Journal Logo

Special Feature

Reducing Waste in the Clinical Setting

Wohlford, Sara MPH, RN; Esteves-Fuentes, Nathalia MHA, BS; Carter, Kimberly Ferren PhD, RN, NEA-BC

Author Information
AJN, American Journal of Nursing: June 2020 - Volume 120 - Issue 6 - p 48-55
doi: 10.1097/01.NAJ.0000668744.36106.24
  • Free
  • Podcasts

Figure
Figure:
After an audit to determine the amount of wasted linen on a unit during a given month, an equivalent amount was displayed in the unit hallway to demonstrate to staff the level of waste that results when they overstock rooms and hoard linen. This remained on display for 24 hours to ensure staff on multiple shifts saw it. Photo by Nathalia Esteves-Fuentes.

Nurses play a critical role in reducing a facility's environmental impact. Sustainability programs have tremendous potential to decrease the environmental footprint of the health care industry and reduce costs. Yet, there is little chance of these programs succeeding without the input and expertise of clinical staff and strong nursing engagement.

In this article, we review the fundamentals of waste reduction in the clinical setting, highlight the important link between environmental sustainability and public health, and explore the steps every nurse can take to bring about change. Case examples from Carilion Roanoke Memorial Hospital, a 703-bed hospital in Roanoke, Virginia, that includes a neonatal intensive care unit (NICU), a children's hospital, and a level 1 trauma center, are presented, illustrating the fundamental steps nurses can take to ensure successful environmental outcomes and cost savings. The aim is to stimulate ideas about the many ways in which nurse engagement can be strengthened.

NURSES AND A GROWING WASTE CRISIS

Global waste generation is projected to grow from 2.01 billion tons currently to 3.4 billion tons by 2050, reflecting a 70% increase.1 The amount of U.S. municipal solid waste, or trash, increased from 88.1 million tons in 1960 to 262.4 million tons in 2015, of which more than 91 million tons were recycled and composted.2 Such trash includes residential waste, as well as commercial and institutional trash, but excludes hazardous or industrial materials. In 1960, per capita municipal solid waste generation was 2.68 pounds per person per day; by 2015, it had risen to 4.48 pounds per person per day.2

Studies indicate that the volume of waste generated in health care settings, particularly in the form of unopened and unused supplies, is an ongoing and costly problem.3, 4 There is a growing body of evidence that nursing engagement at all levels can have an important impact on environmental sustainability, climate change, and waste reduction solutions.5-8 The American Academy of Nursing also recognizes the important role of nurses in environmental issues, noting they can help to ensure organizations adequately support climate change monitoring and public health tracking, related research, and training that can help nurses to implement sustainability initiatives.9 If, during the delivery of care, we are relaundering hundreds of thousands of pounds of unused linens, throwing away unused products, and improperly sorting waste—resulting in nonhazardous items, such as packaging, being sent to waste incinerators and the rejection of entire loads of recyclables—then we are, albeit often unwittingly, exacerbating environmental, community, and public health problems.

Below, we examine three opportunities for nurses to promote the fundamentals of sustainability within their work environments: in linen efficiency, supply waste reduction, and proper waste sorting. These examples detail the way in which nurses at our organization have altered its environmental footprint and reduced costs.

LINEN EFFICIENCY

It's been estimated that approximately 10 billion pounds of linen are laundered annually in U.S. health care settings.10, 11 Laundries account for 50% to 75% of total hot water usage in hospitals, according to the Centers for Disease Control and Prevention, which notes this represents about 10% to 15% of a hospital's energy use.12

The continued manufacturing and purchasing of linens derived from raw materials creates additional stress on the environment and threats to public health. Cotton production leads to the release of toxic chemicals and carcinogens into the soil, air, and water.13 In 2017, according to the U.S. Department of Agriculture, an estimated 821.5 million pounds of nitrogen fertilizers were applied to cotton-planted acres in the nine states that account for the vast majority of cotton in this country.14 Both runoff that contains nitrogen and soil leaching contribute to environmental problems, including eutrophication (an excessive amount of nutrients in water bodies that depletes oxygen and affects plant and animal life), and have a negative effect on human health, as a result of the consumption of contaminated groundwater or crops.15

There should also be consideration of the potential environmental and public health impacts of the chemicals and processes utilized by a facility's laundry service. An analysis found evidence of medications, such as lidocaine and dipyrone, in hospital laundry wastewater, which also had a high organic load.16 The environmental burdens, according to the authors of this study, include human toxicity, freshwater eutrophication, and ecotoxicity.16

Laundry service is an integral part of the delivery of safe, quality patient care and should be held to the highest standards to reduce the risk of cross contamination and prevent hospital-acquired infection. With this in mind, the cumulative effect of linen waste and misuse and the resultant impact on the environment should remain a point of consideration for clinical staff. It's vital that staff understand how to reduce linen waste, why this is important, and what resources are available to them to support these sustainability goals (see Linen Efficiency—the Fundamentals).

