Sustainable Medical Waste Management: P1

This research disseration with Queensland University of Industrial Design is ongoing as of 19th May 2022, where this is just the first phase of two. Watch this space for further updates. - Isaac

Introduction

It is ironic that as we create a healthcare system to continually better the health of its population, we also have created a society with which the same system now generates 8 billion tonnes of waste a year, rivalling the food industry (Ordway et al., 2020; Wyssusek et al., 2020). This wasteful machine results from years of stigma and legislative reform stemming from the AIDS epidemic of the 80s. Today, the attitudes within medical practices highly reward the excessive packaging and over discarding of medical devices. Single-use medical devices have become a favoured instrument by many practices, big and small, due partly to their short-term economic savings and thought to be “less hassle” by medical staff (McGain, 2010). Globalisation has developed a system that affords a cheap and affordable single-use class of products in countries with high labour costs, ruling out the practices required to maintain reusable alternatives. Efforts internationally have risen across faculties of medicine to reduce, reuse and recycle their waste streams in response to growing concerns of climate change has presented to the world. Research initiatives within hospital systems have revealed many causes for concern with existing practices medicine has come to accept. Key points of concern include the failure to segregate waste by type and hazardous status and the excessive packaging and liability pressure resulting in over disposal. Today, it has become commonplace for medical staff to joke about “being dressed in oil” due to the excessive use of single-use products typically derived from petrochemicals (Terzon, 2021). So what can be done about this wasteful culture?

Promising initiatives within Australian hospitals have shown us that there are simple practices that can afford impactful results. Dr Forbes McGain from the Western Hospital in Victoria has led and inspired much of the research the following literature review discusses (Terzon, 2021). McCain’s efforts have afforded initiatives within his hospital to replace single-use anesthetic equipment with reusable alternatives in operating rooms, saving the hospital roughly $30,000 per year. Dr Wyssusek et al. (2020) of the Royal Brisbane and Women’s Hospital (RBWH) captured all of their PET waste generated by their operating theatres saving close to two tonnes of waste destined for the landfill diverted to recycling facilities for further processing. Reducing the financial strain on the hospital and also the environmental impact.

While these initiatives have shown promising results, much of the existing literature discussed has research sources from large hospital institutions. This represents a bias in the data and does not represent the whole picture. Much of the population visits general practices and dental clinics far more often than the hospital. It is essential for this study to research this missed industry and develop opportunities to improve the well-being of the medical practitioners involved and patients underserved by contemporary literature (Australian Bureau of Statistics, 2021).

Literature Review

Waste in the Medical Industry

Over the past several decades, the medical industry has transitioned from the practice of cleaning and sterilising items for reuse; to the mass consumption of single-use items disposed of after each use (Kagoma et al., 2012; Merritt et al., 2000). This overhaul was partly due to the HIV/AIDS epidemic of the 1980s, and the fear of blood-borne diseases introduced increased regulation across the industry, which resulted in the increased consumption of single-use products (Laustsen, 2007). Today, the production and disposal of medical goods contribute seven billion tonnes of medical waste to land-fills, making the industry the second largest contributor to land-fill behind the food industry in the United States (Ordway et al., 2020; Wyssusek et al., 2020). However, research suggests that only 2% of hospital waste was recycled in many western countries (McGain, 2010). The frequency of waste produced exacerbates this; one Australian report finds that they make 5kg of waste per patient per day (McGain, 2010).

A healthy ecosystem requires a healthy environment, and anything that alters ecosystem health also may alter the health of its inhabitants.

  • Dr Gary Laustsen (2007)

Single-use medical devices afford much of the waste a medical practice disposes of (Duane et al., 2019). These single-use components include cotton drapes, theatre gowns, respiratory devices, bowls and even metalware devices such as scissors and containers (McGain, 2010). While reusable alternatives exist, many practitioners are reluctant to use them, citing cost as the main reason (Moultrie et al., 2015). A pay-per-use business model has become much more appealing and approachable for management where the costs and liability associated with cleaning reusable equipment may be difficult to monitor (Alfa, 2013; Moultrie et al., 2015). Liability concerns are often discussed in the literature, where many medical institutions are risk-averse to any opportunities that could afford contamination between patients. (Alfa, 2019; Goldberg et al., 1996; Moultrie et al., 2015). These two drivers, cost and liability, enable the consumeristic behaviours we find within many medical institutions. The effect is ironic when you consider the purpose of medicine and its Hippocratic oath in contrast to the environmental impact the industry has on the people it serves (Kagoma et al., 2012).

