Sustainable Cardiac Services

By Paul R. Barach NSW Department of Health, Sydney, New South Wales, Australia
Forbes McGain Department of Anesthesia and Intensive Care, Western Health, Melbourne
Nicholas R. Cox Department of Cardiology, Western Health
Serina S. Cecchin and Scott McAlister EcoQuantum Life Cycle Experts on October 3, 2012

A look at Australia’s waste reduction efforts from the catheterization laboratory to the operating room and beyond

Economic and environmental sustainability are essential to maintaining high-quality health care. Numerous medical innovations have demonstrated that modern cardiovascular care is in constant flux. But health care’s increasing predilection for single-use oil-based plastics and metalware is unsustainable in the long run.

Health care providers tend to be isolated in their specialized domains, with a limited understanding of the full process, the complexity, and the broader implications of how daily health care practices impact the environment. Sustainable solutions will enable cardiologists not only to make sound clinical decisions and provide safer procedures but also to address the growing economic and environmental challenges faced by today’s health care systems.

Financial and Impacts

According to Australia’s National Health and Hospitals Reform Commission, health care spending has increased as a proportion of Gross Domestic Product (GDP) in virtually all developed countries for the past 40 years and is expected to continue on this path. Efforts to contain spending costs have tended to deal with influencing the supply side rather than examining whether this demand stems from the general populace or the medical profession.

Health care also contributes significantly to national CO2 emissions—as much as three percent in the United Kingdom and eight percent in the United States. Hospital procurement and waste generate more energy (and thus more CO2 emissions) than the combined direct energy consumption and transport to and from hospitals. Health care services could take a visible lead in reducing energy, water, and resource usage and CO2 emissions. Despite calls for action to improve sustainability by hospital staff and leadership, there has been mostly apathy.

Process of Reducing and Reusing

Operating room (OR) waste is obvious and increasing, so OR recycling has received the most attention of all sustainability initiatives to date. Separation of infectious waste from general waste is the integral first step to using recycling to reduce financial and environmental costs in the OR. General waste can thereafter be diverted to various recycling streams such as cardboard and paper, metals, non-polyvinyl chloride (non-PVC) plastics, and PVC plastics.

Other sustainability initiatives aimed at reducing or reusing OR items are less frequently encountered, perhaps because they meet resistance from the manufacturers and purveyors of disposable items. Life Cycle Assessments (LCAs) can help illuminate the financial and environmental costs of products, but for various reasons, they have typically not been performed in health care. LCAs usually incorporate the entire "footprint " of an item and include 1) raw materials acquisition; 2) processing and manufacturing; 3) distribution and transportation; 4) use, reuse, and maintenance; 5) recycling; and 6) waste management. LCAs allow for comparisons between similar products (such as single-use versus reusable items), which can make for a more informed choice based on sustainability parameters such as financial costs, CO2 emissions, waste usage and pollution, and fossil fuel and mineral usage. For example, a recent LCA of anesthetic drug trays found that the addition of even small amounts of cotton to the trays consumes relatively large amounts of energy and water.

More research is needed to clarify why single-use items are replacing reusable variants. In many countries, it is illegal to reprocess single-use items; other concerns include infection control, shorter turnaround time of single-use items, loss of more expensive reusables, and costs of etching and tracking reusable metalware.

Procurement policies can differ markedly within and among hospitals. In one hospital, surgeons from different specialties may use either single-use or reusable drapes, gowns, and instruments, depending on their presumed benefits, infection control concerns, ease of use, turnover time, and hospital culture.

Much of the waste in the cath lab could be recycled, yet space constraints may hinder such recycling. The protective cardboard and plastic packaging for catheters can be many times the volume and weight of the catheters themselves, opening opportunities for design modification. Simple behavioral changes, such as staff wearing reusable caps and booties, could negate the need for plastic covers. LCAs could clarify whether reusing procedural packs, gowns, drapes, etc., is less financially and environmentally costly than obtaining single-use variants. For example, many cardiologists are unaware that the EPS catheter tip is platinum. In the United States, reprocessing of expensive angiography catheters has become a major industry because of the significant cost savings possible. Platinum can also be recovered (in lieu of discarding it), which provides some financial benefit to the hospital.

