E. Todd Wheeler Health Fellowship - 2019-2020 - Chris Koss

E. Todd Wheeler Health Fellowship

2019–2020 Yearbook

Christopher Koss Los Angeles Studio

If I were to influence healing through design I'd like to change how we, as a society and a practice, perceive and approach mental health, as I believe it is just as important as any other field of healthcare. In order to achieve this I would need to have a better understanding of how the best medical professionals in the world are diagnosing and treating patients with mental illness, and additionally I would love to explore how we as architects can design an atmosphere within a healthcare facility that respects the numerous mental health issues that exist in our world today.

It seems to me that healthcare architecture has improved significantly in just about every sector other than mental healthcare. Understanding and treating mental illness in our society begins with how the medical field, and design of their facilities, addresses this incredibly important aspect of our lives.

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Education

Research

Master of Architecture, 2019

Acoustical Remediation in the Operating

University of Kansas

Room: Changing How We Hear in the Operating Room

Reducing Waste and Optimizing Supply Expenditures in the Operating Room

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01 Acoustical Remediation in the Operating Room: Changing how we hear the OR Christopher Koss, christopher.koss@perkinswill.com

Abstract

1.0 Introduction

In a revolutionary time of medicine, it seems that every component of the hospital has

Since the 1960s, noise levels in healthcare settings have

cutting-edge technologies and the addition of necessary

changed for the better. While the rest of the hospital experience has improved, operating

steadily increased, and noise is currently a significant source

equipment, and even nonoperative necessary noise

rooms (ORs), being the most stressful environment in a hospital, have only continued to

of dissatisfaction among both hospital staff and patients.

like music.

Not unlike other spaces in a hospital, operating rooms

What was once a quiet, albeit less advanced environment

A literature review was conducted to gather evidence of what the acoustic state of ORs

have experienced an increase in environmental noise and

has evolved into a space with noise levels comparable to a

were, why they were so loud, why this is problematic, and to help arrive at some potential

have become increasingly louder with the introduction of

military jet take-off.

grow louder over the last fifty years.

resolutions. Noise within operating rooms are typically generated by both staff-related and non-staff related activities. Exposure to these high noise levels have detrimental effects on both the patient and the physicians in the space. Adjustments can be made to both operational processes and built environments to remediate operation room acoustics such as anesthesia induction rooms, HVAC sound attenuators, acoustic baffles, passive & active noise cancellation headphones and speakers, haptic feedback alarm technology, as well as staff behavior modifications.

It is critical to the wellbeing of those inhabiting an operating room for any amount of time that the acoustical quality of the space be a driving factor to enable better focus and in reducing errors through appropriate design and management of the operating environment. The conclusion of this study is that there are several components in the OR that can be improved to better nurture an environment conducive to successful operations.

Figure 1: The illustration above shows intensities of different noises relative to the intensities of the maximum recommended noise levels and the actual perceived noise levels experienced during a surgical procedure using the A-weighted decibel scale (dB(A)), which is used to measure average noise intensities. Noise levels commonly experienced in a modern operating room frequently exceed the limits for a hospital workplace, according to the World Health Organization (WHO) and the Environmental Protection Agency (EPA) noise standards1, 2.

Keywords: operating room, acoustical remediation, physician wellbeing, patient wellbeing, healthcare design

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Acoustical remediation in the operating room

2.0 Methodology

3.0 Global OR acoustical standards

What began as several google searches investigating the largest volume

In hospitals as close as Johns Hopkins Hospital in Baltimore,

of complaints between both physicians and patients in a hospital resulted

Maryland and as far as the Hamadan University-affiliated

in a series of scholarly literature reviews on published case studies that

hospital in Semnan, Iran, hospital operating rooms failed the

demonstrated the issue of operating room noise levels. Once a US report

international noise standards across the globe.

proved to be a strong reference for excessive noise levels in domestic ORs, an international investigation of operating room levels found several studies relaying the same message: every country investigated had hospital noise levels exceeding standards set by the EPA, WHO, and their local acoustical standards.

After showcasing each of the studies consistently alarming results, an initial question of noise sources needed answering. Another literature review found several studies specifically conducted to measure sound levels emitted from all relevant intraoperative sound sources: HVAC, music, alarms from equipment, and staff communication, with each source louder than the last, respectively.

After identifying the noise sources and their typical contributions to the noisy operating environment, the next step sought to discover the health effects of elevated OR noise on everyone occupying the surgical space.

The next literature review discovered that exposure to documented OR noise levels had a variety of negative effects on both the wellbeing of the physicians and patients in the space and had negative effects on both intraoperative and postoperative patient outcomes.

A final literature review was conducted to find solutions for remediating OR noise, finding solutions in both the built environment as well as technological applications for ameliorating acoustics in the operating environment.

Figure 2: The illustration above shows the different countries who have conducted studies measuring operating room noise levels and published their results to the public. Each country’s published results exhibit noise levels exceeding guidelines established by both international guidelines (WHO and EPA) as well as their local hospital acoustic standards.

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3.1 Case Study at Johns Hopkins Hospital in Baltimore, MD

Clear communication is found between 250-4000 Hz, and OR noise the frequencies which were typically present during the recorded surgeries coincided within that same frequency

In 2006, a noise level study within operating rooms was

range, which, combined with high sustained levels, raised

conducted at Johns Hopkins University Hospital in Baltimore,

concern regarding clear vocal communication.

MD.3 In total, 38 rooms were measured in three separate

3.2 Case Study in Iran

during their surgeries at 70-85 dB(A), which was well above

it was discovered that noise pollution levels within the

cariology were observed and noise levels measured from

speaking levels of roughly 55-65 dB(A), medical staff either

operating room during surgical procedures exceeded all

the moment of the first incision to the removal of the patient

maintained their vocal volume, risking miscommunication,

recommended standards.

from the OR, which may be considered significant since

or raised their voices to ensure good communication. This

this ignored some of the loudest moments of an operation

environmental and operational condition ran the risk of

-anesthesia induction and emergence, which consistently

compromised communication clarity. While this study was

range between 45 and 80dB(A).

not conducted to examine specific sources of noise pollution,

to average between 55 and 70 dB(A) with significant sound

standards. The researchers concluded that work ought to be

peaks in the 100s of decibels during surgical procedures.

done to reduce the sustained levels of noise in ORs.

