Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review.

BACKGROUND: Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs. STUDY DESIGN: A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework. RESULTS: A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste). CONCLUSIONS: Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy.

OBJECTIVE: Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role. DESIGN: In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO2e) and 1 kg of RMW to 3kgCO2e was assumed. Paired samples t-tests for comparisons. RESULTS: From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO2e by 31.6% (138.8kgCO2e) was found (mean kgCO2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel. CONCLUSION: In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

Conhecimentos e práticas da enfermagem sobre os resíduos de saúde nas unidades pediátricas: revisão integrativa / Nursing knowledge and practices in relation to medical waste in pediatric units: integrative review / Conocimientos y prácticas de enfermería con relación a los residuos sanitarios en unidades pediátricas: revisión integradora

Objetivo: identificar publicações que abordam a educação em saúde relacionada à prevenção da Síndrome da Morte Súbita em Lactentes. Método: revisão integrativa realizada no PubMed, Portal Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Cochrane Reviews, Scientific Electronic Library Online e a Biblioteca Virtual em Saúde. Incluíram-se aquelas nas línguas inglesa, espanhola e portuguesa, sem recorte temporal, disponíveis gratuitamente, independentemente do delineamento. Excluíram-se duplicidades, literatura cinzenta, editoriais e cuja população eram prematuros. Resultados: identificou-se duas categorias de análise: temas para educação em saúde e barreiras e facilitadores de aderência às recomendações de prevenção. O profissional de saúde deve estimular as boas práticas de saúde, identificando barreiras e facilitadores para a adesão às recomendações. Conclusão: o profissional deve trazer a ideia de que todo bebê tem risco potencial para a síndrome da morte súbita e utilizar as estratégias disponíveis para tirá-lo da situação de vulnerabilidade.

Objectives: : identifying the current scientific production in relation to Nursing knowledge and practices on medical waste in pediatric units. Method: integrative review in the Scielo, Cinahl, Web of Science, Pubmed, Scopus and Embase databases, between the years 2016 to 2021, totalizing 13 articles. Results: the findings pointed to three main categories: knowledge and practices in relation to Medical Waste, permanent education like a tool for the disposal of Medical Waste; and sustainability in the context of Medical Waste and its relationship with social responsibility. Conclusion: it is necessary to provide the opportunity for periodic training, as well as the use of self-explanatory instruments that can help all health professionals, especially the Nursing professionals, at the time of practice. It was checked the presence of gaps was verified with studies showing Medical Waste and Pediatric Nursing.

Objetivos:identificar la producción científica actual en relación a los conocimientos y prácticas de enfermería sobre los Residuos Sanitarios en las unidades de pediatría. Método: revisión integrativa en las bases de datos Scielo, Cinahl, Web of Science, Pubmed, Scopus y Embase, con un marco temporal de 2016 a 2021, totalizando 13 artículos. Resultados:los hallazgos apuntaron a tres categorías principales: conocimientos y prácticas en relación a los Residuos Sanitarios, educación permanente con una herramienta para la disposición de los Residuos Sanitarios y sostenibilidad en el contexto de los Residuos Sanitarios y su relación con la responsabilidad social. Conclusión: es necesario brindar oportunidades de capacitación periódica, así como el uso de instrumentos autoexplicativos que puedan ayudar todos los profesionales de la salud, especialmente a los profesionales de Enfermería, en el momento de la práctica. Se verifico la presencia de lagunas en los estudios que destacan los Residuos Sanitarios y la Enfermería Pediátrica.

Electrochemical Technologies to Decrease the Chemical Risk of Hospital Wastewater and Urine.

The inefficiency of conventional biological processes to remove pharmaceutical compounds (PhCs) in wastewater is leading to their accumulation in aquatic environments. These compounds are characterized by high toxicity, high antibiotic activity and low biodegradability, and their presence is causing serious environmental risks. Because much of the PhCs consumed by humans are excreted in the urine, hospital effluents have been considered one of the main routes of entry of PhCs into the environment. In this work, a critical review of the technologies employed for the removal of PhCs in hospital wastewater was carried out. This review provides an overview of the current state of the developed technologies for decreasing the chemical risks associated with the presence of PhCs in hospital wastewater or urine in the last years, including conventional treatments (filtration, adsorption, or biological processes), advanced oxidation processes (AOPs) and electrochemical advanced oxidation processes (EAOPs).

Evaluation of Drug Wastage in the Operating Rooms and Intensive Care Units of a Regional Health Service.

