Wastage of Supplies and Drugs in the Operating Room

Roy K. Esaki, MD; Alex Macario, MD

Disclosures

October 21, 2009

In This Article

Reduce, Reuse, Recycle, Restrict

An approach incorporating green practices to ongoing waste management for the operating room is to apply the standard triad of resource conservation: reduce, reuse, recycle. To these Rs we also add "restrict," which is the appropriate separation of regulated medical waste into the appropriate containers.

Reduce

The simplest way to reduce waste is to look for ways to reduce its production from the very outset when the hospital contracts for and acquires materials that will later become trash. Individually packaged components generate more packaging waste than prepackaged disposable kits. However, such grouped packages may increase waste if not all items in the kit are routinely used, or if extra kits are regularly opened to obtain only a single component that is not available individually. Many facilities carefully analyze the contents of surgical and anesthesia kits to avoid the routine inclusion of disposable items that are infrequently used.

In the United States, surgical items made ready for a particular case but not actually used during the particular surgery are often discarded. This is because these items are deemed "unsterile" even if there has been no contact at all with the patient.[15] Because of legal concerns and US Food and Drug Administration regulations, prepared supplies designated for a patient are not usable on another patient. However, such medical equipment can be collected and donated to hospitals in developing countries.[16,17]

Reuse

In a study published in 1997, the term "overage" was used to quantify surgical inventory that is readied but not used and thereby wasted.[18] The acquisition costs of such overage ranged from $5-$13/case, with neurosurgical cases having the highest overage dollar value. To address the overage problem, investigators studied the effect of an intervention that consisted of several elements including: (1) an education program, (2) reduction of surgical setups that created undue amounts of overage (while ensuring ready availability of potentially needed supplies), (3) redesign of surgeon-specific supply pick lists to correctly identify those items needed for a surgery, and (4) introduction of prepackaged supplies for cardiac surgery. These interventions reduced overage costs by 45%.

If unused surgical and anesthesia items cannot be eliminated prior to unnecessary opening, then one strategy can be to replace disposable items with reusable items as appropriate. For example, a hospital that used reusable operating room attire saved $152,000 adjusting for inflation compared with another hospital that used disposable scrub suits and gowns.[19]

One of the foremost concerns about reusable items is the potential infectious risks posed by inadequate cleaning and sterilization. There can also be great associated negative public relations for the hospital if such a thing occurs. This was recently highlighted in the national news when thousands of patients were thought to be exposed to HIV and hepatitis because the tubing, pump, and reservoir used for colonoscopy procedures were rinsed after use but not disinfected as required.[20]

Plastic anesthesia breathing circuits that are replaced after every surgical case also represent waste. However, because of differences in regulatory culture and practice patterns, the reuse of breathing circuits (with single-use filters to prevent cross-contamination) is common in many European countries but is rare in the United States.[21]

Recycle

When surgical or anesthesia items cannot be reused, recycling is another important mechanism to decrease waste. Recycling bins can be placed in operating rooms and other perioperative areas where regular trash bins are located. One barrier to this is that operating rooms are already quite full with other equipment, and there may not be enough space for additional bins. A program at an Australian operating room suite was able to recycle 200 kg per week of non-infectious polypropylene, polyethylene and polyvinyl chloride.[22] Similarly, a labor and delivery suite recycled glass bottles used for local anesthetics.[23] The actual money saved, however, was only a few dollars per week. To have a major impact, these types of recycling programs would have to be one component of a portfolio of hospital-wide green initiatives.

Restrict (Segregate)

When medical waste is inevitable, the appropriate restriction, or separation, of different classes of waste can still be beneficial. Placing the waste into the correct bin can result in cost savings and environmental benefits. A study published in 1996 described a program that disassembled and sorted breathing systems (including circuits, masks, gas sampling lines, and breathing bags) into constituent components for recycling instead of discarding them as regulated medical waste.[4] The authors estimated that this reduced the regulated medical waste generated by the operating room suite by 22.5%. A more recent study from Seattle Children's Hospital found that replacing hazardous medical waste bags with anesthesia waste bins produced $20,000 savings over 6 months.[24]

Nonsharps waste is also commonly found in sharps containers, perhaps indicating uncertainty about what items (such as uncontaminated needleless syringes) should be considered a sharp. Rigid sharps boxes in the operating room may contain as little as 14% appropriate sharps by weight and less than 50% appropriate sharps by volume.[25] Given that disposal costs for sharps containers can be several times the cost of other OR waste disposal, considerable cost savings may result from more stringently restricting the usage of sharps containers to appropriate sharps waste.

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