The best practices in hospital waste management start with procurement. If fewer disposable items are purchased, less total waste will need to be disposed. Better waste classification and careful segregation leads to less contaminated and mixed waste, and more recovered recyclables.
A Solution for Waste Reduction
These simple facts describe the challenges hospital managers face. Delivering quality care while keeping infection rates low and costs under control is a constant demand to be met.
Hospitals face varying realities. If they have an environment or waste manager they usually start at the end of the process, where the waste is waiting to be dealt with, and not at the beginning with procurement. Or hospitals outsource the whole waste management process and pay a hefty price for piece of mind, without being able to reduce waste and associated costs.
Health Care Without Harm (HCWH) is an international coalition of 470 hospitals and healthcare systems, medical professionals, community groups, health-affected constituencies, labour unions, environmental organisations and religious groups in more than 52 countries. Our partner organisation Practice Greenhealth works with over 1,100 hospitals and systems to change to sustainable and eco-friendly practices. Together we work to transform the healthcare sector so it is no longer a source of harm to people and the environment by encouraging and sharing best practices.
Waste Working Groups as Drivers for Change
HCWH recommends setting up hospital site working groups on waste to develop, monitor and enhance waste reduction programmes. In order to be successful these need input and cooperation from experts in all departments and all occupational groups within a hospital. Waste working group members will need to audit hospital practices and set out clear short and long-term goals. Their research should include an analysis of purchased products and medicine from the point of waste, identify the types and amount of discards generated within the hospital, and ideally compare this data with information from a similar medical establishment. Recommendations on reasonable supply management should be developed.
This leads to purchasing practices for products, medicines and food that reduce the amount and toxicity of the waste produced. Procedures should also be developed for the classification, segregation and management of waste from each individual source, and these should be made easily accessible to staff. A programme for separate collection of different waste streams should be developed with an indication of potential recycling markets. Technical parameters for waste management in the facility and premise need to be set. Cost and savings need to be estimated before launching a waste reduction programme. Information material for staff and patients needs to be developed and the staff trained in order to have full buy-in.
Environmentally Preferable Purchasing as a Way Forward
Environmentally preferable purchasing (EPP) means assessing the environmental and human health impact of products before you buy them, and choosing least harmful products/services. One may eliminate products that contain mercury, chlorine compounds, bromine, cadmium, lead and chemical substances that disrupt body functions, i.e. phthalates. The Stockholm County Council, for example, has a list of chemicals that should be avoided when purchasing for their city hospitals. EPP encourages a gradual and ongoing process by which a hospital continually refines and expands the scope of its efforts to select healthy, safe and environmentally sound products and services.
The German consultancy Ökopol worked with circa 70 hospitals in Germany over three years to introduce EPP and found that most hospitals choose overpriced products of low quality. The main challenge Ökopol identified was organising an internal purchasing group that brought relevant staff together. If this was successful then analyses were done, using criteria developed by the team in collaboration with Ökopol, and very quickly products were changed and costs saved.
The introduction of EPP guidelines is key to reducing the amount and toxicity of waste. Source reduction should have a higher priority than even reuse or recycling, where currently some of waste management energy is focused. We need to remember all purchased products will eventually become more or less burdensome and costly wastes. Interestingly the NHS carbon footprint between 1992-2004 represents 25 percent of England public sector emissions, with procurement being 60 percent, followed by building energy use (22 percent) and travel (18 percent). Procurement is not only a major source of waste, but also of CO2 emissions, and thus a shift in purchasing will help to address climate change.
One simple, but very efficient, criteria is that of product weight. Select the product with the lowest weight after comparing this for the same product and its packaging from various suppliers.
Another criteria, applying primarily to packaging and products that do not have direct contact with pathogens, is the potential for reuse and/or recycling. If possible from a hygienic and sanitary point of view, disposable products should be eliminated. Even though reusable products require cleaning, and thus consume energy, water and disinfectants, as a rule the total spending on their purchase and application is lower than in the case of single-use products. It is also environmentally preferable to reuse a product and clean it than to manufacture a new item each time. Analyses carried out in hospitals have shown that disposable products, such as single-use mugs for drug administration, bottles for feeding infants, tongue depressors, colostomy pouches, and intubation tubes, among others, can be substituted without reducing quality of service, to the benefit of both the environment and hospital finances.
Proper Waste Classification and Segregation
In order to reduce cost and waste managers must pay attention and implement carefully planned procedures. First, various wastes have to be correctly identified, segregated, and disposed of to avoid a threat to human health and the environment. If staff members do not find these procedures easy to follow, the different waste streams (municipal, medical, infectious medical, hazardous and low level radioactive waste) will get mixed together and become uniformly hazardous, which requires the most costly and environmentally adverse treatment methods. Thanks to constant progress in segregation, the public hospital of Tours in France managed to reduce its infectious medical waste production from 1.4 kg/bed/day in 2000 to 1.08 kg per bed/day in 2007.
In order to achieve segregation, policies should be understandable and manageable for staff. Containers for separate collections of waste should be located where the waste is generated, in locations that do not get in the way of personnel's everyday duties. The containers need to be clearly labelled. Colour coding and symbols are used to make waste segregation easy for staff. Training and motivation of staff is important for implementing segregation. A hospital in Luxembourg, for example, uses stickers on the bags to identify which department generates the waste, and can reinforce training for staff who are lagging behind in correct disposal. This facilitates data gathering and monitoring of proper waste separation.
More than half of all waste generated in healthcare are various kinds of packaging. Most of this waste does not have any direct contact with infectious agents or hazardous substances. It can often be recycled, and should not be mixed with non-recyclables, infectious or hazardous wastes. King's College Hospital in the UK for example was able to increase the cardboard recycling rate by 115 percent between 2008 and 2009 due to improved internal processes. Key to success here is staff motivation and training, and ease of access to recycling bins.
Waste Treatment and Neutralisation
Infectious medical waste must undergo treatment in order to be downgraded to normal household waste. Treatment can include autoclaving, thermal disinfection, and microwave sanitation. Hospitals should strive to eliminate the amount of waste being incinerated. Gaseous, solid, and water residues from incineration release highly toxic, persistent and accumulative substances into the environment, including dioxins, furans, and heavy metals. The more chlorine-containing products (such as PVC or vinyl plastic, disinfectants, bleached dressing materials etc.), mercury (although there is a general ban on incinerating mercury it may end up in the waste stream) and chemical agents that exist in the infectious waste stream, the more toxic emissions will be released by incineration.
Incineration is also the most costly method of waste treatment, taking into account both investment outlay and day-to-day operating costs. No technology offers a panacea to the problem of medical waste disposal. In general, however, most non-incineration technologies emit fewer pollutants and generate solid residues that are not hazardous and can at times be recycled. Opole Hospital in Poland achieved a 52 percent reduction of emissions (SO2, CO2, NOX) in 2007 compared to 2006 after introducing a waste reduction programme and extending their environment protection activities in line with ISA 14001.
While HCWH realises that in most of Western Europe landfills are coming to an end and incineration is offered as the "solution", especially with waste to energy promotion, we posit that this is a false solution. If we continue to waste and burn our resources then fairly soon we will not have any left to live and treat our patients with. Forward thinking institutions together with industry and governments need to begin getting serious about implementing real solutions for hospital waste. Solutions do exist and can be implemented.
The solution for better waste management lies in the challenge of addressing hospital procurement, improved segregation of nonmedical waste and avoidance of incineration. We have many doctors and nurses who are questioning current practices and working towards healthier alternatives. HCWH is there to be part of this process.
Executive Director, Health Care Without
P. Gluszynski, Ch. Keith and W. Winkler