In a world of throwaways, making a dent in medical waste


c.2010 New York Times News Service

The health care industry has a garbage problem.

It's not just that hospitals, doctors' offices, clinics and other health facilities generate several billion pounds of garbage each year: Buried in that mountain of trash are untold numbers of unused disposable medical devices as well as used but recyclable supplies and equipment, from excess syringes and gauze to surgical instruments.

The problem, fueled by a shift toward the use of disposables that made it simple to keep treatment practices sterile, has been an open secret for years, but getting the health care industry to change its habits has not been easy. No organization currently tracks how much medical trash the United States produces - the last known estimate, from the early 1990s, was 2 million tons a year.

Only recently has the industry begun grappling with the amount of waste it generates, and one reason is that financially stressed hospitals are seeking ways to cut costs.

"We've just seen a sea change," said Cecilia DeLoach Lynn, director of sustainability education at Practice Greenhealth, a nonprofit group in Reston, Va., that is working to shrink the environmental footprint of health care institutions.

"Once upon a time, you had to do a lot of door-knocking to get anybody to pay attention," Lynn said. "These days, folks are asking us not whether or not they should be doing it, but how." Practice Greenhealth's members include around 1,100 hospitals and 80 companies.

Now, a new movement is taking aim at one of the biggest sources of medical refuse - the operating room, which churns out roughly 20 to 30 percent of a hospital's waste.

At a symposium in Baltimore in May, Practice Greenhealth announced an initiative called Greening the O.R. It will explore and vet the best sustainable practices for reducing operating-room garbage, energy consumption and indoor air quality problems - while lowering expenses and improving safety, Lynn said.

Eliminating the squandering of medical supplies and equipment can save on new purchases as well as incineration and landfill fees. Some institutions have turned to interventions like reducing their use of materials, recycling what they do use, and donating leftover but still usable items to developing nations. In a commentary published in March in Academic Medicine, Dr. Martin A. Makary, a gastrointestinal surgeon, and colleagues at Johns Hopkins School of Medicine called for more medical centers to "go green" by recycling disposable single-use medical devices. Several reprocessing companies take certain disposables - like orthopedic drill bits and heart-monitoring catheters - and clean, recalibrate, repackage and resterilize them, then sell them back to hospitals and medical suppliers for 40 to 60 percent of the price of new ones.

The commentary stemmed in part from a frustrating moment two years ago when Makary stared into a trash bin in the operating room after performing routine laparoscopic "keyhole" surgery. As is typical in most hospitals, the wastebasket was full of "perfectly good equipment, much of which was either barely used or never used," he recalled. Many of the devices came from sterilized surgical kits that were opened for the operation; no longer sterile, they got tossed.

Until quite recently, most medical devices - made from durable metal, glass or rubber - could be disinfected for countless reuses. In the 1980s, however, the health care industry began shifting to single-use versions, often made from inexpensive plastics, partly because the emerging HIV epidemic raised fears about the risks of recycling equipment.

Although it soon became clear that sterilization techniques readily killed the virus, the trend toward disposables kept growing. At Hopkins, Makary noticed more and more of his permanently reusable surgical tools being replaced by throwaways. It was, he said, a way "for the industry to make more money."

Some single-use devices can be reused after reprocessing, but a decade ago there was great consternation that inadequately decontaminated products might cause infections. Or that cleaning and sterilization might erode their less durable components, leading to malfunction.

Original-equipment manufacturers and their trade group, the Advanced Medical Technology Association, warned that it was unsafe to recycle devices designed to be used only once. But since 2000, the Food and Drug Administration has required that reprocessing companies meet the same stringent regulations for their products that original-device makers do.

But lingering safety concerns slowed the adoption of reprocessing. To investigate those fears, Gifty Kwakye, then a graduate student at Hopkins, worked with Makary and a colleague, Dr. Peter J. Pronovost, in combing the medical literature for evidence that patients were harmed by recycled devices.

They found none. A report by the Government Accountability Office in 2008 said that the available data indicated no additional health risk from reprocessed disposables. Reprocessing "has a reliable safety record of excellence identical to that of new equipment," the Hopkins researchers concluded in their commentary. Their own hospital contracts with a company to reprocess some of its equipment and is discussing what it could add to the list, Makary said.

