Dr Forbes McGain and his sustainability colleague Catherine O’Shea explain some of the challenges surrounding the recyclability of medical waste in Australia.
In a single week at Melbourne’s 320-bed Western Hospital in Footscray, there were 237 operations and procedures performed.
During this week in December of 2012, the hospital produced 1265kg of waste in the six-theatre facility.
The goal of producing this data was to estimate the financial viability and practicality of recycling in an operating room, but that’s just the tip of the iceberg for medical waste.
That’s according to Dr Forbes McGain, anaesthetist and intensive care physician, who has spent years researching the practicality of environmental sustainability in the medical profession.
The challenges of balancing environmental sustainability with the economics of running a hospital are compounded by the risks of avoiding contamination. Amid these considerations is a desire for doctors like Forbes to help reduce a hospital’s carbon footprint.
“When we look at adopting recycling programs across Western Health’s numerous hospitals, one of the considerations is taking into account the purchase costs versus labour costs of adopting reusable items instead of single use,” Forbes explains.
“Because of Australia’s reliance on coal as a source of energy, reusable equipment has shown in our research to have a higher carbon footprint than disposable equipment. This is because reusable equipment such as anaesthetics relies on washing devices powered by brown coal.”
Forbes says this is very different to Europe, the US and New Zealand (and Tasmania) where the financial and environmental costs of using reusable equipment are both highly beneficial when compared with single-use equipment.
Despite this, reusable equipment has been shown to have a financial advantage. Forbes’ research in conjunction with Melbourne’s Austin Hospital compared the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment. The results showed an annual saving of $32,033 – a 46 per cent decrease in costs. However, the data showed a 480kg increase in carbon dioxide equivalent (CO2 eq) – a unit of measurement which seeks to quantify the effect of greenhouse gases on global warming.
For an Australian hospital room with six operating rooms, Forbes estimates the savings at $30,000, with an increase in CO2 emissions of almost 10 per cent. The CO2 offset depends on the power source mix, while water consumption is greater, and has more than doubled in Forbes’ research.
The figures were calculated using a life-cycle assessment. In another paper, Forbes and his colleagues define a life-cycle assessment as the entire “footprint” of an item, including the financial and environmental costs across its entire life.
The scientific assessment guides the entire process of a product’s life cycle, from raw material acquisition to processing and manufacturing, distribution and transportation, use, reuse and maintenance, recycling and waste management.
In the week of December 2012, Forbes’ audit, published by the International Anaesthesia Research Society, found the 1265kg of waste encompassed 45 per cent general waste, 32 per cent infectious waste and 23 per cent worth of recyclables. The general waste and infectious waste bins contained paper/cardboard, plastics (including polyethylene, copolymers, polyvinyl chloride [PVC]), aluminium and glass. General waste bins contained 243kg of recyclables, with 97kg of paper/cardboard, 141kg plastics and 5kg aluminium and glass. Recycling rates of up to 20 to 25 per cent of total waste are achievable without compromising infection control or financial constraints, according to additional case reports published by the society in 2015.
But despite the audit, progress can be slow. Recycling programs at Western Health hospitals date back to 2009, with the adoption of the Vinyl Council Australia’s PVC Recycling program across various departments. In 2011, Western Health introduced its first Sustainability Officer position, held by Catherine O’Shea.
One of the programs Western Health has been recently recognised for is its single-use metal instruments recycling program. The organisation won an award for its efforts in the health category at this year’s Victorian Premier’s Sustainability Awards. Approximately 500kg of steel was recycled in 2016 after the roll out of the program, representing approximately 80 per cent of all single-use metal instruments.
Catherine says there is a lack of delineation between reusable, single-patient use and single-use devices. She says a reusable device, such as a surgical instrument, is designed to be used many times on different patients, and the manufacturer provides detailed instructions on how it can be safely reprocessed between each patient.
A single-patient device is one that may be used multiple times on the same patient, depending on its design and the manufacturers’ instructions. A single-use device is designed by a manufacturer to be used on one patient only and then discarded.
“Disposable (single-use or single-patient use) items are generally marketed in the place of items that require cleaning as safer, easier, and more cost-effective. None of these things are necessarily correct, and waste is rarely considered,” Catherine says.
“You wouldn’t know unless there was life-cycle analysis to ascertain whether these marketing claims were indeed correct. Life-cycle analysis studies are rarely done in healthcare because they rely on industry support to provide information that is often ‘commercial in confidence’.”
Plastic forms a majority of the material these devices are made of, and many items, such as hospital gowns, are made of a hybrid of materials.
“With respect to plastics, most things you would buy as a consumer are labelled with a resin code. However, in medicine, we don’t know what plastic they are because they’re not stamped with a resin code and the packaging doesn’t indicate what sort of plastic they are,” Catherine says.
She notes the Therapeutic Goods Act doesn’t require the recyclability of an item be identified, with some manufacturers spontaneously placing it on their packaging. She believes a regulatory authority, such as the state-specific environmental protection authorities, could potentially regulate for transparency in stipulating a product’s recyclability.
“A manufacturer could be required to perform a life-cycle analysis of the new item to an agreed benchmark in order to obtain Therapeutic Goods Administration approval,” Catherine says.
“It should also be required to state clearly the materials that make up the product and its packaging, together with its recyclability or otherwise. The manufacturer could then be held to providing evidence-based rationale (i.e. safer, cheaper, easier) in marketing.”
She says one of the main challenges is continuing to balance the financial, environmental and social cost of medical recycling.
Catherine notes the barrier to change is cost, as often it can be more expensive to recycle. Initially, for Western Health, a commingled bin pick up was more expensive than the same volume of landfill to dispose of, as the landfill went into a compactor. However, with a long-term vision, the organisation was able to increase recycling volumes to the point of also running a commingled compactor. It now recycles up to 38 per cent of its total waste.
“While it’s initially expensive to start with and create the infrastructure systems, it will generally pay dividends in a big way long term,” she says.
Epworth Hospital Richmond, another finalist at this year’s Premier’s Sustainability Awards, was the first hospital in Australia to recycle both aluminum and PVC hospital products. Epworth’s nine hospitals across Victoria are expected to recycle about 3000 aluminum canisters and 80 m3 of PVC products each year.
Rebecca Pascoe, Registered Nurse, has helped champion the project by liaising with nurses and hospital staff.
Rebecca and her colleagues have also implemented other recycling streams and methods of improving sustainability in the organisation.
A key problem, she says, has been finding waste disposal companies who are willing to deal with hospital waste, due to the misconception that all hospital waste is ‘contaminated’ from needles and blood.
“There seems to be a misunderstanding that all waste from a hospital is ‘clinical waste’,” she says.
“In fact, we segregate our waste into different bins and our clinical waste is dealt with separately from the other waste streams.
“This clinical waste contains any items that are contaminated by blood or have been in contact with a known or suspected infectious patient. All other waste is segregated into either recycling or general waste.”
She says another issue surrounds changing organisation systems to integrate sustainable practises, and educating healthcare staff on the ground to influence proper disposal habits.
“It all takes time and a lot of perseverance,” she says.
However, she remains confident the progress is happening.
“I think we are really starting to turn a corner and improve sustainability outcomes at our facility. Staff and management are really proud of our initiatives, especially with our nomination as a finalist in this year’s sustainability awards.”
Featured image: Rebecca Pascoe, Nurse at Epworth Richmond Operating Theatres, shows off the hospital’s PVC and aluminium canister recycling program.