Sustainable perioperative practices - Reducing, reusing or recycling

By ahhb
Thursday, 26 June, 2014

Dr Pat Nicholson PhD, RN, RM, has been involved in perioperative nursing for more than 30 years. Dr Nicholson discusses the evidence behind reducing, reusing or recycling in the perioperative setting.
FEATURED- garbageIn Australia more than 260,000 tons of solid waste is produced each year with hospitals among the most energy-intensive facilities, accounting for a significant percentage of the accumulation of greenhouse gas and carbon dioxide emissions1. Significant resources are consumed by healthcare facilities and while medical waste is a necessary by-product, some of which is hazardous, correct management of this waste is required in order to reduce the impact on the environment2.
Factors contributing to the world-wide surge of healthcare facility waste include the increased use of disposable medical supplies and single-use non-recycled items3. This trend has developed in response to the growing concern over the transmission of infectious diseases, such as hepatitis or HIV, resulting in an increased use of disposable devices and packaging4. With a significant portion of medical waste potentially recyclable, with 75% to 90% of healthcare waste comparable to domestic waste, given the potential fiscal profit associated with the efficient reduction of clinical waste it is becoming vital for all healthcare facilities to consider waste reduction strategies to address environmental issues and reduce resource costs5.
Up to 90% of regulated medical waste is misclassified due to a misunderstanding of the clinical waste classification system and the requirement of segregating waste6 resulting in perioperative environments contributing between 20% and 70% of all healthcare waste each year. This is disproportional to the total waste generated by the facility7. Regulated medical waste undergoes hazardous waste disposal which is eight to 20 times the cost associated with disposal of general waste8; therefore a reliable system for separating and segregating hazardous and non-hazardous waste is essential in the operating suite.
Although the myriad of environmental impacts from the inappropriate disposal of waste could be addressed through behavioural change and proper segregation of regulated medical waste9 there is limited scientific, evidence-based literature detailing safe and effective green activities in the perioperative setting10. Recycling can be difficult due to concerns and regulations regarding regulated medical waste and biohazardous materials, however, many supplies that do not come into contact with body fluids or blood are able to be recycled, such as cardboard, paper, glass and plastic11, decreasing the amount and cost of waste disposal and reducing potential human and environmental health threat12.

“By promoting the reduction of waste production, conserving energy, using green or environmentally friendly products, recycling, and reusing resources and materials in the operating suite healthcare professionals can actively promote, and take action in minimising waste13.”