David Nexon, senior executive vice president of the Advanced Medical Technology Association, acknowledged that with increased oversight, where devices have won FDA clearance based on review of additional data validating their safety and effectiveness after being reprocessed, the products are now "probably pretty safe." Still, Nexon questioned the safety of recycled products for which FDA does not require such data.

Karen Riley, an FDA spokeswoman, said that only a minority of reprocessed devices were exempt from the requirement for extra validation data, because they posed a low safety risk. They include blood pressure cuffs and other devices that may touch the skin but not penetrate it.

Many organizations, from Practice Greenhealth to the American College of Cardiology, support reprocessing as a safe strategy. Today, more than half the country's hospitals send at least some of their single-use devices to reprocessors, said Daniel J. Vukelich, president of the Association of Medical Device Reprocessors. The group represents Ascent Healthcare Solutions and SterilMed, the two companies that perform about 95 percent of reprocessing in the United States.

Ascent estimates that its 1,800 hospital clients diverted 2,650 tons of garbage from landfills in 2009; one major customer, the Hospital Corporation of America, which owns 163 hospitals, eliminated 94 tons of waste last year through reprocessing.

While recycling is helpful, even reprocessed disposables must eventually be thrown away, said Dr. Rafael Andrade, a general thoracic surgeon at the University of Minnesota Medical Center, Fairview, who spoke at the recent Practice Greenhealth workshop. The bigger goal, he said, should be to resume the old practice of relying on permanently reusable equipment. "We're just trying to undo a lot of the damage we've done," Andrade said.

For now, another approach is to cut back the use of disposables at the source by streamlining packaged surgical kits. Last year, Andrade and a nurse, Lynn Thelen, started an "O.R. green team" at Fairview. With input from colleagues, they scrutinized 38 types of operating room packs, figured out which supplies were never used (like plastic basins, catheters, syringes and dressings), and asked their medical product vendor to remove them.

One kit for implanting an intravenous port in chemotherapy patients contained 44 items, but the green team downsized it to 27 items and swapped disposable gowns and linens for reusable ones. That trimmed a pound of trash and $50 in supply costs per procedure. So far, Thelen said, the various kit reformulations have prevented 7,792 pounds of waste and saved $104,658.

Similarly, at Rochester General Hospital in upstate New York, surgeons have agreed to use standardized supply kits selected to cover most of their needs while leaving little unused, said Dr. Ralph Pennino, the chief of plastic surgery. The goal has been to "work systems out so we don't have anything to reprocess," he said.

Leftover items are donated to InterVol, a nonprofit organization started in 1989 by Pennino. Each week, its volunteers gather about 8,000 pounds of unused supplies and reusable equipment from regional health care facilities, then ship the stock to clinics in more than two dozen countries, including Somalia and Haiti.

"Anything we collect would have been disposed of," Pennino said - hospital beds, operating tables, crutches and, in one case, tens of thousands of brand-new hypodermic needles. Other humanitarian relief groups, like Project C.U.R.E., do similar work.

After the Haitian earthquake in January, one of InterVol's business sponsors lent two corporate jets to fly in teams of doctors and nurses and 8,000 pounds of supplies, said Pennino, who participated in medical relief efforts in Leogane, near the quake's epicenter.

Sometimes, medical donations are a one-person campaign, as in the case of Scott Barlow, a nurse at the clinic at Yosemite National Park in California. Barlow volunteered in two long stints during the last two years at Gimbie Adventist Hospital, based in a poverty-stricken town in Ethiopia where children die from starvation and rickets.

Currently back in California, Barlow scrounges what he can to send to Ethiopia, including scissors and unused excess dressings from the medical kits used at the Yosemite clinic.

On his first missionary trip with family and friends in 2008, Barlow took along a small trove of old equipment, including two microscopes, a centrifuge and blood-analysis machines donated by Doctors Medical Center in Modesto, Calif. "We just packed our luggage as full as we could with that kind of stuff," Barlow said. "Everything I brought, they needed."

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