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Optimizing Anesthesia-Related Waste Disposal in the Operating Room: A Brief Report

Hubbard, Richard M. MD*; Hayanga, Jeremiah A. MD, MPH; Quinlan, Joseph J. MD*; Soltez, Anita K. MSN, RN; Hayanga, Heather K. MD, MPH*

doi: 10.1213/ANE.0000000000001932
Healthcare Economics, Policy, and Organization
Free

Misappropriation of noncontaminated waste into regulated medical waste (RMW) containers is a source of added expense to health care facilities. The operating room is a significant contributor to RMW waste production. This study sought to determine whether disposing of anesthesia-related waste in standard waste receptacles before patient entry into the operating room would produce a reduction in RMW. A median of 0.35 kg of waste was collected from 51 cases sampled, with a potential annual reduction of 13,800 kg of RMW to the host institution, and a cost savings of $2200.

Published ahead of print April 21, 2017.

From the Departments of *Anesthesiology, Cardiothoracic Surgery, and Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Accepted for publication December 30, 2016.

Published ahead of print April 21, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Richard M. Hubbard, MD, Department of Anesthesiology, University of Pittsburgh Medical Center, 3471 Fifth Ave, Suite 910, Pittsburgh, PA 15213. Address e-mail to hubbardrm@upmc.edu.

The operating room (OR) is a major source of waste production, accounting for 20%–30% of hospital totals.1 These waste products may be broadly divided into noncontaminated solid waste (SW) and regulated medical waste (RMW). RMW requires special processing to safeguard the public from exposure to infectious diseases and other potential dangers. The World Health Organization reports that 80% of health care waste is SW, with only 10% of health care waste representing RMW.2 Despite this fact, many health systems process large proportions of noncontaminated waste as RMW.3–5

The high volume of RMW production places a significant economic burden on the health system and may cause a severe negative environmental impact. High-temperature incineration is typically utilized in the disposal of RMW. This method routinely produces numerous environmental toxins, including furans, metals, dioxins, and multiple gases.6,7 The process contributes to an increased cost of up to 500% when compared with costs for SW disposal.1 Numerous barriers prevent the implementation of prudent waste reduction strategies in the OR. These include a lack of knowledge by medical personnel surrounding waste disposal policies and hospital environmental initiatives.8,9 Such ignorance may lead to placement of heavy, noncontaminated materials such as bags of intravenous fluids or mechanical equipment into the RMW stream. Other barriers include institutional fear of negative publicity in the event that RMW should reach landfills. This has further been fueled by public health concerns over the disposal of waste associated with emerging diseases (such as prion disease, Zika, and Ebola).10–12 Despite these challenges, multiple health systems in and outside the United States have instituted practical, cost-cutting, and environmentally protective waste reduction and redistribution strategies.13,14

Anesthesia-related materials are thought to comprise approximately 25% of OR waste, with an estimated production of 2300 kg/OR/y.10,15 In its 2012 publication, “Greening the Operating Room and Perioperative Arena,” the American Society of Anesthesiologists set out a number of simple strategies to reduce the amount of RMW produced in the OR.1 One such suggestion was the use of SW disposal bins before patient entry into the OR, and closing the bins after patient arrival, thus preventing the risk of contamination. In this quality improvement study, we sought to determine whether implementing this strategy in a large academic medical center would result in a significant decrease in the anesthesia-related production of RMW, and further, whether the decrease would lead to cost savings for the institution.

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METHODS

The study was conducted at a large university hospital on 7 individual weekdays in July 2015. All ORs staffed by anesthesia residents during daylight hours were included. Anesthesia personnel were provided a brief description of the study via email and in-person, and signs were posted at anesthesia workstations to help ensure participation. Before the start of each workday, an SW, nonhazardous waste bag was placed in lieu of an RMW biohazard waste bag at the anesthesia workstation, and providers were instructed to use it for all nonhazardous waste before the start of each case. The SW bags were to be closed upon entry of the patient into the OR, at which time the investigator would remove the bag and replace it with an RMW, biohazard waste bag for use during the procedure. The time (in seconds) required for the investigator to complete this task was measured, and the nonhazardous waste bag was weighed using a hanging scale. This process was repeated for every additional case throughout the day. Needles and other “sharps” were not included in this study because these materials must be separated into specific containers separate from the RMW biohazard waste bags. The study is in keeping with the Standards for QUality Improvement Reporting Excellence guidelines (as prescribed by the EQUATOR Network) and was deemed exempt by our institutional review board because it did not constitute human research.