“By promoting the reduction of waste production, conserving” energy, using green or environmentally friendly products, recycling, and reusing resources and materials in the operating suite healthcare professionals can actively promote, and take action in minimising waste13. Active participation in waste management requires an awareness of State and Federal legislation or regulations, and local healthcare facility policies related to waste regulation, waste classification, and waste segregation practices14 in order to develop a sustainable regulated medical waste segregation program. It should be considered that while compliance with National and State-wide waste management practices is important standard precautions to prevent or contain the spread of infection should take precedence over waste management principles15.
Leadership, commitment and active involvement in supporting the environment is required by all disciplines within the perioperative team in order to develop a program that supports a sustainable, environmentally-conscious perioperative area16 with support from nursing management and other key stakeholders essential17. Healthcare facilities should have appropriate waste management systems to ensure all waste is managed in accordance with legislative requirements18 including the provision of adequate resources. A multidisciplinary environmental team should be established, with membership including key stakeholders19 to identify, implement and evaluate best practice in developing an environmental sustainable program and ongoing review and management of healthcare waste. This includes development of policies, to guide staff in improving environmental outcomes20. Waste segregation depends on the knowledge of staff at the point of generation21 therefore healthcare facilities should provide education to all workers on waste minimisation, and promote a culture of reduce, reuse and recycle resources and supplies22.
Patricia-Nicholson_009Dr Pat Nicholson Phd, RN, RM
Dr Pat Nicholson PhD, RN, RM, has been involved in perioperative nursing for more than 30 years. With a background in education she coordinated the Anaesthetic and Perioperative Postgraduate Courses and she currently coordinates the Nurse Practitioner Masters course at the University of Melbourne. Pat is a senior lecturer and holds the position of Director of Teaching and Learning in the Nursing Department as well as an honorary research position at Peter MacCallum Cancer Centre. Her PhD focused on instrument design and measurement of nursing competencies using Item Response Modeling, with her current research interests including cultural sensitivity, education using simulation and pressure injury development in surgical patients.
Pat is the current President of the Victorian Perioperative Nurses Group. She represented Victoria on the Australian College of Operating Nurses Board for four years and was made a Fellow in 2010. She was the team leader for the development of a new Guideline for the ACORN 2014 – 2016 Standards for Perioperative Nursing (Environmentally Sustainable Perioperative Practices). Team members involved in the development of the guideline: Catherine Steel, Pauline Hayden, Avril Brown
Tackling waste at the source of generation in an effort to reduce waste disposal requirements is considered best practice in waste management with the aim to avoid or recover as much of the waste as possible. Healthcare facilities should therefore commit to establishing a performance improvement program to promote reduction of waste, reusing and recycling supplies according to State / Federal and healthcare facility policies and practices with receptacles for recycling placed in areas where the waste is generated. Distinguishing features to facilitate waste segregation, such as colour-coded bins i.e. silver for metal, blue for plastic, slotted top for paper and round top for cans, are essential for the segregation at the point of waste generation and success of the program. During the setting up in preparation for the surgical procedure a system of designated general waste bags should be initiated to reduce non hazardous material being included in clinical waste bags as up to 80% of solid waste is produced before the patient enters the operating theatre23.

“Waste segregation depends on the knowledge of staff at the point of generation21 therefore healthcare facilities should provide education to all workers on waste minimisation, and promote a culture of reduce, reuse and recycle resources and supplies.”

The impact of reusable and disposable products when purchasing supplies, equipment and/or surgical instruments should be considered as waste generation is directly related to the purchase and supply practices in each unit24. In order to explore opportunities to minimise waste generated a critical analysis of purchasing practices, inventory delivery, storage space requirements as well as the impact of waste streaming when purchasing supplies and equipment is required25. Indirect costs incurred during manufacturing of medical products should also be considered.
Healthcare staff should actively promote and participate in natural resource conservation strategies, including water, electricity and natural gas measures, that are cost effective, conserving natural resources that are eco-friendly and are sustainable26. Strategies includes recycling, reprocessing of equipment and supplies, increasing energy efficiency, managing pharmacological waste27, turning off equipment (pumps and computers) when not in use, checking and maintaining equipment, turning off lights in the department when room is not in use or upgrading and install occupancy sensors in areas, use energy-efficient electrical equipment, lights and appliances, evaluating waterless scrubs, off hours shut down (set hours when equipment is turned off throughout department) and solar film on windows28.
recyclingNurses and healthcare workers have an obligation to provide care that does not harm the environment and it is everyone’s responsibility to think globally while acting locally in their practice.

  1. Kaplan et al., 2012; Kwakye, et al., 2011

  2. Townsend & Cheeseman, 2005; Tudor, Barr & Gilg, 2007

  3. Laustsen, 2007; Laustsen, 2010; Conrardy, Hillanbrand, Meyers, Nussbaum, 2010; Jang et al., 2006; Kagoma et al., 2012; Kaplan, Sadler, Little, Granz, & Orris, 2012; Penn et al., 2012; Practice Greenhealth 2011

  4. Hutchings & White, 2009

  5. Tudor et al., 2007; Wormer et al., 2013

  6. Conrardy et al., 2010; Hutchings & White, 2009; Jan et al., 2006; Kaplan et al., 2012; Kwakye et al., 2011; Lee & Mears, 2012a; Lee & Mears, 2012b Lee, 2002; Southorn et al., 2012; Stonemetz et al., 2011)