Box 1
Box 1:
Linen Efficiency—the Fundamentals

Case in point: linen waste reduction. In 2018, our organization's laundry services and sustainability and nursing departments partnered to focus on reducing linen waste in our largest facility. Previous linen waste reduction programs had successfully reduced waste and cost. But, in recent years, old habits had returned, leading to a steady recurrence of wasteful practices.

Our facility was using 12.73 pounds of linen per adjusted patient day (for the purposes of this project, we did not include surgical linen or isolation gowns in our calculations). The recommended amount of linen storage in the hospital was 125% of daily usage; however, we found that linen storage was stocked at 375% of daily usage. Our focus was ensuring that staff understood the concept of linen waste and its financial, environmental, and health implications. We also wanted to make sure they knew how to improve workflow to decrease waste. Staff project owners—including unit directors; nurse clinical team leaders; clinical associates; and nurses participating in Carilion's RN Career Advancement Program, which assists RNs in career development—helped to determine appropriate par (periodic automatic replenishment) levels. They also designed and implemented process change and performance improvement goals and metrics. To follow are five actions we took to reduce linen waste.

Adjust par levels. Par levels were compared with those recommended by the director of laundry services. Staff project owners were involved in making small, incremental adjustments to decrease usage levels. We opted to keep par levels slightly above the recommended 125% to allow for additional increases in volume or patient acuity. For example, one unit's daily par level was set at 1,472 linens in stock each day. We found that, on average, the unit only utilized 353 pieces of linen per day. Based on the recommended 125%, and taking into consideration feedback on volume and acuity provided by the unit director and other staff project owners, the daily par level was adjusted to 500 pieces of linen in stock on the unit.

Bed-change policy review. Upon review of the existing bed-change policy, we found that many staff members were unaware of the correct bed-change process. Whereas policy calls for flat sheets, blankets, and incontinence pads to remain on the bed unless visibly soiled, some staff members were stripping beds daily and remaking them entirely. To improve on this practice, staff established a process by which linens are changed every other day unless visibly soiled or the patient prefers otherwise.

Communicate. To communicate and celebrate this positive change, new signage was placed in patient rooms on select units. It explained the new process and the goals of reducing waste and energy use. Patient response has been positive, with no negative feedback from patients on the pilot units.

Educate. An awareness and education program was designed to remind staff of key strategies for linen waste reduction. Signs were posted, and PowerPoint presentations and a read-and-sign document of key points were disseminated to staff, both individually and via group presentations at staff meetings.

Audit with display. A data collection tool was designed, and staff members were charged with documenting the amount of clean linen remaining in a patient's room after discharge. Per our organization's infection control policy, any remaining clean linen must be relaundered. Audits were completed on several units, and data were extrapolated for each unit to determine how much clean linen was wasted in one month. Laundry services would then lend nursing an equivalent amount of linen to display in the unit hallway, visually demonstrating for staff exactly how much linen is wasted each month on their unit when they overstock rooms and hoard linen.

The project, which took place during a six-month period, engaged 41 units. Linen utilization decreased from 12.73 pounds to 11.41 pounds per adjusted patient day, with a decrease in inventory stocked on the floor from 375% of daily use to 183% of daily use. Total savings from the project were $83,252.

SUPPLY WASTE REDUCTION

The disposal of unused supplies is costly, often avoidable, and has a significant impact on the environment. The long-ignored problem of supply waste is increasingly becoming more visible as health care organizations focus on cost transparency. Nursing engagement is necessary to reduce the tens of thousands of pounds of unused products that are thrown out or donated annually, often because supplies are opened and available “just in case” they are needed. In many situations, they are never used but must be disposed of. For example, on a Friday, nurses may overstock a patient's room with expensive wound care supplies for dressing changes just in case there is difficulty obtaining supplies from materials management over the weekend. Or, two or more expensive central line kits may be taken to the bedside before placement just in case one is dropped or a new kit is needed for a second attempt. Sometimes nurses overstock patient rooms with supplies during a shift just in case the unit is too busy to restock the room during a shift change. In each of these instances, bringing excess supplies into the patient's room raises the risk that the supplies will be contaminated, opened unnecessarily, or forgotten and then expire, resulting in waste. Every piece of product has a life cycle—finite natural resources are used to manufacture, transport, and dispose of products, and each step in this process has a significant effect on the environment.

