howard. "The hospitals that have had the most success are those that create a position," she said, and her organization is seeing hospitals open up more waste manager and energy manager positions.

The sustainability process requires ongoing education and an employee engagement strategy. "Whether hospitals are interested or not, they will be left behind" if they don’t address these waste issues, Howard said.