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Reduce—recycle—reuse: guidelines for promoting perioperative waste management
Gary LaustsenThe inclusion of the environment as an important professional nursing domain and the promotion of holistic nursing practices provide a theoretical and ethical base upon which environmentally sustainable nursing practices can prosper. The profession is recognizing the anomalies that exist in the current, parochial understanding of the concept of environment.
Through clinical and research efforts on behalf of environmental health issues, nurses can provide current and future generations with the opportunity for a healthy home, neighborhood, and planet. (1(p27))
A healthy ecosystem requires a healthy environment, and anything that alters ecosystem health also may alter the health of its inhabitants.
The professional activities and behaviors of individuals, including nurses, may influence local and global ecosystems. Nursing practices cause known and sometimes unknown effects on ecosystems. The health of an ecosystem is intertwined with human activities, and the health of humans also is intertwined with the health of an ecosystem. Considering the complex interactions between organisms and the environment may lead to alternative behaviors and actions that reduce environmental degradation. Such behaviors can become a part of both the personal and professional activities of individuals.
Many people seek to act, both personally and professionally, in more ecologically appropriate ways. Promoting environmentally responsible practices in the work setting may provide congruence between a nurse's personal desire to behave ecologically and his or her ability to work ecologically. It is important, therefore, for nurses to understand and study how their personal and professional behaviors may have positive or negative interactions with the ecosystems upon which all life depends.
As proponents and caretakers of human health, nurses should seek to participate in professional activities that minimize the negative effect on the health of local and global environments. Exploring ways in which nurses can work ecologically will provide insight into these activities and encourage nurses to reflect on their own practices.
Environmental degradation is a multifaceted problem that has ecological effects on the health of all living populations, including the human population. Richardson (2) offers some advice and examples of what could be considered ecologically friendly nursing practices. He refers to these behaviors as "green nursing." Melamed (3) elaborates on ways perioperative nurses can contribute to pollution prevention in the health care setting. Green nursing practices may reduce the negative effects that nursing activities have on the environment without altering the quality of patient care.
A challenge for the nursing profession is to translate a concern for global ecosystems and general ecological beliefs into professional practice activities. Developing ecological behaviors in the nurse's professional environment can
* improve local and global environments,
* decrease the amount and cost of waste disposal, and
* reduce potential human and environmental health threats.
Ultimately, such ecological activities will help promote a more sustainable human ecosystem. Green nursing practices also can be promoted through improved management of materials in the hospital perioperative setting.
HISTORICAL AND LITERATURE REVIEW
Excessive waste in health care settings has developed into a significant problem during the past 30 years. Concern about the spread of bloodborne diseases (eg, HIV, hepatitis B) and public exposures to inappropriately disposed medical waste has led to increased regulation. (4) Concurrently, there has been an increase in the production of disposable medical supplies. (5)
Large health care facilities, such as hospitals, historically used incinerators to dispose of medical waste. Many products used in health care settings contain polyvinyl chloride, which, when incinerated, can result in the release of dioxin, a known carcinogen, into the environment. The US Environmental Protection Agency (EPA) at one time considered dioxin from incinerated medical waste to be the second largest source of this known carcinogen. (6) Medical waste incineration also is responsible for the release of mercury into the environment. Mercury, when converted to methyl mercury, can enter and ascend the food chain, becoming concentrated in fish. Ingestion of mercury-laden fish is a health concern, especially for pregnant women and young children. The problems of medical waste incineration, improper waste disposal, and general environmental degradation and the effects of these issues on human health eventually were recognized. Organizations such as the EPA, American Nurses Association, Health Care Without Harm (HCWH), and Hospitals for a Healthy Environment (H2E) have looked for ways to reduce the negative effects of health care practices on the environment.
Both HCWH and H2E are organizations that were established to promote responsible health care activities that positively affect environmental health. Health Care Without Harm seeks to
transform the health care industry worldwide, without compromising patient safety or care, so that it is ecologically sustainable and no longer a source of harm to public health and the environment. (7(p2))
The primary goal of H2E is to "educate health care professionals about pollution prevention opportunities in hospitals and health care systems." (8(p1)) These organizations provide valuable services, and the focus of their efforts is directed toward governmental, administrative, and managerial aspects of health care institutions.