If supply waste is a problem on your unit, it's important to understand the source of the waste and how to reduce the amount sent to landfills (see Supply Waste Reduction—the Fundamentals). Ask yourself:

  • Why is this happening?
  • What is the source of the waste?
  • What is this costing the facility?
  • Can this be addressed?
  • Is the process creating the waste unavoidable?
  • Can the unit, as a starting point, donate the unused product to support international missions or education to divert the items from landfills?
Box 2
Box 2:
Supply Waste Reduction—the Fundamentals

Case in point: mission donation program. In 2016, in most areas of our hospital, unused supplies left in patient rooms after discharge were considered contaminated. In these areas, the expectation was for all products to be thrown away, including clean and unopened supplies stored in non-isolation rooms. This led to excessive amounts of waste and a high financial cost to our hospital.

Nursing staff identified habitual or frequent overstocking of patient rooms as one source of the problem. The lack of a process for collecting and appropriately donating items was another. To help correct this, we established a process for the collection and donation of unused supplies that can't be returned to inventory when a patient is discharged. These items are now donated to international missions, as well as to medical and nursing educational programs associated with our health care system.

Collection containers were placed on every nursing unit in the hospital, and both clinical staff and environmental services discharge team members are responsible for checking all cabinets and drawers for unused, unopened supplies after a patient is discharged. Table 1 highlights the types and volume of supplies collected from one unit—the NICU—over the course of a month (November 2016). Any supplies that enter the room of a patient on isolation precautions are disposed of per the infection control policy and never placed in the collection bins. In conjunction with this collection process, education was provided to staff in the form of signage, PowerPoint presentations, and in-person conversations during staff meetings to encourage them to reduce waste at the source.

Table 1
Table 1:
Inventory of Donated Supplies from the NICU, November 2016

To date, our program has donated 87,000 pounds of medical supplies and equipment, equivalent to approximately 43 tons of waste diverted from landfills. This represented a total savings to our organization of $32,000. This savings is partially attributable to supplies being redirected to medical and nursing education programs supported by the organization, thereby reducing expenses for new educational supplies. In addition, our organization paid less in waste disposal fees because of the reduced amount of waste it sent to landfills.

PROPER WASTE SORTING

Health care is complex in every way, and the associated waste streams are no exception. It's vital that nurses appreciate the importance of proper waste sorting; what resources or programs are available; how to appropriately sort waste; and the financial, environmental, and health implications of improper sorting (see Proper Waste Sorting—the Fundamentals). If a nurse has an interest in improving environmental sustainability in the clinical space, ensuring the proper sorting of pharmaceutical waste, recycling, and regulated medical waste is an excellent way to have a significant positive impact.

Box 3
Box 3:
Proper Waste Sorting—the Fundamentals

Pharmaceutical waste. Pharmaceutical waste typically enters water systems via the drain or landfill. Both pathways are associated with potential environmental and health implications.

Down the drain. When medications are flushed down the toilet or emptied into drains, they are routed to local treatment facilities. Wastewater treatment facilities are not capable of fully degrading many pharmaceutical compounds. As a result, traces of chemicals and pharmaceuticals pass through the sewer system, ultimately entering streams, lakes, and rivers.17

In addition to the human health and environmental concerns associated with the disposal of pharmaceuticals in the sewer, there are regulatory implications for health care systems, and the consequences for noncompliance can be severe. The Environmental Protection Agency (EPA) published a final rule last year prohibiting health care facilities from disposing of hazardous waste pharmaceuticals down the drain.18 Additionally, per the Resource Conservation and Recovery Act, fines leveled by the EPA against a health care system for noncompliance in the proper sorting and disposal of hazardous waste streams may reach $74,552 a day per occurrence.19, 20

Pharmaceuticals in landfills. Leachate is a liquid waste product of landfills that contains a mixture of chemicals. It results when precipitation and groundwater move through solid and liquid waste from residential, industrial, and commercial sources. Often, following wastewater treatment, leachate will be discharged into rivers, lakes, wetlands, or oceans still containing numerous contaminants of emerging concern.21 In a study of final leachate samples, researchers determined that the most frequently detected contaminants of emerging concern included lidocaine (found in 91% of samples), cotinine (86%), carisoprodol (82%), and carbamazepine (77%).22 Researchers have also described the direct effects of pharmaceuticals in discharged leachate on aquatic life, including adverse implications for biological responses.23

It's imperative that staff have a clear understanding of the facility's processes for sorting pharmaceutical waste—including container type, color, and placement on the unit for each type of waste—and why compliance is important to public and environmental health.