  7. Kagoma, Stall, Rubinstein & Naudie, 2012; Laustsen, 2007; Laustsen, 2010; Conrardy, Hillanbrand, Meyers, Nussbaum, 2010; Kaplan, Sadler, Little, Granz, & Orris, 2012; Kwakye et al., 2011; Practice Greenhealth, 2011; Southorn et al., 2012; Wormer et al., 2013

  8. Ciplak & Barton, 2012; Greenhealth Practice 2011; Kaplan 2012; Lee & Mears, 2012;Nussbaum, 2009; Sattler, 2003; Stonemetz et al., 2011

  9. Ciplak & Barton, 2012; Greenhealth Practice 2011; Sattler, 2003

  10. Laustsen, 2007; Laustsen, 2010; Lee & Mears, 2012a; Lee & Mears, 2012b Kwakye 2011; Stonemetz et al., 2011; Townend & Cheeseman, 2005

  11. Laustsen, 2010; Southorn et al., 2012

  12. Conrardy et al., 2010; Laustsen, 2007

  13. Conrardy et al., 2010; Kagoma et al., 2012; Kaplan, et al., 2012; Kwakye et al., 2011; Laustsen, 2007; Laustsen, 2010;Townsend & Cheeseman, 2005

  14. Reale, 2007; WHO, 2013

  15. ANZCWMIG, 2007

  16. Laurer, 2009; Laustsen, 2007; Lee & Mears, 2012a; Lee & Mears, 2012b Reale, 2007; Saver, 2009

  17. Laurer, 2009; Lee, 2002; Saver, 2009; Stonemetz et al., 2011; Tudor et al., 2007; Wormer et al., 2013

  18. ANZCWMIG, 2007; Lee et al., 2004; Townsend & Cheeseman, 2005; Waste management Australia, 2010

  19. Laustsen, 2007; Wormer et al., 2013; WHO, 2013

  20. Kaoma et al., 2012; Laustsen 2007; Wormer et al., 2013

  21. Ciplak & Barton, 2012; Laustsen, 2010; Reale, 2007

  22. Conrardy et al., 2010; Jang et al., 2006; McGain et al., 2012; Kaiser, 2001; Kagoma et al., 2012; Kaplan, 2012; Laustsen, 2010; Riedel, 2011; Wormer et al., 2013

  23. Kagoma et al., 2012; Southorn et al., 2012

  24. Conrardy et al., 2010; Jang et al., 2006; Kaiser et al., 2001; Overcash, 2012

  25. Kaplan, 2012; Kagoma et al., 2012; kwayke 2011; Laurer, 2009

  26. Kwakye 2011; Laustsen, 2010

  27. Kwakye, 2011; Laustsen, 2007

  28. Kaplan et al., 2012; Kagoma et al., 2012; Kwakye et al., 2011; Laurer, 2009; Laustsen, 2007; Wormer et al. 2013

Reference List
Australian and New Zealand Clinical Waste Management Industry Group (ANZCWMIG). (2007). Industry code of practice for the management of clinical and related waste (5th ed). Available from Accessed Feb 18, 2014. [S]
Ciplak, N., & Barton, J R 2012. A system dynamics approach for healthcare waste management: A case study in Istanbul metropolitan city, Turkey. Waste Management Research, 30, 576 – 586.
Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J. 2010 Jun;91(6):711-21. [C]
Hutchings, D., & White, S. 2009. Coming round to recycling, BMJ, 338, 746 – 748.
Jang, J-C., Lee, C., Yoon, O-S., & Kim, H. 2006. Medical waste management in Korea. Journal of Environmental Management, 80, 107 – 115.
Kagoma Y, Stall N, Rubinstein E, Naudie D. People, planet and profits: the case for greening operating rooms. CMAJ. 2012 Nov 20;184(17):1905-11 [D]
Kaiser, B., Eagan, P.D., & Shaner, H. (2001). Solutions to healthcare waste: Life-cycle thinking and ‘green’ purchasing. Environmental Health Perspectives, 109, (3), 205 –207.
Kaplan S, Sadler B, Little K, Franz C, Orris P. Can sustainable hospitals help bend the health care cost curve? Issue Brief (Commonw Fund). 2012 Nov;29:1-14. [D]
Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. 2011 Feb;146(2):131-6. [D]
Laustsen G. Greening in healthcare. Nurse Manage. 2010 Nov;41(11):26-31. [D]
Laustsen G. Reduce--recycle--reuse: guidelines for promoting perioperative waste management. AORN J. 2007 Apr;85(4):717-22, 724, 726-8. [D]
Lee RJ, Mears SCa. Greening of orthopedic surgery. Orthopedics. 2012 Jun;35(6):e940-4. doi: 10.3928/01477447-20120525-39. [D]
Lee RJ, Mears SCb. Reducing and recycling in joint arthroplasty. J Arthroplasty. 2012 Dec;27(10):1757-60. doi: 10.1016/j.arth.2012.04.020. [C]
Lee, B-K, Ellenbecker, M.J., Moure-Eraso, R. 2004. Alternatives for treatment and disposal of regulated medical wastes. Waste Management, 24, 143 – 151
McGain F, White S, Mossenson S, Kayak E, Story D. A survey of anesthesiologists’ views of operating room recycling. Anesth Analg. 2012 May;114(5):1049-54. [C]
Nussbaum, G.F. (2008). Alternative waste management strategies. Perioperative Nurs Clin 3(1) 63 – 72.
Overcash, M. 2012. A comparison of reusable and disposable perioperative textiles: Sustainability state- of-the-art 2012. Anesthesia and Analgesia, 114(5), 1055 – 1066.
Penn, E., Yasso., S.F. & Wei, JL. 2012. Recuing disposable equipment waste for tonsillectomies and adenotonsillectomy cases. Otolaryngology – Head and Neck Surgery, 147, 615 – 618.
Practice Greenhealth. Greening the OR; Guidance Documents. Practice Greenhealth. 2011-2013. [D]
Reale, E. 2009. Nurses key to success of waste segregation program. Australian Nursing Journal, 17(3), 7. [D]
Riedel, L. 2011. Environmental and financial impact of a hospital recycling program. AANA journal, 79(4), S8 – S14 [C]
Sattler, B. 2003. The greening of health care: environmental policy and advocacy in the health care industry. Policy Politics and Nursing Practice, 4(6), 6 – 13 [D]
Saver, C. 2009. Staff spearheads an OR’s green effort. OR Manager 25(1), 24 – 25 (level IV).
Southorn, T. Norrish, AR., Gardner, K & Baxandall, R. 2012. Reducing the carbon footprint of the operating theatre: A multicentre quality improvement program.
Stonemetz J, Pham JC, Necochea AJ, McGready J, Hody RE, Martinez EA. Reduction of regulated medical waste using lean sigma results in financial gains for hospital. Anesthesiol Clin. 2011 Mar;29(1):145-52. [C]
Townend W & Cheeseman, C R. 2005. Guidelines for the evaluation and assessment of the sustainable use of resources and of wastes management at healthcare facilities. Waste Management & Research, 23, 398 – 408.
Tudor, T. Barr S & Gilg, A. 2007. Strategies for improving recycling behaviour within the Cornwell National health Service in the UK. Waste Management & research, 25, 510 – 516. World Health Organization. (2013). Safe management of wastes from healthcare activities. (2nd ed).
World Health Organization. Available at:
Wormer BA, Augenstein VA, Carpenter CL, Burton PV, Yokeley WT, Prabhu AS, Harris B, Norton S, Klima DA, Lincourt AE, Heniford BT. 2013. The green operating room: Simple changes to reduce cost and our carbon footprint. The American Surgeon, 79, 666 – 671.
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