Wastage of Supplies and Drugs in the Operating Room

Roy K. Esaki, MD; Alex Macario, MD

Disclosures

October 21, 2009

In This Article

Introduction

Anyone visiting an operating room would be impressed by the staggering amount of garbage produced even after a simple 90-minute surgery. In fact, a routine operation in a hospital often produces more waste than a family of 4 might produce in an entire week. One reason operating rooms generate so much waste is the need for absolute sterility of surgical supplies and equipment, which creates the need for extra packaging and creates an impetus for the use of disposable equipment. There is a large environmental and financial cost to such waste, however, and it is especially important in these times to be mindful of such concerns. As such, this article will review what is known about waste generation in the hospital and operating room and will discuss various waste management strategies.

Hospital Waste

A landmark study from almost 2 decades ago (performed at a 385-bed private teaching hospital) found that 6.6 kg of waste was generated per patient per day, and estimated that 41 tons of operating room waste (compared with 11 tons from the wards) could be saved if reusable alternatives were available.[1] The main components of hospital waste include plastics (46%), paper (34%), liquids (12%), glass (7.5%), metals (0.4%), and anatomic waste (0.1%).[2] Waste management strategies should be implemented hospital-wide, and beyond patient-care areas. For example, cafeterias may produce more than twice the amount of plastic waste than that generated by anesthetic tubing used in the operating room.[3]

Surgical Waste in the Operating Room

Based on anecdotal reports in the United States, it has been estimated that operating rooms generate 20%-33% of total hospital waste,[4,5] even though the surgical suite represents a proportionally smaller area of the hospital (Figure).

Figure. Waste generated from blood and other fluids administered to a patient undergoing a major surgical procedure.

In addition to packaging and intentionally disposable supplies, surgical waste can also involve more costly medical devices. A study of joint replacement surgery found that the knee or hip implant, each of which may cost thousands of dollars, was wasted in 2% of the procedures.[6] The reasons for the implant waste included potentially avoidable causes such as improper trialing, failure to check implant size and model before opening the package, and dropping of the implant.

Anesthesia-Related Waste in the Operating Room

Potential anesthesia-related waste might include items such as syringes, bottles and vials for anesthetic drugs, and airway equipment and hoses. Historically, the waste of anesthetic gases (eg, nitrous oxide and inhaled anesthetics) has been of concern, as less than 5% of the inhaled anesthetic is metabolized by the patient, with the majority being eliminated by patient breathing.[7] Modern scavenging systems minimize the exposure of operating room personnel to these waste gases, but the waste gases are ultimately emitted into the environment. Reducing expired anesthesia gas would reduce the greenhouse gas nitrous oxide and its potential effect on global warming. Fortunately, the two most commonly used anesthesia gases, sevoflurane and desflurane, contain neither chloride nor bromide, and thus should not pose a threat to stratospheric ozone and are less likely to be potential greenhouse gases.[8]

Another anesthesia-related concern is drug waste, which occurs when medications are drawn up but are unused and discarded at the end of the day. In one study, all opened but unused or unusable intravenous anesthesia drugs left over at the end of the day were collected for 2 weeks.[9] Thirty different drugs in 57 syringes and 139 ampules were collected from 166 cases, amounting to an average cost per case of $10.86 for discarded drugs. The medications contributing to the greatest cost of waste were phenylephrine (21%), propofol (15%), vecuronium (12%), midazolam (11%), labetalol (9%), and ephedrine (9%).

A separate study of 25,481 surgical patients calculated the percentage of drug actually administered to patients relative to the amount dispensed.[10] Only 33% of the succinylcholine prepared for a patient was administered, meaning that two thirds of the prepared drug was wasted. Similarly, 51% of propofol, 47% of midazolam, and 39% of rocuronium was prepared but not administered. The most common reason for drug waste was need to dispose of full or partially full syringes. A separate study of pediatric anesthesia found that 80% of epinephrine, naloxone, flunitrazepam, ephedrine, and cisatracurium were wasted, with rocuronium and nalbuphine having the highest waste cost.[11]

Given these findings, it may be beneficial to use prepackaged anesthesia drug syringes that can be saved for subsequent cases if unopened. This may be most useful in situations where many medications need to be drawn up at the beginning of the day. Drug waste and cost of the syringe disposal could be reduced if full but unused syringes could be saved and reused.[12]

In addition to medications, anesthesiologists commonly use various devices that are potential sources of waste. Interestingly, some medical products (eg, the laryngeal mask airway) are brought to market in a reusable form, and eventually evolve into a disposable, single-use unit. This can be attributed to the marked reduction in the cost of the disposable airway, and elimination of the need to clean and sterilize a multiuse device.[13] In contrast, other supplies that have traditionally been disposable may eventually switch to a reusable form. For example, reusable warming blankets are being tested as an alternative to disposable forced air warming blankets.[14]

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