• Waste reduction programs in health care facilities can reduce costs and increase safety.
• This article explains how all health care professionals can reduce costs by waste segregation, source reduction, reuse, and recycling.

An often overlooked opportunity for cost reduction at health care facilities is in waste management. Hospitals in the United States generate more than 6,600 tons of waste each day-the "byproduct" of quality health care.(1) This represents approximately 1% of all the waste generated in America each day. That may not sound like much, but it is significant for any one type of institution, and hospitals are paying millions of dollars for waste disposal--dollars that could be put to better use for patient care, staff development, or reducing health care costs.

Waste management practices at many facilities are also posing "invisible" risks to hospitals and their employees. Recognizing that most hospitals spend thousands of dollars each year on unnecessary waste disposal and that facilities often put workers at risk handling waste, these invisible costs become all too visible.

In this age of mergers, downsizing, and decentralization of care delivery, waste management may seem a minor concern. Some hospitals continue to seek a single technological answer to all their waste problems, wishing that the waste Would simply disappear. Other hospitals are beginning to view waste management as a major opportunity to:

• rebuild ties with their local community,
• create significant savings, and
• reduce general liability through a series of simple, straightforward approaches.

If waste management is so easy, why are more facilities not jumping on the bandwagon?

Cost savings and risk reduction can be achieved by rigorous waste segregation practices and staff training programs. Facilities need to provide education to make sure every physician, nurse, clinician, laboratory technologist, and auxiliary support person is as familiar with the facility's waste management program as they are with collecting their paychecks or understanding fire safety procedures. Every clinical procedure and every administrative task--literally everything done in a hospital--creates some type of waste. It may be paper waste in administrative areas, cardboard in supply distribution, infectious or regulated medical waste (RMW) in laboratories, or glass waste (i.e., glucose water bottles) in the nursery.

Everyone creates waste, everywhere, everyday. Building knowledge of and commitment to a facility-wide waste reduction effort takes dedication and resources.

Reducing Costs

Current business practices tend to deter facilities from making major changes in waste management systems. In general, most hospital accounting systems are not designed to hold specific waste generators accountable for their share of the costs associated with recycling the waste. It is usually the environmental services or facilities management department that absorbs the cost of waste disposal for the entire facility. If waste management costs were allocated to points of generation, OR managers, laboratory managers, dialysis unit managers, and food service managers would be in for major "sticker shock" at waste disposal costs. Materials managers and purchasing agents, those people responsible for bringing in the potential waste (i.e., new products), would be asking their suppliers to do something to reduce the waste associated with the products they make. Ironically, many suppliers have already done that by minimizing packaging, packing in recycled materials, and redesigning their products to be smaller or reusable.

Beyond the supplier, waste reduction efforts come largely from human--not technological--intervention. Additional and ongoing training for staff members responsible for waste reduction, education for all hospital employees, and systems redesign are necessary. Waste reduction requires an investment in the human infrastructure, not only a technological infrastructure. Training and systems design are more difficult to implement in the hospital infrastructure than buying a piece of' new technology, but they can be longer lasting, more flexible, and ultimately, more efficient. Technology is an "add-on" to the human system rather than the other way around. Buying appropriate and appropriately sized waste disposal or treatment technologies can generate a huge cost savings for a hospital in addition to avoiding disposal costs.

Segregating Waste

The costs associated with not properly segregating waste are threefold.

1. Disposal of RMW, or what is commonly referred to as 11 red-bag waste," costs a facility anywhere from 10 to 20 times the cost of disposing of it as solid waste or regular trash. Some hospitals are disposing of 50% to 75% of their waste as RMW, whereas the recommended standard is 15%. Some facilities have achieved rates of less than half that. (2) At one New York City hospital, a change in segregation strategies (simply getting personnel to dispose of solid waste in solid waste containers rather than RMW containers) has saved that facility $1 million per year. (3)
2. Only when facilities minimize red-bag waste and increase the amount of waste that can be treated as solid waste, can they truly evaluate recycling and reduction opportunities. The generic composition of solid waste is shown 'in Figure 3. One hospital is currently diverting more than 40% of their waste through a variety of cost-effective strategies including recycling, source reduction initiatives, reuse options, and diversion of organic waste to a composting operation. In 1995, recycling of their paper alone generated nearly $30,000 in revenues for that facility. In addition, the hospital has been recognized as a corporate leader by city officials and was one of the first institutions to comply with local mandatory recycling ordinances. Prior to realizing these benefits, this institution had reduced its RMW to less than 10%. (4)
3. Minimizing RMW will increase worker safety. Workers handling waste in hospitals tend to be the lowest paid, lowest status employees. They often receive little in the way of special instruction in proper handling of waste, which hospitals pay so much to safely dispose of to protect public health. Regulated medical waste is a "special waste," and to receive special handling it should be properly segregated and reduced so that workers are clear that when they handle red bags, they know the bags really do contain materials that require special handling and disposal. Blood spills, mercury and other chemical spills, needle sticks, and other exposures, many of which are under-reported, are still too common in health care institutions. Much of this danger to workers could be reduced by reducing the amount of waste treated as RMW.

Why Regulated Medical Waste?

Why do hospitals dispose of so much of their waste as RMW? There are usually two reasons.

First, in some cases, hospitals operate their own on-site incinerator, and there is not an immediate, obvious cost-saving incentive--especially if the incinerator is linked to energy recovery. Some hospitals literally "red bag" everything, including waste from the chief executive officer's desk. What happens when that incinerator is shut down (more than half the hospital incinerators have been shut down in the last 10 years)? Hospitals will experience soaring costs associated with paying a vendor to haul away the waste. There will be no easy solutions for reducing RMW in a culture that never had to segregate waste.

Worker health and safety is also an issue. If all waste, or a major portion of the waste, is treated as RMW, workers disposing, collecting, and handling waste may become less careful about handling waste they know to be mostly paper, tissues, cans, bottles, and boxes. Handling RMW must be done with great care by trained and properly equipped workers. A facility that does not distinguish its waste at the point of disposal is more likely to not enforce proper protocols in terms of waste handling, posing threats to waste workers.

Second, many hospitals have overcompensated in response to the expired Medical Waste Tracking Act, the Occupational Safety and Health Administration's (OSHA) bloodborne pathogen standard (i.e., for worker safety, not waste disposal), and public fear (i.e., finding needles on beaches). Interpretation of and response to these standards, regulations, or public concerns has led many hospitals to "red bag" everything, that has come in contact with patient areas (eg, newspapers, flowers) and anything that looks remotely medical (eg, medical device and product packaging). Hospitals have to contend with a myriad of regulations (eg, Environmental Protection Agency [EPA], OSHA, state, Department of Transportation [DOT]), standards (e.g., Joint Commission on Accreditation of Healthcare Organizations [JCAHO] Environment of Care, Centers for Disease Control and Prevention [CDC]), and "best practices," as well as public and employee misconceptions of medical waste. The complexity of the issue is further exacerbated because 42 of the 50 states define RMW differently.

What are Your Costs?

Environmental services managers could probably recite waste costs in their sleep. Usually, solid waste or trash (e.g., paper, boxes) costs two to six cents per pound for disposal. Regulated medical waste (e.g., infectious, biohazardous) costs anywhere from 19 to 40-plus cents per pound for disposal. Hazardous waste (e.g., chemicals, some types of batteries, mercury, solvents) costs from $1 to $6 per pound for disposal. As a department manager, you may budget for supplies, staff, and capital equipment. Can you honestly walk into your supply room and identify the costs of the products your staff uses or the cost for disposal of the waste your department generates?

Costs for waste disposal vary frorn institution to institution depending on facility size, volume of waste, and disposal fees. Waste costs are directly proportional to the types of waste produced and the amounts in each category. There are two general standards of "best practices" to evaluate hospitals' infectious waste management practices.

• Standard I: Infectious waste should not exceed more than 10% to 15% of total waste stream volume 6e, solid waste plus regulated medical waste plus hazardous waste plus recyclable waste).
• Standard II: In an optimal situation, infectious waste (including sharps) should be between 1.0 to 2.5 lbs. per bed per day. This number will be influenced by many factors, including segregation practices and the amount of disposable products used in care. (5)

Controlling the infectious waste stream will determine the volumes of other waste streams. Legal decreases in infectious waste will increase solid waste and will increase opportunities to segregate more waste materials for recycling. Both of these options for waste management are much less hazardous and expensive than managing infectious waste.

There are now enough hospitals that have made significant reductions in infectious waste in enough different regulatory environments to feel assured that any hospital in the country can significantly reduce their RMW. Some hospitals who have closed their on-site incinerators have gone from nearly 100% red-bag waste to less than 20% red-bag waste in only a few years. Other facilities have dropped infectious waste rates well under the 15% standard through a commitment to ongoing staff training and new systems monitoring.

Reducing waste costs can occur through a variety of methods. These include waste segregation, source reduction, reuse, and recycling.

SEGREGATION. Segregation is a process through which staff members efficiently separate waste streams into categories that optimize costs, ensure worker safety, and ensure compliance with hospital standards and regulatory forces (e.g., EPA, OSHA, DOT, Department of Health, Department of Energy, CDC, JCAHO, fire code, ergonomic safety).

Segregation means that the generator of waste takes responsibility for property segregating waste (e.g., paper in the paper bin, flattening cardboard boxes, disposing of syringes and needles in a sharps container, disposing of the packaging generated before surgery as either solid or recyclable waste, disposing of only the truly contaminated waste as infectious or RMW).

Systems must be established that allow for efficient segregation. Aspects of these systems include regular staff training and providing containers that are adequately sized, strategically placed, and consistently labeled. Segregation practices also need to be part of hospitals' corporate policy--an organizational "thou shalt."

SOURCE REDUCTION. Source reduction means not creating waste in the first place. There are dozens of opportunities to reduce waste without compromising patient care or worker safety. Several examples are listed below.

Bedding: Discontinue use of disposable egg crate pads. Hospitals are now buying mattresses with built-in egg crate foam pads rather than buying disposable foam underlays for patients.

Paper: Reduce paper consumption through double-sided copying as a standard policy, e-mail and voice mail to replace written memos, and others.

Patient admission kits: Kits or elements of kits can be purchased that meet the real needs of the patient and are relevant for the specific length of a stay rather than having one kit fit all situations.

Real savin gs begin with product management. Deciding what products will be used in patient care has a major impact on the amount of waste facilities generate. For example, disposable underpads are used to line patients' beds to prevent soiling of the sheets. Many nurses use three beneath the draw sheet and two or three on top of the sheet. There are, however, alternatives. Many companies now make reusable underpads that are often large enough to not only serve as underpads, but as drawsheets as well. These products eliminate the need for disposable underpads and cloth drawsheets. One hospital recently reported a projected annual savings of $70,000 (reducing 22,000 pounds of waste) simply by eliminating disposable underpads. (6) Consider the cost-saving possibilities of evaluating a number of items when switching one high-use disposable product to a reusable product produced a savings of $70,000 in disposal costs alone (not to mention procurement costs, storage costs, and storage space).

REUSE. Another strategy to reduce waste is reuse. Years ago, the reuse of products and supplies was commonplace in health care. Disposables became more prevalent in the last two decades and have, in many cases, served the health care field well. An overuse of some disposable supplies can be curtailed with significant waste reduction results. A return to reusables, in some situations, is beginning to make sense again, and many facilities are adopting reuse as a waste and cost reduction strategy. Each hospital must evaluate the use of reusable clinical supplies and products. Each situation is unique. Some examples of reusable supplies include respiratory therapy products, underpads, gowns, dishware, and mattresses with built-in egg crates. In office settings, remanufacturing laser and copier toner cartridges can cut the price of these high-cost items in half. The issues surrounding using reusables vary from state to state and facility to facility, and waste disposal costs can be an important factor when institutions evaluate the option for reusables.

RECYCLING. The goal of any recycling program is to divert as much waste material as possible from landfills and incinerators and return valuable resources into circulation in the economy. Recycling can save a hospital money by reducing landfill, hauling, and other disposal related costs. In a growing number of communities recycling certain materials is mandated by law.

Many recyclable materials can generate revenues of their own. In some cases, the recycling markets are better now than in past years, and the cost of recycling has declined. Many waste vendors will provide rebates on fees for services (e.g., equipment rental, hauling based on sale of the recyclables they collect). Many others provide free containers and equipment or will finance needed equipment from the money generated from the sale of the facility's recyclables. There are a number of arrangements that hospitals have made with vendors to enhance their recycling programs.

Recycling is often not considered a vital component in hospital waste management. Private recycling firms tend to shy away from hospitals because they share the public's inaccurate perception of all hospital waste. Given the current market prices for recyclable materials (especially waste paper), however, many vendors have overcome this hesitation and are actively seeking hospital contracts. A great deal of education needs to take place with waste vendors to introduce them to the many opportunities that exist for recycling materials from health care settings. Some hospitals have achieved total recycling rates of more than 40% of their total waste stream.

Making Waste Management Work

It takes leadership to make waste management work. Several top-level hospital administrators have championed waste reduction at their institutions for a variety of reasons. These individuals worked to address an immediate crisis brought on by waste mismanagement or regulation or have seen waste minimization as a means of solving another issue or problem. In some cases, it was as simple as reducing the bottom line, taking the significant cost savings realized from waste reduction to meet other needs. Annual cost savings attributed to enhanced waste management programs go as high as $1 million. (7) Some hospitals that developed good waste segregation practices have been able to capitalize on the lucrative recycling markets and are receiving revenues for paper, plastics, and other materials, which at one facility will exceed $100,000 per year. (8)

Administrators who exert leadership in this area can also prepare their institution to meet new JCAHO standards for the environment of care, prepare for changes in federal air and waste regulations affecting hospital waste incinerators, and anticipate local recycling regulations. Top management can also meet other goals by improving community relations through rethinking their waste management practices. The health care literature is full of examples of citizen groups and communities objecting to the development or continued use of medical waste incinerators in their area. In some cases this has become an "environmental justice" issue for poor or minority communities.

Hospitals need to be responsive and responsible about the impact that their operations have on the local community. This ranges from provision of health care services to the use of energy, water, and disposal of waste. Hospitals have the tools and methods available to make waste management a positive attribute of their operation rather than a negative burden. The choice rests with each individual institution.

1. W A Rutala, C G Mayhall, "Medical waste reduction strategies for health care facilities," position paper (Woodbury, NJ: The Society for Hospital Epidemiology of America, 1992) 40.

2. Ibid.

3. H G Shaner, C L Bission, G McRae, An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities (Chicago: Anierican Society of Healthcare Environmental Services, 1993) 3.

4. H G Shaner, G McRae, The Guidebook for Hospital Waste Reduction Planning and Program Implementation (Chicago: American Society for Healthcare Enviromriental Services, in press).

5. Shaner, Bission, McRae, An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities.

6. Shaner, McRae, The Guidebook for Hospital Waste Reduction Planning and Program Implementation.

7. Shaner, Bission, McRae, An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities, 3.

S. Shaner, McRae, The Guidebook for Hospital Waste Reduction Planning and Program Implementation.

RESOURCES

H G Shaner, G Mcrae, "Managing Wastes In Merger Conditions: Optimizing Systems," Technical Paper (Chicago: American Society Of Healthcare Environmental Services Of The American Hospital Association, 1996).

No Time To Waste: Resource Conservation For Hospitals (Boston: Fanlight Productions, 1995) Videotape.

Cascadia Consulting Group, Hospital Plastics Characterization And Recycling Feasibility Study, (800) 937-4113.

The Healthcare Resource Conservation Coalition (H RCC) (6 15) 85 1-6507.

The Coalition of Northeastern Governors (CONEG) Initiative On Source Reduction, Washington, DC (202) 624-8450.

Hollie Shaner, RN, is president and co-founder of CGH Environmental Strategies, Inc., Burlington, Vt. Glenn McRae is an organizational analyst and management consultant in Burlington, Vt.

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