BACKGROUND: Pharmacological treatments for critical processes in patients need to be initiated as rapidly as possible; for this reason, it is a standard of care to prepare the main anesthesia and emergency drugs in advance. As a result, 20%-50% of the prepared drugs remain unused and are then discarded. Decreasing waste by optimizing drug use is an attractive strategy for meeting both cost containment and environmental sustainability. The primary end point of this study was to measure the actual amount of drug wastage in the operating rooms (ORs) and intensive care units (ICUs) of a Regional Health Service (RHS). The secondary end point was to analyze and estimate the economic implications of this waste for the Health Service and to suggest possible measures to reduce it. METHODS: This prospective observational multicenter study was conducted across 12 hospitals, all of which belong to the same RHS in the north-east of Italy. Data collection took place in March 2018 and included patients admitted to ICUs, emergency areas, and ORs of the participating hospitals. Data concerning drug preparation and administration were collected for all consecutive patients, independent of case types and of whether operations were scheduled or unscheduled. Drug wastage was defined as follows: drugs prepared in ready-to-use syringes but not administered at all and discarded untouched. We then estimated the costs of wasted drugs for a 1-year period using the data from this study and the yearly regional pharmacy orders of drugs provided to the ORs and ICUs. We also performed a sensitivity analysis to validate the robustness of our assumptions and qualitative conclusions. RESULTS: We collected data for a total of 13,078 prepared drug syringes. Drug wastage varied from 7.8% (Urapidil, an alpha-1 antagonist antihypertensive) to 85.7% (epinephrine) of prepared syringes, with an overall mean wastage rate of 38%. The estimated yearly waste was 139,531 syringes, for a total estimated financial cost of €78,060 ($92,569), and an additional quantity of medical waste amounting to 4968 kg per year. The total provider time dedicated to the preparation of unused drugs was predicted to be 1512 working hours per year. CONCLUSIONS: The overall extent of drug wastage in ORs and ICUs is concerning. Interventions aimed at minimizing waste-related costs and improving the environmental sustainability of our practice are paramount. Effort should be put into designing a more efficient workflow that reduces this waste while providing for the emergency availability of these medications in the OR and ICU.

Liquid plasma reduces waste and health care expenses compared with thawed plasma at a Level I trauma center.

BACKGROUND: Balanced resuscitation strategies have led to increased utilization of plasma. Fresh frozen plasma that is thawed and never used is a large source of blood component wastage. Thawed plasma (TP) and can only be stored for 5 days. Liquid plasma (LP) has never been frozen and can be stored for 26 days. Due to longer storage duration, we hypothesized that using LP would result in decreased waste and cost savings compared with TP. METHODS: We performed a retrospective review of all trauma patients at our Level I trauma center in the years 2015 to 2016. We compared 2015 when only TP was used to 2016 when both TP and LP were used. All plasma units ordered for trauma patients were tracked until the time of transfusion or wastage. Wastage rates were compared between years and plasma type. RESULTS: There were 5,789 trauma patients admitted to our institution from 2015 to 2016. There were 4,107 plasma units ordered with 487 (11.9%) units wasted. During 2015, 2,021 total units of plasma were ordered with 273 (13.5%) units wasted which was a significantly higher rate than 2016 when 2,086 total units of plasma were ordered and 214 (10.3%) units were wasted (p = 0.0013). During 2016, 1,739 units of TP were ordered and 204 (11.7%) units were wasted which was significantly higher than LP wastage, 347 units ordered and 10 (2.9%) units wasted (p < 0.001). Of the 477 wasted TP units, 76.9% were ordered no more than two times before being wasted and 95.8% were ordered no more than three times before being wasted. Of the 10 LP units wasted, 40% were ordered no more than two times before being wasted, and 50% were ordered no more than three times before being wasted. If TP was wasted at the same rate as LP, 368 fewer units of plasma would have been wasted representing US $39,376 (US $107/unit) of wasted health care expenses. CONCLUSION: At a Level I trauma center, the addition of LP to the blood bank for trauma resuscitations significantly reduced plasma wastage rates and health care expenses. LEVEL OF EVIDENCE: Level III, Economic/Decision.

Considerations for environmentally sustainable head and neck surgical oncology practice.

OBJECTIVE: To evaluate the potential role of head and neck oncologic surgeons in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future. REVIEW METHODS: This literature review searched for relevant literature about the relevance of waste in surgical head and neck oncology practice and the innovative alternatives to decrease its effect on environment. CONCLUSIONS: Head and neck oncologic surgeons have a role in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future. However, there exist only limited data on waste management and other procedures in surgical oncology to promote these practices. IMPLICATIONS FOR PRACTICE: By increasing awareness of the corresponding issues of waste production within the healthcare environment, head and neck surgeons can have a pioneering role in considering how to reduce, recycle and reuse in a more efficient manner. As research in this field accumulates, healthcare providers can engage both managers and clinicians in this process. It remains imperative to provide these professionals opportunities for their work force to rethink current practices in a manner that prioritizes environmentally sustainable head and neck surgical practices.