Potential hearing loss and clear speech disruption were the two major concerns raised by high OR sound pressure levels.

hammering and device alarms with an intensity of about

procedures.4 Comparing collecting data with both

as plastic surgery, neurology, orthopedics, urology and

ORs exceed both the WHO’s guidelines and the EPA’s noise

pollution with a maximum intensity of 93 dB(A), followed by

hospitals to measure sound levels during different surgical Iranian’s national standards and international standards,

it successfully confirmed suspicions that noise levels in

The noise of falling objects was the largest source of noise

Iran in five separate Hamadan University-affiliated

Given the sustained sound pressure levels in the ORs

Sound pressure levels at Johns Hopkins Hospital were found

sound were found to be 94 dB(A) and 55 dB(A), respectively.

In 2016, a cross-sectional study was conducted in Semnan,

buildings: Weinberg, Meyer, and Blalock. Operations such

3

During all operations, the highest and lowest levels of

78 dB(A). Illustrated by figure 4, most procedures produced noise levels exceeding local Iranian standards as well as international standards.

While procedural and equipment related noises consistently produced the highest volume of sound, staff communication

According to the findings of this study, the main sources of

was consistently ranked within the top three sources of

noise in operating rooms at the Besat, Fatemieh, Shahid

operating room noise. As medical equipment obsolescence

Beheshti, Farshchian, and Ekbatan hospitals were the “noise

has remained an ever-fluctuating variable, in the past it

of trolley movement in the corridor” at about 70dB; “noise

has been simply too difficult to design for the acoustical

of the autoclave system” at around 67 dB; “autoclave noise

remediation of specific medical equipment devices. With

during dehydration” at 71dB; and finally “trolley movement

medical equipment beeps, alarms, and general sounds

noise in corridors” at 71dB.4 Orthopedic procedures were

being so difficult to predict, controlling the noise levels

found to have the highest noise levels and heart surgery to

of staff communication was the more reasonable and

have the lowest level noise levels.

predictable solution.

“The majority of the surgical divisions … experienced sound

Figure 3: The charts above demonstrate noise levels measured in John Hopkins Hospital operating rooms. The bar graph on the left illustrates an array of procedures exceeding the standards and guidelines outline by the Environmental Protection Agency (EPA) and World Health Organization (WHO). The line graph on the right maps the average background noise levels relative to frequency of the three measured operating rooms. It is important to note that, across the three ORs, the lower frequencies add the most amount of noise to the space.

pressure peaks of at least 110 dB and levels over 120 dB were not uncommon. It is certainly possible that these very high sound pressure peaks could negatively impact the hearing of surgical staff over time.”

–Jonathan Kracht, lead researcher 32

Figure 4: The charts above demonstrate noise levels measured in Hamadan University-affiliated hospital operating rooms. The bar graph on the left illustrates an array of procedures, most of which exceed the standards and guidelines outline by the EPA, WHO, and local Iranian National Noise Standards. The chart on the right illustrates the three greatest sources of noise levels in each OR and whether they exceed the Iranian National Noise standard of 65 dB(A).

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3.3 Case Study in China

time of this study, there were no published results showing OR noise levels compliant with the guidelines established by

Between August 2015 and March 2016, a comprehensive

4.0 OR Noise Sources

the WHO, EPA, or Chinese national standards.

After reviewing several instances where operating room noise

care hospital with a description of its operating rooms’

There was significant variation in noise levels by category

levels unanimously exceeded standards set by the EPA, WHO,

noise levels.5 It was accomplished by monitoring 23 ORs

of surgery with ophthalmic surgery having higher noise

and measuring their noise levels with dosimeters. This

levels than otolaryngologic and general surgeries. However,

investigation was the first time dosimeters were used to

based on discussions with the OR staff, the perceived

monitor noise levels in ORs. These dosimeters were unique

noise levels observed were narrowly varied across the ORs.

with real-time monitoring metrics, which provided more

Based on the observations of those conducting the study,

accurate measurements of the noise levels occurring in ORs

staff conversation and activities were major sources of OR

than tools used in previous studies.

noise. They also concluded that noise originated from the

study was conducted to provide a Chinese tertiary

and local authorities, it was then discovered that the sources of OR noise were from equipment and alarms, staff related noise, music, and HVAC systems.

Figure 6: Greatest Sources of Noise in the Operating Room.

Duke Medicine Pavilion, Durham, North Carolina (Image Credit: Robert Benson)

functioning laminar airflow system and medical equipment,

The study aimed to discover noise level deviation from

with anesthetic monitors generating many distracting

international and local standards and additionally

alarms and alerts, which occurred multiple times in only a

categorize different noise levels by category of surgery. Like

few minutes. Surgical instruments generated sudden and

the Iranian study, the results show OR noise levels exceeding

distinct sounds that often left lasting resonating noise for

those set by both local and international standards.

several seconds. While this study did not aim to observe the

Regulations in China asserted that OR noise levels should

noise levels of specific instruments and various noise sources

not exceed 50 dB(A), however results from this study showed

within ORs, it served as further proof that operating room

100% of the measurements exceeding standards set by the

noise levels commonly exceeded the recommended levels of

WHO, EPA, and Chinese guidelines. The noise level in the ORs

both local and international standards and guidelines.

ranged between 59.2 and 72.3 dB(A). Additionally, at the

“Excessive noise may also have detrimental effects on staff health. Evidence suggests that high noise levels (greater than 55 dB(A)) are associated with adverse events, such as hypertension, fatigue, annoyance, burn-out, stress and

Figure 5: The charts above depict measured noise levels of various operations in a tertiary care hospital operating room. The bar graph on the left illustrates an array of procedures, all of which exceed the standards and guidelines outline by the EPA, WHO, and local Chinese National Noise Standards. The bar graph on the right illustrates the frequency of how often noise levels were measured at certain dB(A) levels. In this case, every measured noise level exceeded all three noise standards.

headaches. All values measured in the present study were greater than 55 dB(A), which suggests that excessive noise may pose a potential health risk to OR staff.”

–Xiaoxiao Wang, lead researcher 34

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Acoustical remediation in the operating room

4.1 Equipment Alarms From operating tables to surgical instruments and monitors,

OR remains controversial. One study discovered that more

every instrumental component of an operation added noise

than 60% of OR physicians listen to music while performing

to the operating environment. Equipment related noises

surgery, and about 50% of them preferred listening at

included anesthesia equipment and alarms, suction devices,

medium to high levels, which added as much as 87 dB(A) or

as well as surgical instruments like drills, cautery devices,

more to the OR environment.7

and dissection tools. Monitors in a modern operating room had many alerts and alarms commonly cited as the most distracting noises, providing extraneous, ambiguous, and

4.3.1 The argument against music in the OR:

even false information. In one cardiac surgery study, there

Objectively, music added much more noise to the OR

was an average of 359 ± 159 alarms, 80% of which had no

as it was usually played at a level loud enough to mask

relevant significance to the success of the procedure. In a

the space’s ambient noise, which decreased physicians’

contradictory fashion, operating room staff often became

focus and ability to communicate with one another. One

desensitized to these alarms and even sometimes turned

study found that “26% of anesthesiologists feel that music

them off, which posed a potential risk to the patient’s

reduced their vigilance and impaired their communication

health. Equipment noises were measured as high as 120

with other staff, and 51% felt that music was distracting

dB and were caused by the clashing and clanging of metal

when a problem was encountered. 78% felt that music

instruments being dropped, equipment movement, electric

that they disliked was the most distracting”.6 On the other

and air-powered instruments, hammers, monitors, and

hand, a following study failed to identify any adverse

alarms. An increasing number of technical equipment within

effects of self-selected or classical music on psychomotor

operating rooms resulted in significantly higher noise levels.

tests performed by resident anesthesiologists.⁶ Other

The more complex the procedure, the more critical it was for

studies reported a “detrimental effect of music on

team members to understand each other in order to perform

surgical performance, especially among less experienced

and manage demanding tasks, which was challenging in

surgeons. In one randomized controlled trial of novice

such a noisy environment.

surgeons, music during training procedures was shown

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to cause distraction and impaired performance.⁶ One study tested the effect of common operating room noise 4.2 Staff-related noise

on 15 surgeons’ auditory ability by way of the “Speech

Between entering and exiting the room, both procedure-

In Noise Test”, which grades one’s ability to accurately

related and procedure-nonrelated conversations, and

understand speech with background noise.⁷ They used

smartphone usage, staff themselves added a variety of

four different conditions: quiet, filtered noise, filtered noise

sources of noise to the OR space. Studies have shown that

and operating room noise, and finally filtered noise with

staff-related activities are the most persistent source of

operating room noise and the addition of music. They found

noise production during procedures, measured at levels as

that the surgeons’ performance in the quiet setting was

high as 78 dB(A).6

significantly better than in the noisy setting and the noisy plus music setting, proving that little noise was better than noise with music. The researchers concluded that reducing

4.3 Music

noise levels in operating rooms was essential in avoiding

While there were many unavoidable contributing factors to

miscommunication.⁷

noise levels in ORs necessary for the success of the operation, one of the greatest avoidable noise contributing factors was music. Music, being a special type of noise, can soothe the mind in stressful situations, but the music’s presence in the

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Figure 7: The presence of music in the operating room remains to be a point of contention for operating room staff across the country.

(Image Credit: VectorPouch)

by 62-72% of surgeons and physicians in operating rooms to

task completion time and hand distance traveled was

help drown out the background cacophony with something

significantly shorter when participants were listening to

they enjoy hearing, however the addition of this music

Jamaican or hip-hop music as opposed to no music at all.⁹

added up to an additional 87 dB in an already tumultuous

Another study, which evaluated how physicians and nurses

environment.⁸

responded to music while working in the OR with the influence of music, found that 63% found music to have a beneficial effect on the communication between staff, and

4.3.2 The argument for music in the OR:

77% reported music to have a calming effect, which made

On the other hand, there were sources that showed benefit

them more efficient.10

to the presence of music in the OR. In fact, one controlled clinical trial suggested that music decreased stress levels

A separate study concluded that due to the high level

and improved the efficiency of surgeons and operating

of concentration required for surgery surgeons could

room staff.⁹ Ten medical students volunteered for the study

cognitively ‘‘block out’’ both noise and music.11 These results

by completing relatively simple simulated surgical tasks.

supported the hypothesis that music was nonproblematic

While performing the tasks, each participant was instructed

as only 2 of 15 participants found music to be distracting in

to listen to jazz, classical, hip-hop, and Jamaican styles of

some intraoperative situations.

Additionally, many anesthesiologists also felt that music

music in order to measure how their completion time and

could impede the ease and accuracy of completing their

hand travel distance varied per each participant based

duties. According to a report published by the British

upon the type of music. To control the study, the volunteers

Medical Journal (BMJ), music has become popularly used

were also subjected to silence. The study concluded that

Additionally, patients not undergoing general anesthesia were also affected by music in the operating room. In fact, music had a sedative and anxiolytic, or anxiety reducing,

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Acoustical remediation in the operating room

5.0 OR Noise is Problematic

effect on patients before, during and after their surgery.

Additionally, with the addition of their choice of music, surgeons reported fewer feelings of anger, hostility, fatigue

Ample evidence proved that noise levels in operating

Noise and particularly unexpected, high-intensity noise,

and anxiety while performing their tasks. This beneficial

rooms universally exceeds the standards of both local and

was a scientifically proven biological stressor that produced

effect seemed independently effective regardless of

international standards. For a multitude of reasons, these

startled reactions, activated fight or flight responses, and

whether ambient OR noise was also being blocked out.

standards were typically disregarded because organizations

stressed both autonomic and endocrine systems causing

Through a variety of tests of those experience OR noise,

either ignored or were unaware of a loud operating room’s

a variety of negative health effects. Exposure to such

it was determined that the presence of music decreased

ramifications.

occupational noise levels even as low as 75 dB(A) had both

frustration, confusion, fatigue, and anxiety.10

short and long-term adverse health effects.⁶ Predisposing

Entities such as the World Health Organization, the

Music’s role in the operating room was found beneficial for

Environmental Protection Agency, the Occupational Safety

a surgeon’s mood and ability and the conscious patient’s

& Health Administration, and the National Institute for

comfort. Ultimately, better mood states were attained by

Occupational Safety & Health set these noise standards

allowing music in the OR and proved for better surgical

at their respective limits for the purpose of protecting the

performance, better patient care, and could possibly

health of those exposed to these loud environments for

improve and lengthen surgeons’ careers.10

varying periods of time. All the while, conditions proved

factors such as age, medical conditions, medications, and an individual’s lifetime cumulative noise exposure each influenced the extent of how an individual physiologically responded to OR noise. As more and more studies proved the noise levels in operating rooms to exceed safe levels, it was important to understand the consequences.

potentially detrimental to the success of the operation, the patient’s health, and even the wellbeing of physicians

4.4 HVAC systems

working in this environment.

In order to comply with state-specific codes and hygiene requirements dealing with indoor air quality, most operating rooms’ mechanical systems needed to perform a minimum of 20 air changes per hour (ACH).12 However, most hospitals operated from 25 ACH to as many as 40 ACH. Each time these air changes were initiated, anywhere between 15 and 84 dB(A) of noise was added to the space (ACH).

Figure 8: Operating Rooms are loud, but why should we care?

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Acoustical remediation in the operating room

5.1 Adverse effects of OR noise on physicians

5.1.3 Negative Physiological Effects Excessive noise had detrimental effects on physicians’

5.1.1 Negative operational effects

physiological health. Evidence suggested that chronic

The most serious effect of excessive noise in the operating

exposure to elevated noise levels (greater than 55 dB(A))

room was impaired reliable communication. Of all staff-

was associated with fatigue, hypertension, fatigue, stress,

related contributors to medical errors, miscommunication

headaches, and increased burn-out.14

was found to be the most frequent.⁷ Vital communication between technicians, surgeons, nurses, and anesthesia

Growing evidence exhibited more cases of noise-induced

providers was often obstructed by high noise levels.⁷

hearing loss in nurses and surgeons who consistently

Additionally, staff performance, such as the frequency of

worked in operating rooms. One study found that 66%

operating room turnaround, was directly related to impaired

of anesthesiologists performed much more poorly on

communication.13 Typically, non-verbal communication

hearing tests, and individuals younger than 55 years old

and lip reading were used to improve understanding when

had significantly worse auditory acuity than the general

hearing had become impaired, however, in the OR visual

population.15

cues were blocked by surgical masks worn during surgery.⁷

In general, the physiological effects of noise resulted in

Unnecessary background conversations interfered with

multiple involuntary stress responses from the human body.

operative performance to a greater extent than other types

When a sound stress signal was received, several different

of noise, as it was usually distracting or lead to an additional

areas of the brain reacted defensively, which included the

masking effect. It was found that for 90% accuracy of speech

secretion of adrenaline, noradrenaline, and catecholamine -

understanding, speech had to be 10-15 decibels above

all associated with a short-term boost in energy resulting in

ambient noise levels.⁷ Therefore staff raised their voices by

long term exhaustion.16

necessity which only led to greater OR noise levels.

Brief, intense noise exposure has been linked to an increase

Sudden unexpected noise as little as 30dB(A) above

in blood pressure, heart rate, and other cardiological

the background level caused a ‘startle reaction’ among

abnormalities, while chronic noise exposure has been

operating room staff, which reduced vigilance and impaired

associated with a greater prevalence of various forms

concentration during critical periods of surgery. Additionally,

of cardiovascular diseases like hypertension, angina

surgeon’s performance of complex tasks may have been

pectoris, myocardial infraction, and even in extreme cases

adversely affected by noises even at lower levels if they were

premature death.⁶

unpredictable and uncontrollable.

5.2 Adverse health effects of OR noise on patients

5.1.2 Negative Cognitive Effects Engaging in constant, complex mental activity, surgeons,

5.2.1 Patient surgical-site infections

nurses, and anesthetists consistently required high levels of

A surgical-site infection (SSI) is an infection that occurs

concentration. Studies testing short-term memory recorded

after surgery in the part of the body where the surgery took

worsening in anesthetists’ mental efficiencies after exposure

place. They could range anywhere from trivial skin-related

to prerecorded OR noise.⁵

infections to more serious infections under the skin that might affect vital body organs. While the CDC provided

Noise, even at moderate intensities, hindered psycho-

guidelines and tools to help fight SSI occurrences, there may

motor, memory, attention, and intellectual functions. When

have been an additional missing variable contributing to

a physician was engaged in complex mental performance

SSIs. That missing variable may have been OR noise levels.

that required heavy working memory and multitasking,

Figure 9: The line chart above compares the average intraoperative sound levels above baselines for patients with and without surgical-site infection in respect to the duration of the procedure. The findings suggest a positive correlation between OR noise and SSIs.

evidence (Figure 9) that OR noise levels and SSIs might

staff and negatively impacted surgeon focus. Given that

have a positive correlative relationship.16 This effectively

an operating room staff brought a variety of experience

meant that the louder the OR, the higher the chance of

levels to the operating table, a case could be made that

a surgical-site infection. From a high level perspective,

less experienced operating team members would be more

the study’s results suggested that higher OR sound levels

negatively impacted by noise than more experienced

increased the probability of a patient contracting an SSI,

members, as more experienced surgeons block out noise

which could cause further complications and increase their

easier than their younger peers. Ultimately, there was a

need for care. Obviously, there were countless variables

positive correlation between noise and SSIs. Given this

that contributed to the success or failure of an operation

relationship, OR noise has been accepted as a probable

such as surgeon experience, clear communication, surgeon

cause for more difficult operations, which often lead to a

performance was especially hindered while an individual

Several studies discovered a relationship between noise

skill, and even simple task execution. However, along with

longer operation, prolonging patient exposure to harmful

was exposed to irrelevant background conversations.⁵

in the operating room and surgical-site infections. For

hindering general comfort levels, high noise levels in ORs

airborne microorganisms, and more cases of surgical-

example, one 2008 study showed statistically significant

contributed to more difficult communication between

site infections.

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Acoustical remediation in the operating room

6.0 OR Solutions for sound amelioration

5.2.2 Negative physiological effects

Additionally, a 2018 study of surgeon

Noise in the operating room also posed

mental stress levels demonstrated a direct

a threat to the wellbeing of anesthetized

relationship between acute mental stress

In order to provide a quieter environment for physicians and

6.1.2 Sanitary acoustic baffles

patients in both the short and long term.

and surgical performance by utilizing a

patients, there were several solutions found to be beneficial

Within the scope of addressing the built environment’s

Unlike a conscious person in a noisy

technology typically designed for athletes

when incorporated in various stages of the operating room

design to remediate noise levels in operating rooms, the

environment, anesthetized patients were

to measure heartbeat-triggering electrical

design process.

introduction of sound-absorbent ceiling and wall panels

found to be particularly vulnerable to

impulses providing precise physiological

acoustic trauma. Anesthetic drugs weaken

data for workouts.17 Worn by surgeons

the stapedius muscle, which contracts and

to measure a variety of surgeries, the

protects the cochlea when exposed to loud

technology was used to time stamp and

sounds, and provided an point of concern

correlate a relationship between surgeon’s

for patient wellbeing.6 When the protection

surgical performance and stress levels. It

given by the stapedius muscle was

was found that when surgeons were under

compromised, even short spikes in sound

acute mental stress caused by a negative

pressure levels harmed the most sensitive

thought or a sudden loud noise, they

part of the inner ear, the cochlea, which was

made up to 66% more mistakes resulting

responsible for hearing.

in complications such as bleedings, burns,

is a topic of contention. The Healthcare Infection Control Practices Advisory Committee of the Centers for Disease 6.1 Built environment solutions

Control and Prevention provided standards for healthcare

6.1.1 Anesthesia induction rooms

facilities infection control, and had a section that focused on OR routine cleaning of both horizontal and vertical surfaces,

Because of their constant presence in the OR, their proximity to the noisiest equipment, and the fact that the

which is followed by the Facilities Guidelines Institute (FGI).19

largest OR sound spikes occurred during their involvement,

FGI’s 2018 Guidelines for Design and Construction of

anesthesiologists were especially negatively affected by a

Healthcare Facilities, which is the authoritative guide for

noisy operating room.⁶ In fact, 84% of anesthesiologists self-

healthcare design standards in the US, called for operating

reported that their performance was negatively impacted

rooms to have monolithic ceilings and walls free of fissures

by loud OR noise levels.⁶

or crevices. However, there are manufacturers who have

provided further evidence of negative

One solution already utilized in hospitals today is the

created cleanable sound absorbent panels that have

5.2.3 Higher risk of critical mistakes

OR noise effects on surgical success and

presence of an anesthesia induction room, which in practice

In the operating room it is imperative that

ultimately patient outcomes. The study

was referred to as Non-Operating Room Anesthesia

each operating team member wore a

established a direct relationship between

(NORA).18 NORA was effectively defined as administering

surgical mask to prevent patient surgical-

OR stressors and surgical mistakes, which

anesthesia outside the operating room, which was

site infections but doing so also removed

would further prove a relationship between

typically done to patients undergoing general anesthesia.

the ability for lip-reading. Physicians are

high noise levels and poorer surgical

Including quicker OR turnaround times and a less stressful

forced to depend on their own auditory

performance.

patient experience, NORA removed one of the noisiest

and torn tissues. These measured incidents

perception of what is being asked of them.

This circumstance leads to greater risk for indistinguishable differences between two similarly pronounced words, such as “fifteen milliliters” and “fifty milliliters”.

Minimal speech discrepancies can lead to a multitude of adverse health effects when misinterpreted. Every bit of

Ultimately, a quieter environment promoted better communication between physicians and safe task completion. Providing a space best suited for clear physician communication and surgeon focus would coincide with providing a proper space for surgery.

been utilized in surface-applied instances and would be appropriate for an OR application.19 These panels have proven their durability, having been “battle tested”, by resisting damage from typical operational sanitization chemicals without any effect. They also could be designed to minimize fissures and crevices, which would comply with FGI’s guidelines.

procedures during an operation from the operating room.

By practicing nonoperating room anesthesia, the impacts of auditory stress on both the patient and anesthesiologists would become isolated from extraneous OR noise, and

Figure 10:This graphic is an example of the adjacent relationship between the OR and a non-operating room anesthesia room.

ultimately save the OR from one major contributor of noise pollution. From an operational standpoint utilizing a NORA would necessitate extra anesthesiologist training, however

information communicated was critical for

the overall benefits of a quieter OR

the operation’s success, and any miscues

outweighed upfront additional training,

created a potential for seriously harmful

and as a result have become progressively

and even lethal conclusions.

more popular.

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6.1.3 HVAC sound attenuators

were at containing and transporting air.

Mechanical ventilation was a necessity for

The best sound attenuation results were

producing positive pressure in the patient

produced by using metal ducts coupled

area to reduce the chances of surgical-

with sound-absorbent baffles. These metal

site infections, however the operation of

ducts reduced perceived noise levels when

ventilation added as much as 84 dB(A) to

coupled with sound-absorbent mineral

the operating room.⁶ The necessary protective positive pressure from mechanical ventilation caused significant sound energy, which followed a path from its source to where it was perceived in the room. The sound energy that reached the end supply grille was perceived as sound.

6.2 Technological solutions

filtered pertinent audio signals through individual audio channels for necessary team members. Additionally, they

6.2.1 The ‘silent operating theatre optimization

placed transmittable microphones next to each monitor

system’ (SOTOS)

and technical device alarm programmed to only alert

A study conducted by Martin G Friedrich for the University

pertinent team members, which was only transmitted to the

Medical Center in Göttingen,

necessary team members. To overshadow any remaining

fiber or fiberglass baffles, which increased

Germany aimed to develop a device that reduces ambient

noise, each team member listened to their choice in music

the amount of contact between the airflow

noise for the OR team without hindering their ability to

at their specified volume, and as soon as a member of the

path and reduced sound energy. Sound

communicate.21 SOTOS utilized headsets with microphones

operating team spoke, the music was lowered to the lowest

attenuators acted like acoustic baffles

issued to all members of the operating team that would filter

perceptible volume. By isolating team member exposure

inside HVAC ductwork, they reduced the

irrelevant noise and transmit only operative, individually

to necessary alerts and communication while canceling

perceived sound in the duct space by

pertinent information.

irrelevant noise and providing desired music, SOTOS

disrupting airflow while maintaining laminar

First, they found headsets with active noise cancelling and

provided the potential to create a much quieter perceived

20

flow levels necessary to protect the patient from surgical-site infections.

operating room environment. The initial study tested 21

microphones for interactive communication. After finding

cardiac surgeon teams. No team members experienced

four different types of suitable headsets, they calibrated

In order to remedy this acoustical burden,

technical or communication issues, and 100% of surgeons

the microphones to capture only the physician’s voice

HVAC duct sound attenuators have been

and perfusionists, 100% of nurses, and 91% of anesthetists

by utilizing noise gates that only captured vocal audio

implemented during the construction phase

gave a positive review.

from the wearer’s voice. They then designed an internal

in order to dial back mechanical ventilation

routing system involving a communication matrix, which

noise production during operation. Metal ducts were just as effective at containing and transporting sound energy as they

Figure 12: This graphic shows the audible relationship between the operating room teams during an operation. The squares indicate the relationship of which parties can hear each other. For example, the surgeon (S) can be heard by the entire surgical team (A1, A2, P), the head anesthesiologist (A), and the head nurse (N) while the surgeon cannot hear the anesthesiologist’s assistant (AA) nor the assistant nurse (N2).

Figure 11: This graphic is an example of how a sound attenuator works. Sound is generated at the source of mechanical ventilation and then passes through the attenuator which baffles noise without significant pressure reduction.

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6.2.2 Noise cancelling speakers

6.2.3 Haptic feedback and role-specific alarms

An investigation into the application of sound canceling

For removing excessive alarm and monitor noise from the

speakers being incorporated into the built environment

OR environment, haptic technology was a significantly

was conducted to apply the notion of noise cancellation for

beneficial breakthrough in both medical and dental

predictable noise sources such as mechanical ventilation.

interventions. Haptic perception is the cognitive process of recognizing signals and even objects through sensations of

In early 2019, Bose announced a press release for Bose

touch. This haptic technology utilized embedded software

“QuietComfort Road Noise Control” technology, which

to create sensations by actuators, which are small motors

is a noise cancelling application designed for cars to

that generate vibrations in a wearable application. Typically

cancel the sound of unwanted natural external sound

utilized for immersive virtual reality, haptic feedback

sources.22 By using microphones and signal-processing

technology added a tactile sense to a virtual environment

software, the technology perpetually measures noise-

through torso jackets, arm sleeves, and even a full body

producing vibrations. The technology then determines a

suit. Research has demonstrated the potential for operative

calculated acoustic cancellation frequency which is then

benefits to substituting auditory alarm feedback with

played through the car’s internal speaker system, reducing

haptic feedback in operating environments, and has shown

unwanted noise sources. While this technology was designed

6.3 Other solutions

7.0 Client Takeaways

6.3.1 Modifying staff intraoperative behavior

Patient outcomes and a physician’s wellbeing are among a

A simple, inexpensive, and reliable change for lowering OR

hospital’s highest priorities. A hospital should not house a

noise levels was found in properly educating physicians

space detrimental to the health of its inhabitants. From an

about the benefits of respecting the acoustic environment of

operational standpoint, it has been previously proven that

an OR by removing unnecessary noise from the environment.

patient stays were shortened by a quieter, safer, and more

This was demonstrated by developing a behavior

efficient operating room, which lowered the chance for SSIs

modification program aimed to educate staff members

and intraoperative complications. By minimizing patient

about noise sources, the potential harm of noise pollution,

stays and avoiding complications as a result of a loud OR, the

and solutions such as minimizing irrelevant conversations,

hospital would better serve as a space for healing. Beyond

mindfully leaving and entering the OR, and reducing

that, operating room staff were happier, less stressed, less

smartphone sounds. The positive effectiveness of this

fatigued, and more attentive when the operating room was

training has been demonstrated in intensive care units and

quieter. Ultimately, having a happier, healthier staff made

acute inpatient hospital wards.⁶

for a better OR environment and improved the patient experience.

promise for further implementation.23

for cars, it has the potential for cancelling unnecessary OR noise sources and unwanted noise sources in general.

An operating room application of haptic vibration alarms

6.3.2 A combination of some or all proposed solutions

Soon, noise cancelling speakers could be programmed to

would alleviate the acoustical environment by replacing

All previous options could work independently, albeit some

cancel unwanted, predictable noise sources in an OR like

beeps and alarms with relevant tactile alerts programmed

more effective than the others, however when combined

HVAC, suction devices, and alarms to alleviate the space’s

to alert the wearer’s attention. Vibrations in different areas

they would provide even more effective OR acoustics results.

noise levels. While there was little publicized information

of a haptic glove, sleeve, or suit would allow physicians to

on the noise cancelling speakers and their intent for future

“feel” different types of alerts instead of hearing alerts,

A best-case scenario for ameliorating operating room

applications, Bose has been fine-tuning this revolutionary

which would replace auditory alarms with haptic-based

technology with the intent for an application beyond the car.

technologies and ameliorate OR acoustic conditions.

8.0 Conclusion From improving physician and surgeons’ quality of work to improving patient outcomes and turnover rates, a quieter operating room improved the efficiency and effectiveness of

acoustics would compound multiple solutions and positive

performed operations. Operating room acoustic alterations

outcomes, which would create a much quieter environment

at any point in the design/construction process would greatly

conducive to clear communication, focused attention, and

improve the prevalence of successful operations as well as

the wellbeing of operating room inhabitants.

the wellbeing of surgeons, physicians, and patients.

Achieving a quieter operating room, aligned with today’s operational standards, would require acoustical and mechanical engineers’ presence earlier in the design process to coordinate the benefits of design choices like anesthesia induction rooms, noise cancelling speakers, and HVAC duct sound attenuators. Sanitary acoustic baffles were less dependent on the project’s design and could be implemented at any almost given time. Technological solutions like rolespecific noise cancelling headphones and haptic feedback alarms would require physician instruction and more widespread study in OR environments. Additionally, training physicians to respect the “sterile cockpit” concept would be beneficial when used in conjunction with any other solutions.

Figure 13: This graphic shows how noise cancellation works. Unwanted external noise is captured with a microphone, the opposite amplitude of that noise is then calculated and emitted through a speaker along with a desired audio signal or music.

Combining any or all these solutions would create a quieter space conducive to successful operations.

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[7] Way JT, Long A, Weihing J, et al. (2013). “Effect of noise

[16] Kurmann, A., Peter, M., Tschan, F., Mühlemann, K.,

on auditory processing in the operating room”, J Am

Candinas, D. and Beldi, G. (2011). “Adverse effect of noise in

Coll Surg. Vol. 2013, No. 216(5), pp:933-938. doi: 10.1016/j.

the operating theatre on surgical-site infection”, Br J Surg,

jamcollsurg.2012.12.048

Vol. 98, No.7, pp: 1021-1025. doi:10.1002/bjs.7496

[8] Vahed N, Kabiri N, Oskouei MM, et al. (2017). 130: “The

[17] Grantcharov, P.D., Boillat, T., Elkabany, S., Wac, K.

Effect of Music in Operating Room:A Systematic Review.” BMJ

and Rivas, H. (2019). “Acute mental stress and surgical

Open. Vol. 2017, No.7:bmjopen-2016-015415.130. doi: 10.1136/

performance”, BJS Open, Vol. 3, No. 1, pp: 119-125. doi:10.1002/

bmjopen-2016-015415.130

bjs5.104

[9] Siu, K.-C., Suh, I. H., Mukherjee, M., Oleynikov, D., &

[18] Youn, Ann Misun et al. (2015). “Anesthesia and

Stergiou, N. (2010). “The Effect of Music on Robot-Assisted

sedation outside of the operating room”, Korean Journal

Laparoscopic Surgical Performance”, Surgical Innovation, Vol.

of Anesthesiology, Vol. 68, No. 4, pp: 323-31. doi:10.4097/

17, No.4, pp:306–311.

kjae.2015.68.4.323

[10] Ullmann, Yehuda et al. (2008). “The sounds of music in

[19] The Facilities Guidelines Institute, (2018). Guidelines for

the operating room”, International Journal of the Care of the

design and construction of hospitals. 2018 Edition.

Injured, Vol. 39, No. 5, pp: 592–597.

[20] C Bujoreanu and M Benchea, (2016). “Experimental [11] K. Moorthy, Y. Munz, S. Undre, and A. Darzi, (2004).

study on HVAC sound parameters”, IOP Conference Series:

"Objective evaluation of the effect of noise on the

Material Science Engineering, Vol. 147, No. 7, doi:10.1088/1757-

performance of a complex laparoscopic task," Surgery (St.

899X/147/1/012051

Louis), Vol. 136, No. 1, pp: 25-30.

[21] Friedrich MG, Boos M, Pagel M, et al. (2016). “New Acknowledgments

Figure 14: Quiet operating rooms yield better staff, better patient outcomes, and ultimately a better operating environment.

Many thanks, Perkins and Will, for enabling and promoting this research.

References [1] United States Code, (1972). Noise Control Act, 42 USC 4905.

[4] Giv, Masoumeh Dorri et al. (2017). “Evaluation of noise pollution level in the operating rooms of hospitals: A study in

[12] American Society of Heating, Refrigerating and Air-

technical solution to minimise noise exposure for surgical

Conditioning Engineers, (2001). ASHRAE Standard: ASHRAE

staff: the ‘silent operating theatre optimisation system’”, BMJ

Standard 62-2001. New York, New York: The Society, 2001.

Innovations, Vol. 2017, No. 3, pp: 196-205.

[13] Hasfeldt, Dorthe, et al. (2010). “Noise in the Operating

[22] Bose, (2019). “Bose Introduces QuietComfort Road Noise

Room—What Do We Know? A Review of the Literature.”

Control.” Bose Global Press Room. Retrieved on 4/2020 from

Journal of PeriAnesthesia Nursing, Vol. 25, No. 6, 2010, pp.

https://globalpressroom.bose.com/us-en/pressrelease/

380–386., oi:10.1016/j.jopan.2010.10.001.

view/1966.

[2] Concha-Barrientos, Marisol, Steenland, Kyle, Prüss-

Iran”, Interventional Medicine & Applied Science. Vol. 9, No.2,

Üstün, Annette, Campbell-Lendrum, Diarmid H, Corvalán,

pp: 61-66. doi:10.1556/1646.9.2017.2.15

[14] Berglund B, Lindvall T, Schwela D. (1999). “Guidelines for

[23] Burdick, Kendall J., et al. (2018). “Benefits of Sonification

community noise”, World Health Organization, Retrieved

and Haptic Displays with Physiologic Variables to Improve

burden of disease from work-related hearing impairment

[5] Wang X, Zeng L, Li G, et al. (2017). “A cross-sectional study

on 4/2020 from http://www.who.int/docstore/peh/noise/

Patient Safety.” Proceedings of Meetings on Acoustics, Vol. 35,

at national and local levels / Marisol Concha-Barrientos,

in a tertiary care hospital in China: noise or silence in the

guidelines2. html (accessed 5 Aug 2015).

No. 1, doi:10.1121/2.0000941.

Diarmid Campbell-Lendrum, Kyle Steenland. World Health

operating room”, BMJ Open, Vol. 2017, No. 7, pp: e016316. doi:

Organization. https://apps.who.int/iris/handle/10665/43001

10.1136/bmjopen-2017-016316

[15] Wallace MS, Ashman MN, Matjasko MJ, (1994).

[3] Kracht, Jonathan & Busch-Vishniac, Ilene & West, James,

[6] Jonathan D. Katz, (2014). “Noise in the Operating Room”,

Anesthesiology, Vol. 1994, No. 81, pp: 13–28.

(2007). “Noise in the operating rooms of John Hopkins

Anesthesiology, Vol. 2014, No. 121(4), pp:894-898. doi: https://

Hospital”, The Journal of the Acoustical Society of America.

doi.org/10.1097/ALN.0000000000000319.

Carlos F. et al. (2004). Occupational noise: assessing the

“Hearing acuity of anesthesiologists and alarm detection”,

Vol. 2007, No. 121, pp: 2673-80. 10.1121/1.2714921.

