Sustainable perioperative practices - Reducing, reusing or recycling

Dr Pat Nicholson PhD, RN, RM, has been involved in perioperative nursing for more than 30 years. Dr Nicholson discusses the evidence behind reducing, reusing or recycling in the perioperative setting.
In Australia more than 260,000 tons of solid waste is produced each year with hospitals among the most energy-intensive facilities, accounting for a significant percentage of the accumulation of greenhouse gas and carbon dioxide emissions¹. Significant resources are consumed by healthcare facilities and while medical waste is a necessary by-product, some of which is hazardous, correct management of this waste is required in order to reduce the impact on the environment².
Factors contributing to the world-wide surge of healthcare facility waste include the increased use of disposable medical supplies and single-use non-recycled items³. This trend has developed in response to the growing concern over the transmission of infectious diseases, such as hepatitis or HIV, resulting in an increased use of disposable devices and packaging⁴. With a significant portion of medical waste potentially recyclable, with 75% to 90% of healthcare waste comparable to domestic waste, given the potential fiscal profit associated with the efficient reduction of clinical waste it is becoming vital for all healthcare facilities to consider waste reduction strategies to address environmental issues and reduce resource costs⁵.
Up to 90% of regulated medical waste is misclassified due to a misunderstanding of the clinical waste classification system and the requirement of segregating waste⁶ resulting in perioperative environments contributing between 20% and 70% of all healthcare waste each year. This is disproportional to the total waste generated by the facility⁷. Regulated medical waste undergoes hazardous waste disposal which is eight to 20 times the cost associated with disposal of general waste⁸; therefore a reliable system for separating and segregating hazardous and non-hazardous waste is essential in the operating suite.
Although the myriad of environmental impacts from the inappropriate disposal of waste could be addressed through behavioural change and proper segregation of regulated medical waste⁹ there is limited scientific, evidence-based literature detailing safe and effective green activities in the perioperative setting¹⁰. Recycling can be difficult due to concerns and regulations regarding regulated medical waste and biohazardous materials, however, many supplies that do not come into contact with body fluids or blood are able to be recycled, such as cardboard, paper, glass and plastic¹¹, decreasing the amount and cost of waste disposal and reducing potential human and environmental health threat¹².

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“By promoting the reduction of waste production, conserving energy, using green or environmentally friendly products, recycling, and reusing resources and materials in the operating suite healthcare professionals can actively promote, and take action in minimising waste¹³.”
DR PAT NICHOLSON

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“By promoting the reduction of waste production, conserving” energy, using green or environmentally friendly products, recycling, and reusing resources and materials in the operating suite healthcare professionals can actively promote, and take action in minimising waste¹³. Active participation in waste management requires an awareness of State and Federal legislation or regulations, and local healthcare facility policies related to waste regulation, waste classification, and waste segregation practices¹⁴ in order to develop a sustainable regulated medical waste segregation program. It should be considered that while compliance with National and State-wide waste management practices is important standard precautions to prevent or contain the spread of infection should take precedence over waste management principles¹⁵.
Leadership, commitment and active involvement in supporting the environment is required by all disciplines within the perioperative team in order to develop a program that supports a sustainable, environmentally-conscious perioperative area¹⁶ with support from nursing management and other key stakeholders essential¹⁷. Healthcare facilities should have appropriate waste management systems to ensure all waste is managed in accordance with legislative requirements¹⁸ including the provision of adequate resources. A multidisciplinary environmental team should be established, with membership including key stakeholders¹⁹ to identify, implement and evaluate best practice in developing an environmental sustainable program and ongoing review and management of healthcare waste. This includes development of policies, to guide staff in improving environmental outcomes²⁰. Waste segregation depends on the knowledge of staff at the point of generation²¹ therefore healthcare facilities should provide education to all workers on waste minimisation, and promote a culture of reduce, reuse and recycle resources and supplies²².
Dr Pat Nicholson Phd, RN, RM
Dr Pat Nicholson PhD, RN, RM, has been involved in perioperative nursing for more than 30 years. With a background in education she coordinated the Anaesthetic and Perioperative Postgraduate Courses and she currently coordinates the Nurse Practitioner Masters course at the University of Melbourne. Pat is a senior lecturer and holds the position of Director of Teaching and Learning in the Nursing Department as well as an honorary research position at Peter MacCallum Cancer Centre. Her PhD focused on instrument design and measurement of nursing competencies using Item Response Modeling, with her current research interests including cultural sensitivity, education using simulation and pressure injury development in surgical patients.
Pat is the current President of the Victorian Perioperative Nurses Group. She represented Victoria on the Australian College of Operating Nurses Board for four years and was made a Fellow in 2010. She was the team leader for the development of a new Guideline for the ACORN 2014 – 2016 Standards for Perioperative Nursing (Environmentally Sustainable Perioperative Practices). Team members involved in the development of the guideline: Catherine Steel, Pauline Hayden, Avril Brown
Tackling waste at the source of generation in an effort to reduce waste disposal requirements is considered best practice in waste management with the aim to avoid or recover as much of the waste as possible. Healthcare facilities should therefore commit to establishing a performance improvement program to promote reduction of waste, reusing and recycling supplies according to State / Federal and healthcare facility policies and practices with receptacles for recycling placed in areas where the waste is generated. Distinguishing features to facilitate waste segregation, such as colour-coded bins i.e. silver for metal, blue for plastic, slotted top for paper and round top for cans, are essential for the segregation at the point of waste generation and success of the program. During the setting up in preparation for the surgical procedure a system of designated general waste bags should be initiated to reduce non hazardous material being included in clinical waste bags as up to 80% of solid waste is produced before the patient enters the operating theatre²³.