Environmental sustainability in neurointerventional procedures: a waste audit.

BACKGROUND: Operating rooms contribute between 20% to 70% of hospital waste. This study aimed to evaluate the waste burden of neurointerventional procedures performed in a radiology department, identify areas for waste reduction, and motivate new greening initiatives. METHODS: We performed a waste audit of 17 neurointerventional procedures at a tertiary-referral center over a 3-month period. Waste was categorized into five streams: general waste, clinical waste, recyclable plastic, recyclable paper, and sharps. Our radiology department started recycling soft plastics from 13 December 2019. Hence, an additional recyclable soft plastic waste stream was added from this time point. The weight of each waste stream was measured using a digital weighing scale. RESULTS: We measured the waste from seven cerebral digital subtraction angiograms (DSA), six mechanical thrombectomies (MT), two aneurysm-coiling procedures, one coiling with tumour embolization, and one dural arteriovenous fistula embolization procedure. In total, the 17 procedures generated 135.3 kg of waste: 85.5 kg (63.2%) clinical waste, 28.0 kg (20.7%) general waste, 14.7 kg (10.9%) recyclable paper, 3.5 kg (2.6%) recyclable plastic, 2.2 kg (1.6%) recyclable soft plastic, and 1.4 kg (1.0%) of sharps. An average of 8 kg of waste was generated per case. Coiling cases produced the greatest waste burden (13.1 kg), followed by embolization (10.3 kg), MT (8.8 kg), and DSA procedures (5.1 kg). CONCLUSION: Neurointerventional procedures generate a substantial amount of waste, an average of 8 kg per case. Targeted initiatives such as engaging with suppliers to revise procedure packs and reduce packaging, digitizing paper instructions, opening devices only when necessary, implementing additional recycling programs, and appropriate waste segregation have the potential to reduce the environmental impact of our specialty.

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology.

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

Organización de los servicios y preparación de la respuesta hospitalaria para el manejo de pacientes asintomáticos leves ante el Nuevo COVID -19 / Organization of services and preparation of the hospital response for the management of mild asymptomatic patients in the face of the New COVID -19

Este documento da orientación provisional procura fortalecer la respuesta de los servicios hospitalarios ante la posibilidad de tener casos en el país de COVID-19, especialmente en la parte de prevención de la transmisión a del fortalecimiento de las precauciones estándar para la prevención y control de infecciones, con énfasis en el lavado de manos y el uso de equipo protección personal por parte del personal de salud. Además, provee orientaciones para organizar los servicios hospitalarios para adecuar áreas de aislamiento, cuidados intermedios y áreas de triage. El documento también orienta para la proyección de costos de insumos: Material medico quirúrgico, medicamentos, recursos humanos, entre otros como preparación para la respuesta (AU).

Capture of I131 from medical-based wastewater using the highly effective and recyclable adsorbent of g-C3N4 assembled with Mg-Co-Al-layered double hydroxide.

This paper reports a very high capacity and recyclable Mg-Co-Al-layered double hydroxide@ g-C3N4 nanocomposite as the new adsorbent for remediation of radioisotope-containing medical-based solutions. In this work, a convenient solvothermal method was employed to synthesize a new nano-adsorbent, whose features were determined by energy dispersive X-ray (EDS/EDX), XRD, FESEM, TEM, TGA, BET, and FT-IR spectroscopy. The as-prepared nano-adsorbent was applied to capture the radioisotope iodine-131 mainly from the medical-based wastewater under different conditions of main influential parameters, (i.e. adsorbent dose, initial I2 concentration, sonication time, and temperature). The process was evaluated by three models of RSM, CCD-ANFIS, and CCD-GRNN. Furthermore, comprehensive kinetic, isotherm, thermodynamic, reusability cycles and optimization (by GA and DF) studies were conducted to evaluate the behavior and adsorption mechanism of I2 on the surface of Mg-Co-Al-LDH@ g-C3N4 nanocomposite. High removal efficiency (95.25%) of 131I in only 30 min (i.e. during 1/384 its half-life), along with an excellent capacity that has ever been reported (2200.70 mg/g) and recyclability (seven times without breakthrough in the efficiency), turns the nanocomposite to a very promising option in remediation of 131I-containing solutions. Besides, from the models studied, ANFIS described the process with the highest accuracy and reliability with R2 > 0.999.

Optimization of intravenous immune globulin use at a comprehensive cancer center.