In the early 1990s, AORN also examined perioperative practices to promote pro-environmental activities. In October 1993, AORN published its "Recommended practices for environmental responsibility in the practice setting." (9) Table 1 is a summary of this document. Many of these guidelines have served as templates "for other nursing organizations to use in developing best practices for environmental responsibility." (3(p1159)) More recently, at the 2006 AORN Congress, delegates ratified a "Position statement on environmental responsibility." (10)
In a review of health care literature on environmental issues, a salient finding was a lack of research studies that measured or critically examined environmental responsibility in nursing practice. Most of the available articles were predominantly anecdotal, theoretical, or philosophical discourses based on thoughtful analysis but without qualitative or quantitative research designs or methodologies. Authors of these articles have suggested nursing activities that can lead to more proenvironmental nursing practices. (1-3,6,11-27) Some of the broad categories reflecting environmentally friendly activities that were identified by these authors include
* reducing waste,
* conserving energy,
* using green products, and
* recycling materials.
PROBLEM PRACTICES
In addition to inappropriate disposal of hospital wastes, clinical nursing practices that lead to environmental problems include excessive waste generation, excessive energy consumption, and the use of nonrecyclable products. Hospital products can be a source of pollution both when they are produced and when the hospital disposes of them.
WASTE GENERATION. Excessive waste generation in nursing practice often is related to the purchase and use of single-use, nonrecyclable products. Abbey (5) notes that modern, technologically dependent health care facilities, especially in perioperative areas, have accepted a position that cleanliness depends on the use of disposable products to protect patients. Other nursing practices that contribute to waste generation include excessive use of disposable bed liners, diapers, and paper towels; unwarranted paper photocopying and printing; and unnecessary over-packaging of medical supplies. (6,21,28,29)
ENERGY CONSUMPTION. Excessive energy consumption in nursing practice is partly related to the increased use of medical technology devices. As more electrical instruments and machines are used (eg, monitors, infusion pumps, computers), more energy is required both to manufacture and operate these devices. Most hospitals operate continuously, increasing the use of energy for heating and lighting as well as using other utilities and resources. The increased demand for single-patient hospital rooms requires larger hospitals; more equipment; and consequently, increased energy use. Paech (28) identified this self-propelled growth as "mega-technology." She challenged nurses not to blindly welcome this, suggesting that nurses should weigh the moral and philosophical issues of accepting technological development.
SINGLE-USE ITEMS. Any assessment of current and new medical technology should include an "ecological viewpoint" that questions how products are manufactured, disposed of, and/or recycled. (28) The reliance on and use of nonrecyclable products causes environmental pollution both through increased energy consumption during manufacture and in their disposal. An increased volume of disposable waste requires more energy-consuming trips to dump sites, and this burdens already overused landfills.
ENVIRONMENTAL AWARENESS
Awareness of the relationship between the quality of the environment and the quality of air and water is low among health care workers.
Unfortunately, environmental education is not a standard part of the curriculum for physicians, nurses and other health professionals. (30(p3))
Topf (31) identified factors that she proposes may help explain individual and group indifference to the greening of hospitals. These individual psychological factors include environmental paradoxes, myths, value conflicts, and denial. Topf identified several factors that contribute to environmental numbness, including
* diffusion of responsibility,
* pluralistic group ignorance, and
* groupthink. (31)
A detailed explanation of these factors, however, is beyond the scope of this article.
CASE VIGNETTE
As part of the author's doctoral research, a team of perioperative nurses from a large, western, US urban hospital were recruited to participate in a community-based action research project to promote environmentally-friendly practices in the perioperative unit. This group of individuals, called the Green Team, chose to explore the excessive waste generated in the perioperative setting.
ONE DAY, ONE OR, AND ONE RED BAG. To help illustrate the problem of excessive waste, and specifically the inappropriate disposal of biohazardous (ie, red bag) waste, a descriptive analysis was performed on the contents of a single receptacle of red bag waste removed from the OR after a surgical procedure was completed. To accomplish this, the lead researcher arrived unannounced at the hospital OR and asked an environmental services staff member to bring a receptacle of red bag waste from an OR in which an abdominal aortic aneurysm endograft surgical procedure had recently been completed.
CASE FINDINGS AND RESULTS. The Green Team measured the weight of the red bag's contents on a zeroed scale before analyzing its contents. The weight of the bag was determined to be 8.64 kg (19 lbs). Each item in the red bag then was removed, cataloged, and placed on a large drape. As similar items were removed, the count of each item was monitored and tallied (Table 2).
Items considered biohazardous based on AORN standards include
* sharps, used and unused;
* cultures and stocks of infectious waste;
* animal waste;
* selected isolation waste;
* pathological waste; and
* human blood, blood products, and body fluids. (32)
These items were kept separate from the non-regulated waste. After all red bag contents were removed, the team measured the weight of the regular (ie, non-biohazardous) waste on a zeroed scale. Regular waste was found to represent 7.91 kg (17.4 lbs) of the original 8.64 kg total weight. Regular waste, therefore, contributed 92% of the weight of what was discarded as biohazardous waste, and the true biohazardous waste accounted for only 8% of the total weight in this one receptacle.
The results of this investigation demonstrated that there was significant inappropriate disposal of OR wastes into the biohazardous waste receptacle. This investigation, however, represents only a single red bag from a single procedure, and the results are not intended to be transferable to other hospitals or situations. It is hoped that the findings from this investigation will help increase awareness of the problem of inappropriate waste disposal.
GUIDELINES FOR PERIOPERATIVE GREENING
Greening has been described as behaviors or activities that improve environmental outcomes. (26) Promoting the greening of the perioperative environment can be accomplished in small steps over time and does not require a major overhaul of existing systems. Some of the recommended ecologic nursing practices may fall outside the control of individual nurses. Implementation of these practices may occur only as a result of the decisions and influence of facility administrators or managers.
Improving current systems may require some initial monetary or personnel investment. In time; however, there often is a positive economic return. Additionally, when ecological practices are put in place, often there is an improvement in the attitude of nurses toward their workplace because they feel their personal environmental behaviors are welcomed into their professional workplace. (14)
A critical aspect of achieving success in the perioperative setting is the need to include all stakeholders in the greening process. An individual's passion for improving the system may create discordant feelings in others when new policies or procedures affect work efforts. Some of the stakeholders who need to be involved in a perioperative greening campaign include members of the perioperative nursing staff, medical staff, ancillary staff, and environmental services, as well as managers, unit managers, and the administrators who oversee perioperative services. Representatives from these groups can offer their own perspectives on the feasibility, development, and enactment of any new greening practices.
It also is important to address the perioperative greening process in small steps. Initiating changes in too many areas at the same time can be challenging, and personnel may resort to wanting things the "way they used to be" to moderate their anxiety about excessive change. Buy-in from perioperative staff members is more likely to be obtained when change takes place in small, discrete steps. Developing a timetable of recommended ideas for the long-term greening of the perioperative area will help everyone see the overall goals without the burden of dealing with excessive change.
There are specific ways in which the perioperative setting can become more ecologically friendly. Three main categories for promoting perioperative greening are to reduce, recycle, and reuse.
REDUCE
Reducing the amount of materials used in the perioperative setting ultimately leads to a reduction in the amount of waste generated. A current trend in hospitals seeking greener practices is to use environmentally preferred purchasing (EPP). This is defined as
the act of purchasing products/services whose environmental impacts have been considered and found to be less damaging to the environment and human health when compared to competing products/services. (8)
A 10-step guide to starting an EPP program can be found at the H2E web site at http://www.h2e-online.org. Health care facilities that use EPP
* significantly reduce the overall impact on the environment;
* reduce costs by
** purchasing supplies at lower prices,
** making changes that eliminate the amount of waste disposed, or
** reducing the need for worker safety measures and hazardous waste disposal;
* provide a healthier environment for patients, workers, and employees by reducing exposure to hazardous substances in products such as cleaners, solvents, and paints; and
* create opportunities for positive publicity and promotion. (8)
Organizations interested in pursuing EPP also should consider having a representative attend a CleanMed conference. Information about these conferences can be found at the CleanMed web site at http://www.cleanmed.org. At these conferences, health care facilities looking to purchase environmentally preferred supplies are brought together with the companies that offer these supplies. The CleanMed organization also promotes the building of green health care facilities.
SURGICAL PACKS, Another way to reduce waste is to reconsider the contents of surgical packs. Prepackaged surgical packs often contain items that routinely are not used because of surgical staff member preferences. Suppliers may be willing to work with individual facilities to develop surgical packs that contain only the specific items that typically are used and requested by members of the surgical staff. Removing unused items from these packs not only will reduce the cost of the pack, but also will eliminate the cost of disposing of these additional items into the hospital waste stream. Some facilities also may find that it is more cost-effective and reduces waste when the facility's own central supply services puts together surgical instrument packs based on surgical staff member requirements.
ENERGY CONSUMPTION. Energy consumption is a major contributor to environmental degradation. Hospitals and ORs can decrease the negative environmental effects of energy production by reducing energy consumption. Reducing energy use can be accomplished by turning off unused lights, monitors, pumps, and computers. A reduction in the amount of perioperative supplies purchased also indirectly reduces total energy consumed in the manufacture and disposal of these items.
WATER CONSUMPTION. Water is another resource that can be conserved by greening efforts. In some parts of the country water resources are limited. Health care facilities use an enormous amount of water, and often this is not evaluated as a conservation item. Water-reduction strategies include
* fixing leaking plumbing fixtures;
* installing low-flow faucet heads; and
* replacing older toilets with newer, low-flow toilets.
Educating health care workers about water conservation also can produce a significant reduction in overall water use in a facility. (4) The positive outcome of minimizing water consumption in health care facilities is that communities do not need to acquire and treat as much water. The health care facility also reduces its overhead costs when water usage declines. A reduction in water consumption also indirectly reduces a community's energy consumption because it decreases the energy used by local municipal services to acquire and treat the water as well as to treat and dispose of the extra waste water.
RECYCLE
Recycling is something that many people commonly practice at home; however, it can be more difficult to develop recycling attitudes and behaviors in a health care facility. Many people are accustomed to saving paper, aluminum cans, or plastic items for recycling. In health care facilities, it becomes a question of how and where items to be recycled are collected. Facility managers must determine where items to be recycled should be be stored for pickup, who will remove these items from the facility, and whether it will cost money to remove the items. Some recycling centers, however, may pay for some types of items to be recycled (eg, aluminum cans).
The key to a successful recycling program is to develop a coordinated effort among multiple stakeholders. A team effort allows for a more cohesive program to form and helps ensure that recycling will continue even if key members leave or become less involved. Each unit within the facility should appoint representatives to a recycling task force to address how the recycling program could be enacted within their respective areas. Staff members from various departments can contribute ideas and unique viewpoints, which will help overcome barriers to the program and introduce a variety of perspectives. In addition to unit-specific task force members, representatives from ancillary staff, environmental services, infection control, and administration should be included because each of these areas will be involved in maintaining the recycling program, either directly or indirectly.
Another suggestion for developing a successful recycling program is to start small. Typically, it is better to choose a few areas of the facility in which to initiate the program. In these areas, it will be important to choose only a few types of items to recycle at first. After the recycling program is established, other items to be recycled may be added. Starting with items such as aluminum cans or newspapers often is appropriate because people are used to recycling these items at home.
Another form of recycling is to find alternative uses for items that might otherwise be discarded. Many cities have local community organizations (eg, Project C.U.R.E. (33)) that will accept usable items and find appropriate uses for them. If purchased surgical packs contain items that routinely are not used, these items can be donated to agencies that will distribute them to developing areas around the world. Many veterinarians also will accept unused items for use in their facilities.
REUSE
A third method for greening perioperative areas is to reuse items. Historically, sterilization has been a typical method for hospitals to repeatedly reuse surgical instruments. The more recent trend toward using disposable instruments and equipment originated partly from increased concerns over the potential spread of infectious disease such as HIV or hepatitis by reuse of surgical instruments. The expanded development and promotion of less-expensive, plastic surgical supplies and equipment also has contributed to the use of disposable items in health care facilities.
DISPOSABLE ITEM COSTS. Surgical services managers should evaluate the life-cycle costs of disposable items in addition to their monetary costs. These life-cycle costs include the costs of production, transport, storage, use, and disposal of nonreusable equipment. The initial purchase of reusable equipment often is more expensive than the cost of disposable items; however, if the entire life-cycle costs of disposable products are evaluated, it could be that sterilizing and reusing instruments and equipment is more economically and environmentally positive.
BENEFITS OF GREEN NURSING
Greening the perioperative setting may help improve staff member morale, and it promotes both economic savings and ecological sustainability. Many Americans believe in cultivating personal and professional environmentally friendly activities. Nurses interviewed for the author's research indicated the discordant feelings they experienced between their personal desire to live ecologically and the barriers present in the workplace to practice ecologically.
Personnel should become ecologically sensitive and advocate changes that reduce the quantity of waste generated while maintaining quality patient care and worker safety. (32(p525))
Greening practices within the perioperative setting that contribute to sustaining the environment will be welcomed and supported by many members of the health care team. Additionally, working for a facility that promotes caring and conservation will enhance an environmental "esprit de corps" among health care personnel.
Health care practices that support environmental preservation also may enhance economic sustainability. The true economic impact of health care practices and products requires a life-cycle evaluation. Hospital managers need to understand the interconnectedness of resource production, use, and disposal. They also must begin to look beyond the traditional, unit-centered budget. Exploring ways to reduce, recycle, and reuse materials in the perioperative setting also will promote economic benefits to the health care organization.
Holistic care encourages nurses to understand the interactions between humans and their environment. As citizens of local and global communities, nurses should give voice to their holistic vision of personal and environmental health. The commonly used encouragement to "think globally, act locally" is an appropriate slogan to guide nurses in their efforts towards caring for the health of humans as well as the health of the world.
The author acknowledges the nurses at the VA Hospital in Denver, Colo, for their assistance in his research.
RESOURCES
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Gary Laustsen, PhD, APRN, BC, is an assistant professor at the Oregon Health & Science University, La Grande, Ore.
TABLE 1. AORN Recommended Practices for Environmental Responsibility (1) 1. Personnel should actively promote and participate in resource conservation. 2. Surgical supplies should be opened only when there is a reasonable certainty they will be used during the procedure. 3. Single-use and reusable products should be selected and used with consideration for the environment during the entire lifetime of the product. 4. An efficient segregation program for infectious and noninfectious waste should be developed and implemented according to AORN's "Recommended practices for environmental cleaning in the surgical practice setting." (2) 5. Blood, body fluids, disinfectant solutions, and other hazardous materials should be disposed of in accordance with local, state, and federal recommendations and with concern for the environment. 6. Recycling programs should be an integral part of health care facilities' policies and procedures. 7. Sterilization of items in health care facilities should be accomplished with steam sterilization as the method of choice. Alternative methods include low-temperature sterilization technologies (eg, gas plasma, mixed chemical plasma), liquid sterilization (eg, peracetic acid), or ethylene oxide (EO) sterilization. 8. Policies and procedures regarding environmental protection should be written in accordance with local, state, and federal regulations; reviewed periodically; and readily available within the perioperative practice setting. (1.) Recommended practices for environmental responsibility. In: Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc; 2006:525-529. (2.) Recommended practices for environmental cleaning in the surgical practice setting. In: Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc; 2007:551-557. TABLE 2 Red Bag Receptacle Contents Evaluation During an unscheduled evaluation, one large red bag from an OR receptacle was obtained after an abdominal aortic aneurysm endograft procedure, and the bag's contents were analyzed. Initial bag weight on zeroed scale: 8.64 kg Weight of nonbiohazardous waste in red bag: 7.91 kg Items and quantity of materials removed from red bag Item name Quantity Albumin bottles, empty 3 Anesthesia bag 1 Anesthesia mask for patient 1 Anesthesia tubing 1 Blood- or solution-filled syringes 3 Blood pressure cuff 1 (nondisposable) Central line with wire 1 Cloth towel, green 1 Cloth towels, blue 6 Endotracheal tube stylette 1 Endotracheal tubing 1 Fluid tubing 2 Fluid warming set packaging 1 Fluoroscopy unit cover 1 Glass bottles, empty 2 Gloves, nonsterile 46 Hard plastic packaging 6 IV bag, full, with 1 attached tubing IV bag packaging 6 IV bags, empty 8 IV tubing 4 Large saline bottles filled 2 with urine * Nasal canula 1 Oropharyngeal airway 1 Packaging drape 1 Paper drapes 4 Paper sheets from patient monitor 7 Paper surgical gowns 3 Penrose drain 1 Plastic basins 2 Plastic drape 1 Plastic instrument packing 30 Procedure kit wrap 1 Small plastic saline bottles, 2 empty Small cardboard boxes 4 Soft plastic trays 4 Styrofoam packaging 1 Suction tubing 2 Syringe cases 18 Syringes, empty 16 Temperature-regulating blanket 1 Vials, glass 5 Yankauer suction tip 1 Multiple pieces of paper packaging 1 wadded-up ball of bloody surgical gauze. ** Unable to count, but total weight was. 73 kg. * These items are considered potentially infectious material but are not classified as regulated waste; therefore they may be disposed of in the sanitary system and do not require red bag disposal. (1) ** This was the only material that possibly could be classified as biohazardous according to AORN standards and require disposal in the red bag receptacle. These bloody gauzes were not "dripping." (1.) Centers for Disease Control acid Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities. Atlanta, Ga: US Department of Health and Human Services; 2003:143-144. Available at: http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html. Accessed March 2, 2007.
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