Transformational Change

There is a natural tension regarding how much money should be spent meeting major public health challenges (such as obesity, diabetes, and climate change) versus treating individual patients. But transformational change is required to tackle unsustainable health care patterns. In Australia, for example, there are nearly as many deaths per year from chronic conditions exacerbated by motor vehicle pollution (900–2,000) as there are from motor car crashes (approximately 2,000). Reducing air pollution is a transformational change that could reduce CO2 emissions, make people healthier, and reduce health care costs. Reducing air pollution can lead to reduced morbidity—a ban on coal sales in Dublin, Ireland, in the 1990s led to a more than 10 percent reduction in annual cardiovascular and respiratory mortality rates.

There are profound reasons why health care providers and hospital administrators may not want cath lab procedures or OR admission rates to fall, since their reimbursement is tied to utilization. Pay-for-performance models, which would tie physicians’ pay to the appropriateness and value of a procedure, would help. For example, the U.S. Centers for Medicaid & Medicare Services (CMS) Never Events policy denies reimbursement for reasonably preventable errors such as objects left in the body during surgery. Greater emphasis and more research could be targeted to what causes health (salutogenesis) rather than what causes disease (pathogenesis). Although measurements of the "carbon effects " of different models of medical care are not yet mainstream, they are part of a growing pressure on health care to become more sustainable.

Sustainability competencies (e.g., knowledge, skills, and attitudes) should be incorporated into education and training for all health care staff, with special focus on active acute patient care areas such as cath labs and ORs. The World Health Organization, together with the U.S.-based Health Care Without Harm, has called on the medical profession to take the lead in advocating for a healthy and sustainable future. By its very nature, sustainability research requires collaboration by disparate groups. For example, LCAs often require health care providers to ask questions and obtain data, an engineer to examine consumption of various machines, and an LCA expert to access inventories and provide statistical input. A sustainability research program might start by focusing on steps that are already being taken, such as the processes of recycling, reusing, and reducing; LCAs; and radiation research. Some research will encroach on inherently risky areas—such as the carbon emissions associated with greater percutaneous coronary interventions, or the disparity between money spent on cath labs and vascular, thoracic, and cardiac surgery versus smoking control—but this will become increasingly instructive as pressures on the health care system grow.

Sustainability is more than just being concerned about the environment or the amount of waste that is created daily in cath labs or ORs. Sustainability encompasses many facets of the health care environment, from drug supply chains to increasing rates of obesity and cardiovascular disease. The road to sustainability can take several paths. Individual physicians could join with other hospital staff to recycle at work or ask product representatives why a particular item is single-use. Hospitals might appoint sustainability officers and committees to reclaim single-use implements. Sustainability could be embedded in staff training, and cath labs and ORs could be designed to accommodate areas for recycling. Finally, learned bodies such as societies and colleges of physicians and surgeons as well as government research agencies could encourage greater research and education regarding the effects of incremental and transformational changes in the cath lab, the OR, and beyond.

Taking the Hazard Out of Waste

SteriMed Medical Waste Solutions, Inc.