Sources

In 2010 the Victorian public hospital system produced the equivalent of 200,000 households worth of waste, costing the network an estimated 10 million dollars (AUD) annually to discard (McGain, 2010). However, medical waste is regarded differently than your regular household waste, where much of the waste is considered bio-hazardous. This difference in distinction increases the cost of medical waste tenfold, where it costs roughly $1/kg to dispose of within the Australian market (McGain, 2010). Research inside the hospital reveals that the largest source of medical waste originates from the operating rooms, where an estimated 33% of an entire hospital’s waste is generated from these relatively small zones (Goldberg et al., 1996; Kagoma et al., 2012). Studies suggest that up to 80% of the waste generated by the operating room has already occurred before the patient arrives. Therefore, much of the waste from the OR is clean, uncontaminated and easily recyclable (Wyssusek et al., 2020).

However, of all the waste created, it is often discussed that as little as 10% of that disposed material is hazardous to humans, with much of the waste taking the form of packaging and paper (Babanyara et al., 2013; Laustsen, 2007; McGain, 2010). Literature, however, tells us that there is a constant challenge in keeping these two branches of waste separated from one another inside the hospital environment (Kagoma et al., 2012, p. 1907).

Graphic of the types of waste categorised by risk (Babanyara et al., 2013; Laustsen, 2007; McGain, 2010)

This medical waste generation has only been greatly increased by the current world pandemic, COVID-19. Literature indicates that medical waste disposal has risen significantly across the globe. One Sydney landfill reported that the disposal of medical waste has increased by 35%, with some Chinese provinces indicating that they’ve seen a 600% increase in medical waste (Andeobu et al., 2022). Suggesting that the contemporary medical waste problem we are discovering may continue to rise without proper interventions. Media coverage has only improved on how topics regarding medicine are discussed in a public forum, with more eyes being directed to the existing medical waste problem (Terzon, 2021).

Risks & Hazards

An estimated two million healthcare workers globally are exposed to percutaneous injuries from infected sharps each year (Prüss-Üstün et al., 2005). A majority of which resulted from handling found during the disposal stage where there may have been improper packaging of waste (Blenkharn & Odd, 2008; Chartier et al., 2014). The most significant hazards found with medical waste typically come in the form of blood-borne diseases such as Hepatitis B and C and HIV in rare cases. These perceived risks further promote the use of single-use devices as there is a reluctance found from waste-handling personnel with the practice of recycling and reusing (McGain, 2010). Inappropriate handling of waste has also afforded increased regulation in the industry, which in parallel increased the reliance on disposable medical devices (Laustsen, 2007).

Economics & The Environment

With medical waste costing tenfold to dispose of compared to your typical waste, single-use devices' financial burden on the industry is undeniable (McGain, 2010). By replacing the anaesthetic equipment in one Australian hospital with reusable devices, a group of researchers were able to reduce the hospital costs by roughly $30,000 per year; however, this posed environmental implications. Measured CO2 emissions increased by almost 10% from the change. This impact was to be the result of the power source mix found within Australia. Similar studies in the UK with a greater degree of sustainable energy suggested reductions in CO2 emissions were present. The consumption of water was also found to be higher with the increased need to process individual devices (Goldberg et al., 1996; McGain et al., 2017). Suggesting that a more considerable institutional change and further technological development needs to take place to both increase the efficiencies of reprocessing techniques and more sustainable power sources.