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“Waste segregation depends on the knowledge of staff at the point of generation21 therefore healthcare facilities should provide education to all workers on waste minimisation, and promote a culture of reduce, reuse and recycle resources and supplies.”
DR PAT NICHOLSON

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The impact of reusable and disposable products when purchasing supplies, equipment and/or surgical instruments should be considered as waste generation is directly related to the purchase and supply practices in each unit²⁴. In order to explore opportunities to minimise waste generated a critical analysis of purchasing practices, inventory delivery, storage space requirements as well as the impact of waste streaming when purchasing supplies and equipment is required²⁵. Indirect costs incurred during manufacturing of medical products should also be considered.
Healthcare staff should actively promote and participate in natural resource conservation strategies, including water, electricity and natural gas measures, that are cost effective, conserving natural resources that are eco-friendly and are sustainable²⁶. Strategies includes recycling, reprocessing of equipment and supplies, increasing energy efficiency, managing pharmacological waste²⁷, turning off equipment (pumps and computers) when not in use, checking and maintaining equipment, turning off lights in the department when room is not in use or upgrading and install occupancy sensors in areas, use energy-efficient electrical equipment, lights and appliances, evaluating waterless scrubs, off hours shut down (set hours when equipment is turned off throughout department) and solar film on windows²⁸.
Nurses and healthcare workers have an obligation to provide care that does not harm the environment and it is everyone’s responsibility to think globally while acting locally in their practice.
References

1. Kaplan et al., 2012; Kwakye, et al., 2011


2. Townsend & Cheeseman, 2005; Tudor, Barr & Gilg, 2007


3. Laustsen, 2007; Laustsen, 2010; Conrardy, Hillanbrand, Meyers, Nussbaum, 2010; Jang et al., 2006; Kagoma et al., 2012; Kaplan, Sadler, Little, Granz, & Orris, 2012; Penn et al., 2012; Practice Greenhealth 2011


4. Hutchings & White, 2009


5. Tudor et al., 2007; Wormer et al., 2013


6. Conrardy et al., 2010; Hutchings & White, 2009; Jan et al., 2006; Kaplan et al., 2012; Kwakye et al., 2011; Lee & Mears, 2012a; Lee & Mears, 2012b Lee, 2002; Southorn et al., 2012; Stonemetz et al., 2011)


7. Kagoma, Stall, Rubinstein & Naudie, 2012; Laustsen, 2007; Laustsen, 2010; Conrardy, Hillanbrand, Meyers, Nussbaum, 2010; Kaplan, Sadler, Little, Granz, & Orris, 2012; Kwakye et al., 2011; Practice Greenhealth, 2011; Southorn et al., 2012; Wormer et al., 2013


8. Ciplak & Barton, 2012; Greenhealth Practice 2011; Kaplan 2012; Lee & Mears, 2012;Nussbaum, 2009; Sattler, 2003; Stonemetz et al., 2011


9. Ciplak & Barton, 2012; Greenhealth Practice 2011; Sattler, 2003


10. Laustsen, 2007; Laustsen, 2010; Lee & Mears, 2012a; Lee & Mears, 2012b Kwakye 2011; Stonemetz et al., 2011; Townend & Cheeseman, 2005


11. Laustsen, 2010; Southorn et al., 2012


12. Conrardy et al., 2010; Laustsen, 2007


13. Conrardy et al., 2010; Kagoma et al., 2012; Kaplan, et al., 2012; Kwakye et al., 2011; Laustsen, 2007; Laustsen, 2010;Townsend & Cheeseman, 2005


14. Reale, 2007; WHO, 2013


15. ANZCWMIG, 2007


16. Laurer, 2009; Laustsen, 2007; Lee & Mears, 2012a; Lee & Mears, 2012b Reale, 2007; Saver, 2009


17. Laurer, 2009; Lee, 2002; Saver, 2009; Stonemetz et al., 2011; Tudor et al., 2007; Wormer et al., 2013


18. ANZCWMIG, 2007; Lee et al., 2004; Townsend & Cheeseman, 2005; Waste management Australia, 2010


19. Laustsen, 2007; Wormer et al., 2013; WHO, 2013


20. Kaoma et al., 2012; Laustsen 2007; Wormer et al., 2013


21. Ciplak & Barton, 2012; Laustsen, 2010; Reale, 2007


22. Conrardy et al., 2010; Jang et al., 2006; McGain et al., 2012; Kaiser, 2001; Kagoma et al., 2012; Kaplan, 2012; Laustsen, 2010; Riedel, 2011; Wormer et al., 2013


23. Kagoma et al., 2012; Southorn et al., 2012


24. Conrardy et al., 2010; Jang et al., 2006; Kaiser et al., 2001; Overcash, 2012


25. Kaplan, 2012; Kagoma et al., 2012; kwayke 2011; Laurer, 2009


26. Kwakye 2011; Laustsen, 2010


27. Kwakye, 2011; Laustsen, 2007


28. Kaplan et al., 2012; Kagoma et al., 2012; Kwakye et al., 2011; Laurer, 2009; Laustsen, 2007; Wormer et al. 2013

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