"Technologies available today for the on-site treatment of medical waste include chemical treatment systems, low-temperature steam disinfection systems, and microwave disinfection systems, " says CEO Dwight Morgan of SteriMed Medical Waste Solutions, Inc., a medical waste technology and management company. The company has developed a patented medical waste processor that simultaneously shreds, macerates, disinfects, and dewaters medical waste by using an environmentally friendly biodegradable disinfectant, which has been registered with the U.S. Environmental Protection Agency (EPA). The engineered cocktail kills all infectious diseases, including H1N1 influenza, severe acute respiratory syndrome (SARS), HIV, tuberculosis (TB), and hepatitis. By using this system, there is no need for incineration of the medical waste, a process which inherently produces dioxins—a known cancer-causing compound. This system also mitigates the high volumes of water used in autoclaving (steam disinfection) and eliminates caustic bleaches and other toxic disinfectants that require neutralization before disposal into the local wastewater system. "Basically the process is carbon neutral because there are no fossil fuels consumed in the on-site waste treatment process, and it has been approved for use in all 50 states, " notes Morgan. "The cost savings to a facility that adopts this on-site waste treatment is as much as 50 percent, with environmental footprint savings in excess of 80 percent. " By treating medical waste on-site a health care facility can eliminate the high costs associated with off-site transportation contracts. Today SteriMed has more than 500 machines operating around the world. The company recently worked with the U.S. Navy to provide them with the new technology; it was a great solution for ships that could not dispose of medical waste while out to sea—the SteriMed processors took care of disinfecting the waste right on the ship.

Stericycle Reduces Waste in the OR and Beyond

The health care services company, Stericycle, offers a multitude of services to help hospitals reduce their environmental impact. Its Sharps Management Service features Bio Systems reusable containers; the service has prevented more than 118 million plastic containers from ending up in landfills. Its Pharmaceutical Waste Compliance programs help hundreds of hospitals, medical offices, pharmacies, and pharmaceutical manufacturers properly dispose of drugs so that they don’t end up in lakes and streams.

What the Hospitals Say

"We turned to Stericycle for all of our sustainability needs, " says Brad Thompson, Director of Hospital Safety & Security at Doctors Hospital in Augusta, Georgia. "It’s basically a one-stop shop and has streamlined our process. " Thompson explains that the hospital’s goal is to reduce its waste by 10 percent in 2012, and the numbers are proving that the hospital will meet its goal. Through the use of Stericycle’s services, the hospital is eliminating the emission of 54,791 pounds of carbon into the air and preventing 94,021 pounds of plastic and 3,964 pounds of cardboard from being sent to landfills. "Stericycle trains employees in the new processes—that education has been an invaluable tool in helping change our hospital’s culture, " notes Thompson.

"At New York Hospital Queens, we don’t have a lot of extra space for recycling, sorting, and storing, " says Vito Cassata, Vice President of General Services and Facilities Planning for the hospital. "We’re in Flushing, which is a great neighborhood, and we want to be a good neighbor. " Cassata states that the hospital turned to Stericycle for single-source waste management and today annually diverts 34,203 pounds of carbon emissions by preventing 7,000 pounds of plastic and 4,500 pounds of cardboard from being sent to local landfills from its reusable sharps containers. The hospital’s overall product recycling (of confidential documents, plastics, aluminum and steel, glass, cardboard, etc.) is 19.7 percent a month of its total waste stream. The hospital has decreased food-related waste by using a Biodigester, which reduces waste in food services. "Our goal is to reach the best practice of 25 percent of total waste reduction, " points out Cassata, and he believes the hospital is well on its way with Stericycle.

St. David’s HealthCare system is one of the leading health care providers in central Texas. The system has six hospitals and is currently planning to divert 53,842 pounds of carbon by not sending 90,743 pounds of plastic and 821,520 pounds of cardboard and mixed recycling to local landfills annually. St. David’s recently began a composting initiative—for paper, food, eco-friendly products, and yard debris waste—throughout the facilities, which will divert up to 35 percent of the municipal solid waste. Jim Posey, Director of Hospitality Services at St. David’s Medical Center, comments, "The center’s goal was to go to a single waste stream initiative. Before we started working with Stericycle, our process was splintered, so it was hard to track what was being recycled and what wasn’t. We’re committed to doing the right thing, which includes reducing waste that might end up in a landfill, so last month we started a composting program in the cafeteria. We have a shadow box showing what goes into each receptacle in the cafeteria, " Posey notes, "You need to make it easy for staff, but it’s important to educate them on the process—Stericycle has been a great support that way. "