In developing countries, the environmental and societal impact is much more severe due to a less sophisticated waste treatment infrastructure. Concerns regarding poor medical waste management include increased environmental pollution of land and water sources and the proliferation of disease-carrying insects and rodents (Babanyara et al., 2013). Literature also displays concern for the ineffective capture of harmful gases such as Nitrous Oxide (N20) used in anaesthetics, which is considered a powerful greenhouse gas, 280 times more potent than CO2 (Duane et al., 2019; Ordway et al., 2020). Within British dental practices, it is estimated that, on average, 163 litres of N20 is consumed per patient, which is equal to roughly 90kg of CO2 (Duane et al., 2019). Technology exists to capture and neutralise the gas; however, it is typically reserved for larger institutions such as hospitals rather than local dental clinics. In conjunction with the estimated water consumption of 33 thousand litres per surgery each year at the same dental clinics, the environmental impact the medical industry across sectors has on the community is evident.

One New Zealand based research team surveyed all dental practices in the country. It found that roughly a quarter of responding dental clinics disposed of all their waste through household waste collection methods. Evidence suggested that many of these clinics were typically located in remote areas indicating an infrastructure failure. Reasons cited included cost as a factor and the perception that the waste was being discarded in domestic waste regardless, so the need to save costs on complex disposal procedures was favoured (Treasure & Treasure, 1997).

Incineration

The primary method of disposing of hazardous and infectious medical waste is through incinerators in developed countries. The residual waste ash can then be disposed of in council landfill facilities (Windfeld & Brooks, 2015). The benefits of this process ensure sterilisation of waste resulting in unrecognisable ash, reducing transport and landfill impacts and costs (Lee & Huffman, 1996). However, environmental health complications exist as a result of the incineration process. The incineration of some plastics and metals can release pollutants in the air, including dioxins and furans, considered human carcinogens (Babanyara et al., 2013). Opportunities exist to reduce the impact these air-borne pollutants have on the public’s health. However, they remain prohibitively expensive even for many hospitals to commission (Windfeld & Brooks, 2015). Autoclaving in literature is considered more environmentally friendly when compared to incineration as it doesn’t release its byproduct into the environment. However, it does offer drawbacks because the process inherently doesn’t affect the appearance of the waste. Typically many institutions will autoclave and then incinerate their infectious waste as many communities offer resistance to non-incinerated medical waste in their landfills (Windfeld & Brooks, 2015).

Research Gap

Most interestingly, the literature fails to identify the waste impact of localised medical practices' on the environment and community they reside within. A majority of the research has solely focused on the hospital institution as the context of their research. This could be attributed to too much of the researcher’s funding being sourced from government entities whose interests lie in the hospital. With what little research does exist regarding private medical practices, it is typically limited to the dental practice. However, the need to develop a greater picture of the topic of discussion is perhaps more important than the hospital institution itself. The Australian Bureau of Statistics (2021) finds that within Australia, 82.4% of survey respondents (n=28,386) visited a general practice, 47.9% saw a dental professional and only 12.5% were admitted to a hospital. Highlighting that the average citizen has more contact with a general practice or dental professional than with the hospital system.

However, much of the literature does provide insight into existing practices large institutions do to reduce, reuse, and recycle their waste. The following discussion explores those techniques employed by hospitals, discovering what is effective and highlights the pain points that many medical professionals have when disposing of their waste.

Reduce, Reuse, Recycle

The three R’s: Reduce, Reuse, and Recycle, have become the mantra of many environmentally focused movements, leaking their way into popular culture and becoming a commonplace activity in many residential settings (Abdul-Rahman, 2014). Sorted in order of importance, the three R’s define the steps someone can take to reduce their environmental impact. First, reduce your impact by not purchasing that thing in the first place. Second, reuse what is acquired for as long as possible to reduce the environmental footprint—finally, recycling as a method to give new life to what is unusable.

Examples of this mantra can be observed in the community in many forms. Charity shops offer the opportunity to reuse what was once loved and provide new life, a form of fashion sustainability (Borusiak & Kucharska, 2019). Many local councils offer their residents bins and guidelines that allow the population to recycle a portion of their waste (Brisbane City Council, 2022). Reduce is often employed when we look at packaging alternatives and recent bans on plastic bags to incentivise reusable options (Abdul-Rahman, 2014; Queensland Government, 2018). However, many of the efforts described apply only to the individual, and many commercial entities have fewer incentives to abide. We have already discussed the current medical industry practices, where the favourability of single-use components has taken up much of the industry’s waste makeup. McGain (2010) finds that 93% of surgical waste could be adverted by recovering linen, paper, and recyclable plastics. One concerning fact is that up to 80% of solid waste produced from a single surgery will have already been generated before the patient arrives in the room (Kagoma et al., 2012). Indicating where most of the issues present themselves, within the excessive packaging that many medical devices come in (Kagoma et al., 2012).

Existing Practices

Reprocessing

Existing practices employed in the hospital environment most commonly will involve using an automated high-pressure steam sterilisation machine (autoclave) to reprocess purpose-built medical devices (Tietjen et al., 2003). The autoclave is considered as gold standard, offering an effective and proven method of sterilisation (Alfa et al., 2010). However, the costs of such machines may be prohibitive for some clinics, ranging from £8,000 (AUD 14k) to as high as £58,750 (AUD 103k) (Priorclave, n.d.). The training and infrastructure around the autoclave are also essential, limiting the range of applications for practical usage. For example, one study highlights that surgical-site infections are ten times more likely to occur in developing countries than in US or European hospitals (Tao, 2012).

Mocom B Classic Autoclave Machine (Henry Schein, n.d.)

The global market means the manufacturing of single-use devices is preferred and often easier to justify economically as labour abroad is typically cheaper than using relatively expensive labour costs reprocessing requires in developed countries (McGain, 2010). This finding is further clarified at the Western Health Hospital in Melbourne, where McGain (2015) finds that the costs of labour to reprocess a reusable metalware device is five times the price of its single-use counterpart in their hospital. However, analysis of the two variants of the same medical device reveals that other than the mechanical finish, they are both comprised of the same essential details, down to the material makeup of each metalware device (McGain, 2015).

Chemical reprocessing alternatives also exist to sterilise; however, they are typically considered not as effective as the autoclave model (Chartier et al., 2014). The benefits of chemical sterilisation offer opportunities for reprocessing where electricity, labour or water quality may be an issue. However, the chemical process requires ultrasonic cleaning for the highest standard of sterilisation by chemical reprocessing. In addition, considerations offered by research offer that the device to be reprocessed mustn’t be left to dry before the sterilisation process (Merritt et al., 2000).

Single-Use Medical Device Reprocessing

The proliferation of single-use medical devices (SUMD) inside the medical structure is undeniable. Most manufacturers have typically warned about the reuse of SUMD, as the risk of infection or breakdown is high if proper sterilisation can’t be guaranteed (Jacobs & Akpinar, 2018). However, the market for reprocessing SUMDs has increased each year, with many hospitals reprocessing in-house and a thriving third-party industry forming in the early 2000s to meet demand. Cost is often cited as to why this practice is usually performed (Jacobs & Akpinar, 2018; Kagoma et al., 2012; Popp et al., 2010). However, liability and safety concerns are discussed throughout the literature as arguments against the growing practice (Cohoon, 2002).

Opportunities

Separating Waste

Literature tells us that much of the infectious waste streams leaving hospitals are comprised primarily of non-infectious material, making up 70 to 80 percent of the volume. This is suggested to be the result of poor sorting practices within hospitals. Legislation exists in many developed counties defining what is medical waste. However, few instructions are employed telling us which objects can be considered infectious. This effect increases the volume of waste treated and incinerated by medical institutions (Windfeld & Brooks, 2015). Proper segregation of medical waste from the operating room (OR) is often cited as potentially the most significant impact on costs and environmental footprint (Kagoma et al., 2012).

Innovation

The highest cost associated with the traditional autoclave system in developed countries is the labour involved to manage and process a clinic’s reusables and waste (McGain, 2015). Therefore, innovation in this space should take place to automate more parts of the sterilisation process that require human attention.

Recycling

Several hospitals have published audits exclaiming the success of recycling programs employed in their waste streams. For example, the Royal Brisbane and Women’s Hospital (RBWH) performed a month-long prospective audit of all 22 of their operating rooms (ORs) polyethylene terephthalate (PET) waste to help understand the total weight that is being discarded each day. The results afforded programs to better train staff and categorise waste within their hospital (Jones, 2020; Wyssusek et al., 2020).

Plastics commonly found in the Operating Room (OR) in Australia. Adapted from Wyssusek et al. (2019)

Plastics commonly found in the Operating Room (OR) in Australia. Adapted from Wyssusek et al. (2019)

Summary

The exploration presented by the literature review has highlighted the importance and urgency of the medical waste problem we have not only in developed countries but also touched on those still developing. We have covered the sources of medical waste within the healthcare institution and discussed methods of processing that waste effectively. However, we should not ignore the irony present in the contrasts between the purpose of the hospital and its environmental impact.

Research has proven that the mismanagement of medical waste will continue to harm the environment and its inhabitants. However, promising results from studies have demonstrated effective methods of dealing with the waste stream disposed of by hospitals. Undoubtedly our hospitals and clinics must continue to provide uncompromising high-quality care. However, the literature tells us that we may be able to become more environmentally aware without compromising either. Investigations into existing waste management practices offer insights into the limitations current practices afford. Cost and liability are often cited as barriers to what is discovered to be effective practices. Nevertheless, opportunities exist to improve upon the current processes within medical institutions.

Further research must be conducted to offer better solutions to a broader range of requirements. However, limitations still exist in the literature as much of the research being conducted is centred around the hospital system. With a vast majority of the population visiting a general practice and dental clinics rather than the hospital, it is clear that further research needs to be conducted to understand the problems associated with smaller practices waste streams (Australian Bureau of Statistics, 2021).

Research Proposal

This research’s goal is to explore existing methods of medical waste management within the Australian medical industry. The study intends to afford design opportunities to facilitate the improvement of medical waste management practices by product or system innovation. Solutions will focus on satisfying the needs of all the medical practitioners, clinic staff, patients and waste disposal providers, maintaining the high-quality healthcare we have come to expect from the Australian public health system. This research seeks to solve issues within smaller, localised medical practices whose resources may be limited compared to larger hospital institutions.

Research Question

This research project investigates the question, how can health professionals remain economically, socially and environmentally sustainable while reducing medical waste disposal in their practice?

Sub Questions

Sub-questions derived from the literature reviews findings are posited to discover several medical waste management system paths.

  1. What types of waste is being discarded?
  2. What economic, social and environment priorities do health professionals have with their practice?
  3. How do waste management processes differ between the hospital and medical practice?

Research Framework

The methodology has been selected based on what will offer the richest data to conclude opportunities. Figure 1. reveals the methodology structure, defining the relationship between two classes of medical professionals and cultural evidence. Data will be drawn from two asynchronous phases involving semi-structured interviews and a cultural probe into a Brisbane based general practice. Discussions will include hospital and private practice perspectives across disciplines to develop brevity of information for thematic analysis. A cultural probe will then also be conducted in conjunction with a Brisbane based general practice to provide a quantitative form of research. These research methods have been favoured to compare the differences between the well-funded hospital system and private medical practices that may have alternate financial goals. As discussed in the literature review, it is crucial to investigate private medical practices' waste impact, as a gap in the research has been identified. It is also important to note that much of the literature written on this topic is based on research that utilises quantitative discovery methods. The proposed methodology in this study uses qualitative forms of discovery opportunities to fill the gap in the research identified. The benefits offered by this distinction may be able to inform us to a higher degree about the existing waste management processes private medical practices have under a scope detailed in its analysis. Not only will empirical data be gathered, but more profound human experiences and behaviours will also be understood within these proposed methods of research offered.

Methodology

This study aims to develop a greater understanding of medical waste management processes found in private medical practices. Primary research will achieve this understanding by effectively using qualitative and quantitative methodologies to address the study’s topic of discussion and objectives. To better understand existing waste management processes, we need to not only offer insights into what is being disposed of but we also need to comprehend the individuals' perceptions of waste. This knowledge will be essential to understanding the human issues found with existing practices.

Interviews

Interviews across both medical industry sectors will offer critical insights into how each perceives their daily waste management. The semi-structured interviews will include discussions with four nurses and doctors from public hospitals and three medical professionals in the private sector. This variety of experiences will enable a rich data collection process taking input from existing hospitals and private practices. In addition, the benefit of this segmented approach will allow opportunities to bridge the divide found between these two healthcare sectors. The interviews will be semi-structured and relaxed to open discussion, covering fundamental topics and allowing for a discovery process.

Data Collection

Interviews will be conducted across various mediums, both in person and over the phone. Both will be audio-recorded and transcribed to enable a coding process that we will use to discover the themes. With the use of semi-structured interviews as the type of research being conducted in phase 1, the flow and standardisation of each interview are essential. Each session will begin with a series of predefined questions that will help the interviewer and interviewee become familiar with each other to promote a further open discussion. The latter half of the session will involve a structure from wider-concept questions that both parties can work with for the interview duration. This approach offers a predictable structure across interviews that will aid in the thematic analysis process where codes can be made standard. Transcribing will be offered by Otter.ai to capture the discussions accurately, and specialist software ATLAS.ti will allow us to apply the thematic analysis methodology effectively.

The thematic analysis framework offers us a meaningful way to develop actionable insights. Deconstructing transcripts into codes over a series of assessments, categories, and themes may be discerned from analytical processes. Critical points of concern and opportunities will be recognisable by the relationships created between the codes, categories and themes (Hanington & Martin, 2012, p. 178).

Cultural Probe

Concurrently, a cultural probe into a private Brisbane medical practice will occur. Cultural probes offer methods to gather rich qualitative and quantitative information about people and their activities. By enabling the user to self-report, the cultural probe process allows them to collect information about activities with minimal influence on their actions. This is important to gather accurate data about waste management processes found within the practice. The kit and its material will attempt to engage with the user in a creative and varied style to promote deeper engagement by developing enthusiasm regarding its completion (Hanington & Martin, 2012). It is crucial to maintain this level of engagement to aid the development of meaningful responses by the user.

Data Collection

A cultural probe kit will be presented to medical practitioners within the chosen clinic where a self-reporting process may occur. The completion of this kit will involve using several dated forms to be filled out each day of the week. Each form will instigate uniform quantitive capture methods by prompting the user to capture, with photography, the waste they discard throughout the day. This will be gathered by guiding the user to a brief survey to submit their photos online securely. This is then followed by qualitative prompts that will enable the practitioners to respond with personal thoughts and opinions in written form, with a response each day expected not to take longer than 5 mins. Survey software, Qualtrics®, offered by Queensland University of Technology (QUT) will be used to capture these images over time through short surveys where the user can submit their data. This synergy of technology and paper ensures a seamless experience while also maintaining confidentially agreements required for ethics. It is important to this study that bias be mitigated as much as possible when developing the questions and prompts for users to respond to. The survey material will aim to reduce the bias found in its content by applying methods developed by Dr Bernard Choi and Dr Anita Pak (2004), describing common biases found in public health research. The data collected will be de-anonymised to offer privacy for the individual’s waste practices. In addition, the kit will ensure the practitioner’s data does not contain patient information to meet confidentially agreements the clinic has with its patients.

Examples

Examples of prompts offered by the cultural probe include:

  • Take a photo of the waste collected after one (1) patient session.
  • Categorise components of the kit (pictured) based on their proper waste disposal methods
  • What do you consider hazardous waste?
  • Order (from 1-4) the most important aspects of treatment to you.
    1. Diagnosis 2. Developing an effective Treatment plan 3. Safe disposal of waste after the session 4. Segregating the waste

Summary

The research’s methodologies and their formats have been chosen with an intentional focus on the private sector of medicine. The gaps within the literature offer us opportunities to generate new theories regarding the waste management processes found in private medical practices.

This study has been developed to create an exhaustive understanding of private medical practices' existing waste management practices. The research’s findings are intended to aid the successful implementation of sustainable waste practices within the context of this study.

Stay tunned for more content soon as the project unfolds…