Recycling. Regional, national, and international changes in the recycling market have resulted in tightened standards in terms of materials accepted. Loads of recycling are more likely to be considered contaminated if they contain materials that are not recyclable. Approximately 25% of all recycling picked up by Waste Management, Inc., a national waste management company, is contaminated to the point that it must be sent instead to landfills, according to an interview with one of the company's executives in 2018.24

It's easy to become complacent and assume it doesn't matter if there is soda in the can that's placed in the recycle bin, or if food waste or napkins are mistakenly thrown into recycling containers. But, considering stricter recycling standards, it clearly does matter. Irresponsible sorting of the most basic recyclable materials can result in entire loads of recycling being sent to landfills. Nurses can promote reduced contamination by encouraging diligence with processes and modeling best recycling practices.

Regulated medical waste and sharps. According to the Occupational Safety and Health Administration (OSHA), regulated waste refers to25

liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Health care professionals have a duty to protect communities and populations from the infectious potential of regulated medical waste throughout the entirety of this waste stream, from the bedside to destruction. The treatment and destruction of regulated medical and sharps waste are highly regulated and monitored by federal and state agencies, such as OSHA and the U.S. Department of Transportation, as well as the Joint Commission. The environmental and public health impacts of the various types of treatments must be considered to fully comprehend the importance of properly sorting waste and how the engagement of the generator (that is, nursing staff) affects environmental sustainability efforts. Currently available treatment technologies rely on two basic approaches to sterilization: excessive heat and chemical agents, or a combination of the two.

Incineration. Incineration of regulated medical waste is associated with serious air quality concerns. Incinerators emit dioxin, furans, mercury, and other heavy metals that can affect human health.26 Incinerators are also inefficient, and the burning of large quantities of fuel generates excessive greenhouse gases (primarily carbon dioxide).26

Autoclaving. This is considered to be a more environmentally preferable option to incineration.27 It's resource intensive, however, consuming gas, electricity, and water in a system that uses dry heat or steam to kill microbial contamination, typically operating at temperatures between 121°C and 163°C.28

Chemical treatment. Chlorine is a common component of chemical treatment systems, which often use sodium hypochlorite solution (bleach). Chlorine in wastewater is known to react with organic matter, leading to organic chlorine compounds that contaminate the environment and are toxic to aquatic organisms.29

Understanding the environmental and health impacts of the treatment and disposal of regulated medical waste can help staff appreciate why it's important to prevent regular trash from entering this waste stream as much as possible. Improperly sorting waste results in sending nonhazardous items, such as packaging, to waste incinerators or other treatment modalities that utilize large quantities of natural resources. Reducing waste at the source is always ideal. Although sending municipal solid waste to landfills isn't a perfect disposal method (none exists), it's preferable to the unnecessary treatment of regular trash using thermal or chemical approaches.

Case in point: regulated medical waste reduction. In 2015, our organization's ED contained 70 beds, with 83,950 annual patient visits. Department leadership raised concerns that excessive amounts of municipal solid waste were being disposed of in the red bags allocated for regulated medical waste. Internal data revealed that regulated medical waste was 11 times more expensive to treat and dispose of than municipal solid waste. We designed a program to reduce misuse with the primary objective of minimizing the risk of disease transmission by decreasing opportunities for the exposure of patients, visitors, and staff to biohazards through improper sorting. Additional benefits included decreasing costs, maintaining closer compliance with OSHA and Virginia's Department of Environmental Quality regulations, and reducing our impact on the environment. The framework for the program was based on a model provided by the Healthier Hospitals Initiative, a national campaign to improve environmental health and sustainability in the health care sector.30

We performed a one-week audit of red bag waste from the ED to gather data on regulated medical waste weight and contents. Bags were marked and segregated from the rest of the facility's regulated medical waste. The life safety consultant weighed the bags and then audited in a manner compliant with OSHA and Department of Environmental Quality regulations. The audit results estimated that the ED was generating 25,687 pounds of regulated medical waste annually. Of that waste, 41.73% was estimated to be municipal solid waste, and 33.65% was estimated to be what we referred to as phantom weight (air). In total, 75.38% of the content of the red bags was municipal solid waste and phantom weight.