PURPOSE: Intravenous immune globulin (IVIG) is a high-cost medication used in a diverse range of settings. At many institutions, IVIG is dosed using total body weight (TBW). Recent evidence suggests that alternative dosing weights reduce waste without compromising clinical outcomes. The objective of this study was to quantify the waste reduction potential generated through the use of alternative IVIG dosing weights. METHODS: We performed a retrospective analysis of all IVIG doses administered from January 2011 through January 2016 to adults (≥18 years). TBW and height at the time of administration were used to calculate prescribed dose (g/kg), ideal body weight (IBW), and adjusted body weight (AdjBW). Three dosing methods were analyzed, as follows: use of AdjBW if TBW is >120% IBW (method 1), AdjBW for all doses (method 2), and IBW for all doses (method 3). Outcomes included potential IVIG use averted, direct drug cost savings, and reductions in outpatient infusion times for each method. RESULTS: A total of 9,918 doses were administered to 2,564 patients over 5 years, representing an average usage of 75,994 g/year. If dosing methods 1, 2, and 3 had been used, the annual use of IVIG would have decreased by 21.9% (16,658 g/year, p < 0.001), 24.2% (18,371 g/year, p < 0.001), and 35.9% (27,252 g/year, p < 0.001), respectively. This translates into average annual cost differences of $2.37 million, $2.62 million, and $3.89 million and average annual outpatient infusion time savings of 841 hours, 920 hours, and 1,366 hours, respectively. CONCLUSION: IVIG dosing optimization through use of alternative dosing weights represents a significant source of waste reduction and cost reduction.

Willingness of patients to use unused medication returned to the pharmacy by another patient: a cross-sectional survey.

OBJECTIVES: Redispensing by pharmacies of medication unused by another patient could contribute to optimal use of healthcare resources. This study aimed to assess patient willingness to use medication returned by another patient and patient characteristics associated with this willingness. DESIGN: Cross-sectional survey. SETTING: A total of 41 community and 5 outpatient pharmacies in the Netherlands. PARTICIPANTS: Total of 2215 pharmacy visitors. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients completed a questionnaire regarding their willingness to use medication returned unused to the pharmacy by another patient, assuming quality was guaranteed. Secondary outcome measures included patient sociodemographic characteristics that were associated with patient willingness, analysed using logistic regression analysis and reported as ORs with 95% CIs. RESULTS: Of the 2215 patients (mean (SD) age 50.6(18.0) years; 61.4% female), 61.2% were willing to use medication returned unused to the pharmacy by another patient. Patients who were unwilling mostly found it risky. Men were more willing to use returned medication (OR 1.3 95% CI 1.1 to 1.6), as did patients with a high educational level (OR 1.8 95% CI 1.3 to 2.5), those who regularly use 1-3 medications (OR 1.3 95% CI 1.1 to 1.7), those who returned medication to the pharmacy for disposal (OR 1.5 95% CI 1.0 to 2.3) and those who ever had unused medication themselves (OR 1.3 95% CI 1.1 to 1.6)). Patients with non-Dutch cultural background were less willing to use returned medication (OR 0.395% CI 0.3 to 0.4)). CONCLUSIONS: When quality is guaranteed, a substantial proportion of patients are willing to use medication returned unused to the pharmacy by another patient. This suggests that implementation of redispensing may be supported by patients.

Knowledge, attitude, and practice of waste handlers about medical waste management in Debre Markos town healthcare facilities, northwest Ethiopia.

OBJECTIVE: Medical waste is a total waste stream which is generated from the healthcare facilities during the healthcare delivery process. It can contain potentially hazardous substances for the human being and the environment. Waste handlers play a significant role for its proper management and they need to have adequate knowledge, attitude, and practices. The study aimed to evaluate the knowledge, attitude, and practices of waste handlers regarding medical waste management in Debre Markos town healthcare facilities, northwest Ethiopia. RESULTS: A total of 55 medical waste handlers were studied from 12 healthcare facilities. Among this, 25 (45.4%) were diploma and certificate holders. The majority (69.1%) of the study participants were not provided with proper training. There was a lack of personal protective devices and waste management equipment supply. Regarding knowledge, attitude, and practices, 25 (45.5%), 43 (78.2%), and 44 (80%) of the study participants had adequate knowledge, favorable attitude, and adequate practice scores, respectively. There was high (30.9%) prevalence of needlestick and sharps injuries. Healthcare facilities should provide periodic training and adequate supplies for the waste handlers. Further study should be conducted on a large scale by including different levels of health facilities and regions of the country.

Human factor-designed multimodal intervention reduces the rate of unused peripheral intravenous cannula insertion.

OBJECTIVE: Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED. METHODS: A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures. RESULTS: Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42). CONCLUSION: Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions.