The term "medical waste" conjures up different images for different people. For most people, it produces an image of infectious waste, including used needles and blood. However, approximately 80% of a medical facility's wastestream can be classified as general refuse, or municipal solid waste (MSW), and is therefore similar to the kinds of waste generated in hotels, restaurants, shopping centers, office buildings, and private residences.

In the hospital setting, a significant portion of the wastestream can be attributed directly to the types of products that are brought on site for facility use. Over the past 15 years, the health-care industry has shifted from a primarily reusable product supply system to a primarily disposable product supply system. The majority of these supplies are hermetically sealed in individually wrapped packages. This shift has dramatically increased the waste generation rates of medical facilities. A recent report in the New England journal of Medicine credited hospitalized patients with the generation of 15 pounds of hospital waste per day.

This article summarizes a Vermont pilot project that targeted the separation and reuse or recycling of the dry, non-patient contact packaging and unused supplies generated in the surgical services wing of the Medical Center Hospital of Vermont (MCHV) in Burlington. Working on the Hypothesis that a significant percentage of waste generated in specialty areas (e.g., surgical services) is actually clean, noninfectious material (and possibly recyclable or reusable), the pilot program was established to:

• Demonstrate that a collection system could be designed to segregate clean, non-patient contact wastes with the complete support of hospital staff.
• Determine the quantities and qualities of such wastes for consideration by potential recycling markets.
• Identify the manufacturers of particular wastes for which alternative materials might be used to enable easier recycling. I Cite areas where waste can be reduced without jeopardizing patient care.

Document that health-care workers have the educational background and experience to differentiate between clean waste and infectious waste. Funding for the study came from a $13,000 waste reduction grant awarded to MCHV by the Vermont Agency of Natural Resources and $3,000 in matching funds from MCHV. Most of the money was used to pay for the principal researchers' time for the pilot study, but a small amount of the grant was needed for collection equipment and educational tools.

MCHV is a 500-bed teaching hospital located adjacent to the University of Vermont's Medical School. MCHV surgeons perform approximately 1,000 surgical procedures monthly, including open heart, orthopedics, eye, and dental surgery.

The surgical services wing of MCHV includes 13 operating room suites, the postanesthesia care unit (recovery room), surgicare, and preoperation hold units. Surgical set vices employs approximately 200 permanent staff members. Each room has several general waste receptacles along with a clearly marked container for red-bag wastes and a plastic red box for the collection of sharps. A small, centrally located room in the surgical services wing (known as the dirty core) is the storage point for waste and soiled linen before its removal to the hospital's main waste dumpsters. Housekeeping personnel are responsible for servicing the dirty core, but surgical services staff members are responsible for taking waste from their units to the dirty core.

White office paper and corrugated cardboard, which are part of Burlington's mandatory recycling program, are separated out for collection. Separate collection bins are strategically located throughout the surgical services wing in areas of high use of computer and office paper. Corrugated cardboard is stacked separately in the dirty core and then removed by housekeepers.

In 1990, MCHV generated an average of three 40-yd3 containers of compacted MSW on a weekly basis, in addition to Its red-bag, hazardous, and nuclear wastes. Approximately 142 tons of corrugated cardboard and white office paper were removed through the recycling program. New target materials were added in 1991, including tin-plated steel and aluminum cans from the food service area, glass bottles from the newborn nursery, nutritional services, pharmacy, neonatal intensive care unit, recovery room, radiology, pediatrics, and critical care areas. High density polyethylene (HDPE no. 2) was added on a hospital-wide level, although dialysis and nutritional services were the largest generators.

Collection of polypropylene (PP no. 5) was implemented in June 1991. Stretch wrap recycling, construction, and demolition waste recovery were added in June 1992, and grease recycling is beginning. Other materials collected include Ziplock pharmacy bags and foam packing peanuts. The items are reused by a variety of community organizations and local businesses. Periodic recycling drives for magazines and directories occur as well. Infrastructures are also in place to divert materials such as used equipment and durables (e.g., carpet and furnishings) to community entities for redistribution.

Preliminary Waste Analysis in Surgical Services

On January 14, 1991 the researchers, with the assistance of the hospital's environmental specialist, a waste management consultant, and a nurse from surgical services sorted through a 12-hour sample of MSW generated that day in the surgical services wing. The collection was unannounced except to surgical services administrative staff so that the wastestream would be as normal as possible. A total of 41 bags of waste--222 lbs--from 32 cases were sorted into 24 categories.

Each bag was weighed before sorting and then each category was weighed at the completion of the sort. The sort provided some important information:

• The blue disposable sheets used in the sterilization process of most of the hospital's reusable instruments and equipment were a significant portion of the MSW generated in surgical services (19%).
• If liquid wastes and bloodied materials were kept segregated, a significant portion of the wastestream would be rigid and flexible plastic packaging and paper/plastic composite packaging.
• A small amount of red-bag material and sharps were found in the MSW trash bags. The environmental specialist planned to work with the surgical services administrative specialist and support specialist on additional training to avoid such mistakes.
• Some instruments and reusable gowns and drapes were mixed in with the MSW, representing a loss of valuable supplies and equipment. Further emphasis was needed on appropriate sorting of these materials to reduce such mistakes, which add to health-care costs.

The sorting sample showed that the challenge would be in finding a way to collect recyclable or reusable materials before they became contaminated with other waste generated during surgical and patient care procedures and to identify the composition of these different types of materials to facilitate attempts to find new uses for them.

Designing the Process

Setting up a collection system for the dry, non-patient contact waste generated in the surgical services wing of MCHV would require a change in procedure by all department staff as well as support from other areas of the hospital. An initial step in the design process was the establishment of a steering committee to review design parameters, and the pilot project's progress.

The steering committee served as an effective sounding board, assisting in review of the equipment and facilities needed to perform the month-long pilot separation program and the educational campaign accompanying the program. It also helped to obtain the cooperation of other areas of the hospital, including security, housekeeping, purchasing, administration, and public relations.

Training for the staff members who volunteered to participate in the May pilot separation project began in April, and it emphasized that controlling contamination would be essential to the success of the program. Only dry, nonpatient contact supplies and packaging were to be included in the collection containers. The often emphasized slogan of the program was "When in Doubt, Throw it Out." The educational campaign included an eight minute video explaining the project, the equipment to be used, and the procedures participants would follow. All affected staff received individual memos, and staff meetings included live presentations, with an endorsement from department heads.

Implementation

Employees willing to participate in the MedCycle collection began on May 1 to segregate wastes generated in the surgical services wing of the hospital, using bluetinted trash bags (with 20% postconsumer recycled plastic resin) as the identifying color of bag liner. (The hospital currently uses red bags for infectious waste and clear or green bags for MSW.) Receptacles for the blue bags were 39-gallon wheeled toters, purchased from a local discount chain. "MedCycle" was prominently displayed on the toter, and ample supplies of blue bags were left on the supply shelf outside the operating room (OR) suites. A sign affixed to the side of each toter listed examples of the types of materials acceptable in the MedCycle bin. (The unacceptable items were also identified in bold letters.)

In the OR suites, the intent was to use the bins only during the setup procedures before the patient entered the room. During this time, OR t technician s and nurses are opening a myriad of packages of supplies for the case and putting them onto a sterile field for quick access during the surgical procedure. The packaging from the setup of any case typically filled at least one MedCycle bag, but the more complex cases, such as heart and orthopedic cases, filled at least two MedCycle bags before the case even began.

Because additional acceptable non-patient contact packaging and materials were generated during the case, circulating nurses (i.e., the auxiliary support nurses during operations) requested per mission from the MedCycle team and department head to continue to fill the MedCycle bag during the surgical procedure. They received permission to do so as long as they were willing to be responsible for materials entering the toter. No contamination occurred as a result of the procedural change.

At the end of each case, employees sealed all MedCycle bags and carried them to one of two large blue gondolas that had been labeled MedCycle Depot. When the MedCycle Depot was full, a housekeeper transported the gondola to a holding area in another part of the hospital, and an empty gondola stored there was taken back. Five gondolas were in circulation during the pilot phase.

During the week, the hospital filled approximately three gondolas daily; it typically generated a much smaller amount on the weekend, depending on the emergency surgeries conducted.

The sorting took place in a basement room in a building adjacent to the hospital. In the basement, researchers weighed blue bags from the gondola in an outer room before bringing them into an Inner room for sorting. They then sorted the contents into 21 categories. When a category bag filled, researchers weighed it, recorded the weight, and moved the bag into a third room for storage

Study Results

According to early visual estimates from the management staff of surgical services, the project resulted in an 80% reduction in the MSW wastestream during May. Management also estimated that more than 75% of the staff participated in the program on a regular basis during the month. Ultimately, the hospital collected 802 bags of MedCycle materials from 982 cases during May, which suggests less than one bag per case. However, because the program was voluntary, some instances may have arisen when the surgical services staff chose not to participate in the MedCycle project. In addition, OR staff were responsible for controlling contamination. Any bag suspected of contamination was discarded by OR staff as either MSW or red bag, depending on the contents.

The material diverted by MedCycle totaled 3,565 lbs, or 1.75 tons. The compositional breakdown of the material is shown in Exhibit 1.

Segregating the MedCycle materials into more specific components was initially hampered, particularly in the plastics category, by an inability on the part of the researchers to identify the plastics by resin types. Only one type of packaging, the sodium and sterile water irrigation solution bottles, was labeled according to the Society for Plastics Industry (SPI) coding system. Contacting vendors to assist in the identification process of these products and packaging is a task of great magnitude because a medical facility may purchase medical supplies from more than 100 vendors. However, the identification process has begun, and several vendors have been helpful in identifying the resins and components of their packaging.

Until this information is complete, the composition of the MedCycle material stream has been divided according to the categories shown in Exhibit 1. Some of these categories were added after several days of sorting because of a prevalence of the material and because the researchers felt a recycling or reuse market would be available for the material as a single item.

Researchers also separated out some materials (e.g., some of the rigid plastic trays) because of their reuse potential. However, until they gather more information from the vendors and plastics engineers, most plastics fall into one of two categories: rigid plastics or flexible plastics (e.g., films and plastic bags).

In the entire 3,565 lbs of materials, sorters discovered only a few instances of contamination: five unused needles (unopened in their original rigid plastic protective packaging); two polypropylene solution bottles still partially filled with sterile water; a few pharmaceuticals; and a HDPE gallon jug container one quarter filled with betadine solution.

Conclusions and Observations

The pilot MedCycle Project conducted at MCHV clearly demonstrated the following points:

• With proper training and internal marketing, hospital personnel would enthusiastically and competently sort prepatient contact materials, resulting in an uncontaminated resource stream.
• Such clean material represented approximately 80% of what had previously been labeled MSW generated in the surgical services wing of MCHV.
• Numerous opportunities existed for reuse of materials, packaging reduction, and recycling.
• Cost-effective and safe means for separating the waste into usable categories exist.
• Recycling markets are interested in the materials.
• Manufacturers are interested in changing packaging practices and materials to accommodate hospital recycling and waste reduction programs.
• Hospitals are interested in making serious efforts to reduce waste as a cost containment measure as well as part of an overall commitment to environmental quality. Researchers also came to the following conclusions:
• MedCycle generated greater interest and participation than standard hospital recycling.
• MedCycle heightened awareness of waste reduction options.
• The pilot project generated tremendous publicity for MCHV.
• Because of the MedCycle separation process, the hospital staff paid greater attention to other standard waste segregation procedures.
• Anecdotal reports from staff indicated that staff had positive feelings about incorporating environmental responsibility into clinical practice.

The pilot separation offered some unexpected findings beyond the successful recycling system. The private laundry service contracting with MCHV noticed a considerable decrease in the quantity of waste items mixed in with the soiled linen they were receiving from the hospital in May. According to the general manager of the linen service, "the probability of our employee and equipment exposure to sharps and other foreign matter [is diminished by] any kind of reduction in this waste flow."

In addition, the purchasing director for MCHV noted that many of the items in the Medcycle sample still sported yellow stickers, which should have been removed at the time the supply was used and attached to the patient's card so that the hospital could accurately charge the patient for supplies used. Thus, MedCycle inadvertently uncovered a problem with an existing system that if addressed may save the hospital thousands of dollars. During the last few days of May, surgical services staff were given MedCycle evaluation forms to complete. Evaluations showed 100% support for the project; in fact, many respondents were disappointed that the MedCycle toters were going to be removed. Staff members felt ownership for the project and were grateful for the opportunity to divert such a significant amount of material from the wastestream.

Next Steps

MedCycle offers a new strategy in managing certain components of medical facility wastes. The pilot project answered a few questions and raised many more:

• What is the compositional breakdown of the non-patient contact materials in a medical facility's wastestream?
• What is the likelihood of standardizing the resins used in packaging and labeling the materials accordingly?
• Are there specific supplies and equipment where reusables are again becoming cost-effective and the environmentally preferred system over disposables?
• What end-use opportunities exist within the medical setting to close the loop with some of these materials?
• How transferable is the MedCycle system to other medical facilities around the country?
• Is economics always the determining factor for purchasing decision-making in the hospital setting?

A roadblock encountered in this study was the public perception concerning the safety of handling waste generated in a medical facility setting. Recycling markets and end-users were initially reluctant to work with the material because they feared health risks from biological contamination. Once they were educated about the separation process their fears diminished, but more work and documentation about infection control is necessary to truly open up marketing opportunities for these materials.

There is a lack of information on the compositional breakdown of the diverse wastestream generated in the medical realm. There is also a very limited understanding of the potential for separating wastestreams before the point of contamination, thereby segregating the infectious and potentially infectious components from the materials that are similar in form and content to materials found in any other manufacturing, retail, or service setting.

Much of the material collected through the MedCycle program was still in storage four months after the pilot project was completed. The sorting and identification process took time, but the materials were then prepared for recycling markets. Markets have been located for the polypropylene, polystyrene, high-density polyethylene, white paper, and corrugated cardboard. The virgin boxboard and brown boxboard became part of a pilot community compost project. Discussions are being held with hydropulpers concerning the composite materials. The rigid plastics will be added to existing plastics streams as resins are identified. The ReStore is handling plastic trays, reusable bags, and some of the polypropylene solution bottles. Reusable medical supplies are being sent to Schweitzer Hospital in Haiti. Blue wraps have been given to Vermont and New York veterinarians for reuse, to local schools and daycare centers, and to area painters.

As a result of this project, MCHV has established a waste reduction specialist position. In addition, MCHV has made a commitment to instituting a permanent MedCycle system in the near future, possibly targeting the collection to specific components identified through the pilot, such as the KimGuard blue wraps, the polypropylene solution bottles, rigid plastics, and a few other high-volume materials. Miniversions of the collection program will be implemented in the emergency room, labor and delivery, and radiology. Upon completion of the evaluation, some form of MedCycle will continue in the surgical services wing.

Connie Leach is a consultant with CGH Environmental Strategies, Inc. Hollie Shaner is a waste reduction specialist at Medical Center Hospital of Vermont and principal of CGH Environmental Strategies, Inc., both located in Burlington, VT. Leach and Shaner began and were the principal researchers for the Medcycle pilot project at MCHV. MedCycle is a registered tradename of CGH Environmental Strategies Inc.

Top | Home