Our hospital paid a disposal rate based on a specified number of pounds of waste per regulated medical waste container. Containers weighing less than the allocated limit generated the same charges as those at the maximum or “full” weight. Regulated medical waste containers filled with bulky and inappropriate items result in more phantom weight and, thus, unnecessary expense to the organization. Regulated medical waste is generally denser than municipal solid waste; for example, blood-soaked gauze is heavier than empty plastic bottles, which are part of the municipal solid waste stream and processed as recycling. A regulated medical waste container filled with empty plastic bottles will weigh less in pounds but have more phantom weight than the same container filled with dense, more tightly packed, and thus heavier, blood-soaked gauze. Therefore, we set a goal to control the amount of municipal solid waste placed in these containers to address the phantom weight issue.

Based on this first audit, the cost of regulated medical waste generated by the ED totaled $9,673 annually; however, $4,036 of this total was attributed to municipal solid waste that was incorrectly disposed of, $2,866 was attributed to phantom weight, and only $2,771 was attributed to properly sorted regulated medical waste. This audit revealed that the total cost of improper disposal on just one unit was projected to be $6,902 annually.

A comprehensive program was designed and implemented over eight months to include:

  • ongoing nursing staff education
    • PowerPoint presentation, huddle/staff meeting, quiz
  • environmental services staff education
    • staff meeting or individual education
  • signage on and around red bag containers
  • relocation of red bag containers and removal from patient rooms when appropriate

At the end of the program, we performed a second audit. Results of this audit demonstrated that the total annual weight of red bag waste from our ED dropped from 25,687 pounds to 20,066 pounds. The total percentage of regular trash in our red bags dropped from 41.73% to 25.47%, and phantom weight dropped from 33.65% to 31.28%. In total, the content of municipal solid waste and phantom weight in our red bags dropped from 75.38% to 56.75%. Total annual savings associated with this project were estimated to be $2,870.

A COLLECTIVE EFFECT

The decisions nurses make about waste and efficiency on the front lines of clinical care matter, and the potential impact on health and the environment should not be underestimated. Staff are performing time-sensitive tasks; therefore, successful sustainability programs should complement existing workflow and minimize additional steps for engagement. Further, nurses should continually seek to improve practice through ongoing awareness and periodic monitoring of processes for consistent performance.

When examining waste on a piece-by-piece basis, it's easy to believe that one person's potential impact is minimal. However, when examined in total, the collective effect is impressive. Regardless of practice setting—hospital, community clinic, school, home, or the multitude of other nursing practice locations—there are countless opportunities each day to engage in reducing the environmental impact of health care. Linen efficiency; supply waste reduction; and the proper sorting of pharmaceutical waste, recycling, and regulated medical waste are possible starting points. Nurses have the potential to improve air and water quality, decrease utilization of natural resources, and reduce health care costs simply by taking a moment and making the right choice.