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RESULTS

Table.

Table.

Figure.

Figure.

Anesthesia residents staffed 53 cases during the study period. Two cases were excluded because waste from the previous day was placed in the anesthesia waste bags, leaving a total of 51 cases included in the analysis. A median weight of 0.35 kg (95% confidence interval, 0.29–0.39 kg) was collected per case. However, the data were strikingly right-skewed, with an interquartile range between 0.21 and 0.46 kg, but a minimum and maximum weight of 0.00 and 5.73 kg, respectively (Figure). As seen in the Table, cases were distributed between a wide variety of disciplines (including general, ear, nose, and throat, cardiac, neurologic, plastic, vascular, thoracic, and orthopedic surgery), with the largest number being represented by general (n = 11) and thoracic (n = 10) surgery. The median weight of first and latter starts was 0.35 vs 0.33 kg (P = .15 on Mann-Whitney test); however, the study was not specifically powered for this calculation. Upon examining the contents of the heaviest waste bags, they invariably contained either unused intravenous fluids or disposable equipment (eg, carbon dioxide absorbent canisters and granules). The average time to complete the task of removing the SW bag and replacing it with an RMW bag at the anesthesia workstation was 50 seconds (SD = 13 seconds).

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DISCUSSION

Utilizing suggestions put forth in the American Society of Anesthesiologists publication, “Greening the Operating Room and Perioperative Arena,” this pilot study sought to determine whether utilizing SW receptacles before patient entry into the OR would reduce RMW production and waste disposal costs.1 Based on institutional case numbers from 2015 and extrapolating from the median weight of 0.35 kg of RMW saved per case, an annual reduction in RMW of approximately 8470 kg (95% confidence interval, 7018–9438 kg) could be anticipated. The institution in this study has 2 autoclave machines on site, resulting in a lower cost compared with those that must pay for third-party RMW processing. Overall, the cost of processing RMW to a nonhazardous material was $0.26/kg. This equates to a modest cost savings of $2200 per year to the institution. However, at facilities that use third-party processing, this cost may increase 3-fold.4,16

The environmental effect of processing this waste is difficult to estimate because it depends largely on the method of sterilization, such as incineration, autoclaving, chemical treatment, and irradiation.2 All such methods have different energy-input requirements and different byproduct profiles.2 Furthermore, the effects of carbon dioxide emissions created in the transport of these materials must be considered. It is important to note that any anesthesiology department attempting to reduce the environmental impact of anesthetic care should also consider other interventions, such as limiting the flows on anesthesia machines to reduce the release of inhaled anesthetics (which may act as greenhouse gases), or limiting the amount of IV anesthetics that are wasted because these may pollute the water supply.1 Results of these studies suggest that reducing the amount of RMW produced by the anesthesia team should be considered as a key part of such an intervention.

Although the potential RMW reduction and cost savings in this study represent only a small fraction of overall hospital waste production, expanding the application of this easily adopted intervention to the entire OR would presumably reap more significant savings and further decrease potential negative environmental impact. Such an intervention is currently being developed as a quality improvement project at this institution.

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DISCLOSURES

Name: Richard M. Hubbard, MD.

Contribution: This author helped with planning the study, reviewing results, editing drafts, data collection, and manuscript writing.

Name: Jeremiah A. Hayanga, MD, MPH.

Contribution: This author helped with planning the study, reviewing results, and editing drafts.

Name: Joseph J. Quinlan, MD.

Contribution: This author helped with planning the study, reviewing results, and editing drafts.

Name: Anita K. Soltez, MSN, RN.

Contribution: This author helped with planning the study, reviewing results, and editing drafts.

Name: Heather K. Hayanga, MD, MPH.

Contribution: This author helped with planning the study, reviewing results, and editing drafts.

This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.

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REFERENCES

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