REFERENCES

1. Kaza S, et al What a waste 2.0: a global snapshot of solid waste management to 2050. Washington, DC: World Bank; 2018. Urban development series; https://openknowledge.worldbank.org/handle/10986/30317.
2. Environmental Protection Agency. Advancing sustainable materials management: 2015 fact sheet. Washington, DC; 2018 Jul. EPA530-F-18-004. https://www.epa.gov/sites/production/files/2018-07/documents/2015_smm_msw_factsheet_07242018_fnl_508_002.pdf.
3. Chasseigne V, et al Assessing the costs of disposable and reusable supplies wasted during surgeries. Int J Surg 2018;53:18–23.
4. Morrow J, et al Reducing waste in the critical care setting. Nurs Leadersh (Tor Ont) 2013;26 Spec No 2013:17–26.
5. Anderko L, et al Greening the ‘proclamation for change’: healing through sustainable health care environments: nurses advocate sustainable design to transform health care. Am J Nurs 2013;113(4):52–9.
6. Cook C, et al Nurses and climate action. Am J Nurs 2019;119(4):54–60.
7. Huffling K, Schenk E. Environmental sustainability in the intensive care unit: challenges and solutions. Crit Care Nurs Q 2014;37(3):235–50.
8. Trombley J, et al Climate change and mental health. Am J Nurs 2017;117(4):44–52.
9. Leffers J, Butterfield P. Nurses play essential roles in reducing health problems due to climate change. Nurs Outlook 2018;66(2):210–3.
10. Sehulster L. Healthcare textiles and laundry 101: management in acute care and residential care [PowerPoint]. Atlanta: Centers for Disease Control and Prevention, Division of Healthcare Quality and Protection; 2011 Nov 16. http://ndhealth.gov/disease/hai/Docs/WebEx/NDHCFLaundry11162011.pdf.
11. Sehulster L. Diligence in infection prevention is key to maintaining the quality of laundered healthcare textiles. Infection Control Today 2017 Oct 6. https://www.infectioncontroltoday.com/laundry/diligence-infection-prevention-key-maintaining-quality-laundered-healthcare-textiles.
12. Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities. Atlanta; 2019. https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html.
13. Thiel CL, et al Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol 2015;49(3):1779–86.
14. U.S. Department of Agriculture, National Agricultural Statistics Service. 2017 agricultural chemical use survey. Washington, DC; 2018 May. NASS highlights; https://www.nass.usda.gov/Surveys/Guide_to_NASS_Surveys/Chemical_Use.
15. Liu CW, et al Effects of nitrogen fertilizers on the growth and nitrate content of lettuce (Lactuca sativa L.). Int J Environ Res Public Health 2014;11(4):4427–40.
16. de Oliveira Schwaickhardt R, et al Combined use of VUV and UVC photoreactors for the treatment of hospital laundry wastewaters: reduction of load parameters, detoxification and life cycle assessment of different configurations. Sci Total Environ 2017;590-591:233–41.
17. Kinrys G, et al Medication disposal practices: increasing patient and clinician education on safe methods. J Int Med Res 2018;46(3):927–39.
18. Environmental Protection Agency. 84 FR 5816. Final rule: management standards for hazardous waste pharmaceuticals and amendment to the PO75 listing for nicotine; 2019.
19. Environmental Protection Agency. 40 CFR Part 19. Civil monetary penalty inflation adjustment rule [FRL–9988-90–OAR–OECA]. Washington, DC 2019.
20. FindLaw. 42 U.S.C. § 6928—Unannotated Title 42. The Public Health and Welfare § 6928. Federal enforcement.
21. U.S. Geological Survey. Landfill leachate released to wastewater treatment plants and other environmental pathways contains a mixture of contaminants including pharmceuticals. Washington, DC; 2015 Nov 13. https://www.usgs.gov/mission-areas/environmental-health/science/landfill-leachate-released-wastewater-treatment-plants.
22. Masoner JR, et al Landfill leachate as a mirror of today's disposable society: pharmaceuticals and other contaminants of emerging concern in final leachate from landfills in the conterminous United States. Environ Toxicol Chem 2016;35(4):906–18.
23. Schoenfuss HL, et al Complex mixtures, complex responses: assessing pharmaceutical mixtures using field and laboratory approaches. Environ Toxicol Chem 2016;35(4):953–65.
24. Albeck-Ripka L. Your recycling gets recycled, right? Maybe, or maybe not. New York Times 2018 May 29. https://www.nytimes.com/2018/05/29/climate/recycling-landfills-plastic-papers.html.
25. Occupational Safety and Health Standards. Bloodborne pathogens [standard no.1010.1030]. Washington, DC 2016. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030.
26. Committee on Health Effects of Waste Incineration, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council. Incinceration processes and environmental releases. In: Waste incineration and public health. Washington, DC: National Academy Press; 2000. p. 34–70. https://www.nap.edu/read/5803/chapter/3.
27. Pierce J, Jameton A. Environmental aspects of health care. In: Pierce J, Jameton A, editors. The ethics of environmentally responsible health care. New York, NY: Oxford University Press; 2004. p. 43–60.
28. Lee BK, et al Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Manag 2004;24(2):143–51.
29. Emmanuel E, et al Toxicological effects of disinfections using sodium hypochlorite on aquatic organisms and its contribution to AOX formation in hospital wastewater. Environ Int 2004;30(7):891–900.
30. Practice Greenhealth. Less waste how-to guide: less waste toolkit. n.d. https://practicegreenhealth.org/tools-and-resources/less-waste-how-guide.
Keywords:

pharmaceutical waste; regulated medical waste; supply waste; sustainability; waste reduction

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.