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02 Reducing Waste in the Operating Room: Optimizing supply expenditures Christopher Koss, christopher.koss@perkinswill.com

Abstract

1.0 Introduction

While medicine has drastically improved quality and expectancy of life across the globe

Producing over 6,600 tons of waste per day, an annual 4

study examined 302 facilities across the state of California

through hospitals, the environmental and fiscal toll of the practice’s material biproducts

billion pounds, U.S. healthcare facilities were contributing

and found the average cost for one minute in a hospital’s

was far from optimized. Within U.S. hospitals, the most particularly resource-dependent

the second most amount of waste, behind only the food

operating room was $36 to $37.3 Of this, direct expenses

and wasteful space, in the most need for reformation, was the operating room (OR).

industry. Labor-delivery and operating room waste

accounted $20.40, wages and benefits cost about $14 per

accounted for approximately 70% of that hospital waste.1

minute, and the OR spent up to $3.50 per minute on surgical

This study sought to define strategies for the reduction of OR waste by defining waste categories, providing their respective environmental and healthcare costs, and proposing proven improvement strategies in order to prioritize better waste management and optimize disposal costs. The research was based upon a literature review of current waste management definitions, reduction strategies, and the ramifications of implementing those strategies. This research analyzed waste segregation and reduction techniques. It proposed strategies for improved environmental and monetary outcomes in the operating room, the space responsible for generating one third of the U.S. healthcare industry’s waste.

By incorporating best OR waste management practices, the U.S. healthcare industry would not only improve its sustainability but also drastically reduce supply expenditures, which would holistically benefit the national healthcare system. This study concluded that the hospital could dramatically reduce its environmental impact and spending in its most critical, resource-demanding space by applying evidence-based OR waste

supplies.⁴ One study analyzing the American Hospital

Despite their relatively miniscule spatial footprint in the

Association (AHA) Annual Survey for 2013, which evaluated

hospital, U.S. operating rooms were responsible for 30% of

nearly 6,200 hospitals in the US, found that the average

the hospital’s waste generation.2 Based on one estimate

individual hospital spent $3.8 million on medical supplies

of total U.S. hospital waste generation, ORs accounted

with the median spending $9.1 million.3,5

for about 2,000 tons of waste per day and about $3 billion in annual disposal costs.3 Additionally, treatment

This study analyzed current operating room waste

of regulated medical waste and anesthesia gas spending

management strategies by category and shared average

contributed to higher healthcare spending and deeper

annual surgical supply expenditures at both macro and

environmental strain.

micro scales. The environmental and healthcare cost of these strategies were then analyzed at micro scales and

Accounting for about 40% of all hospital revenue generation

projected improvements at the national scale; ultimately,

and 60% of hospital supply expenses, the operating room’s

the study proposed waste reduction strategies that

supply expenses represented significant lucrative saving

benefitted sustainability, provided opportunities for

potential for hospitals, and concurrently a significant

significant cost savings, and even promoted workers’ safety.

opportunity for improving waste management.2 In 2014, one

management strategies.

Keywords: operating room, sustainability, waste management, healthcare design

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2.0 Methodology What began as several google searches investigating the

and demonstrating strategies providing improvements, was

space responsible for the most environmental damage and

the call for collective widespread improvement at the micro

highest maintenance cost resulted in a series of scholarly

scale, which proposed outstanding nationwide savings.

literature reviews on published case studies demonstrating

In order to formulate national projections, the researcher

opportunities for improvement within operating room

used the 2013 AHA’s survey totaling 6,200 U.S. hospitals

waste management. These studies examined operating

to propose the total impact of collective individual

room waste disposal costs and subsequent environmental

hospital waste management strategies on the U.S.

impacts. Several domestic reports proved strong references

healthcare industry.

exhibiting U.S. healthcare operating room waste

Figure 1: While the entire U.S. Healthcare industry produced 4 billion pounds of waste per year, operating rooms annually produced 1.3 billion pounds of that waste.

management from a macro scale and focusing on several

These micro scale operating room waste management

individual hospitals’ OR waste management. After analyzing

adjustments were then proposed in an à la carte-like

common OR waste management strategies, the researcher

model; which provided evidence-based options for clients,

analyzed OR waste management examples that adopted

who may consider adopting one or several of these waste

optimized waste strategies and documented improvements.

management saving strategies, to visualize and pick the most appropriate solutions for their facilities.

Categorically showcasing the current status of OR waste management from the United States’ overall performance,

3.0 OR Waste Categories Waste generated in and leaving the operating room was segregated with consideration to infection control, employee safety, and state enforced waste management regulations. Proper healthcare facility waste management practice typically utilized color-coded waste receptacles to segregate different types of medical waste. In the OR, there were typically four main categories of waste.

Figure 2: Generating 40% of the United States’ total income, operating rooms also account for 60% of the hospital’s supply expenditures.

Regulated medical waste required special treatment before proper disposal as solid waste. Solid waste was typically disposed in a landfill, and there were environmental and cost-saving opportunities by further waste segmentation into solid waste and recyclable waste. Liquid waste was either solidified or disposed directly down sanitary sewers to wastewater treatment plants. Lastly, gas anesthesia waste would escape closed anesthesia circuits, which exposed the operating room and the atmosphere to harmful gases.

Figure 3: The graphic above illustrates an annual expense of $3 billion due to the disposal costs of four waste categories: regulated medical waste, solid waste, fluid waste, and anesthetic waste gas.

Distinguishing different types of OR waste, their respective volumes and disposal methods, and their micro and macro disposal expenditures exposed crucial waste spending inefficiencies; this established an argument for OR waste management intervention.

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3.1 Regulated medical waste, or ‘infectious waste’, or

3.1.1 Medical Waste Tracking Act

for their ability to minimize disease causing potential of

state’s waste regulations. However, for the purposes of this

‘biomedical waste’

After widespread concern regarding the spread of

medical waste. These technologies included incinerators,

study, I assumed pharmaceutical wastes were disposed with

The Environmental Protection Agency (EPA) defines

infectious diseases in the 1980s and after medical waste was

various chemical treatments, mechanical systems, and

regulated medical wastes.

regulated medical waste (RMW), also referred to

washing onto shores of east coast public beaches, the EPA

autoclaves. An autoclave is effectively a large pressure

as biohazardous waste, as any waste that may be

implemented the 1988 Medical Waste Tracking Act (MWTA).6

cooker that utilizes steam and high temperatures to

contaminated by blood, body fluids, or other potentially

From June 24th, 1989 to June 21st, 1991 the act gave the

neutralize potentially biohazardous substances. Ultimately,

3.1.2 Regulated medical waste disposal methods

infectious materials or substances. According to Practice

EPA federal authority to regulate medical waste, which the

the act served as a two-year program that established

Since the act’s expiration, individual states and health

Greenhealth, although regulated medical waste typically

act defined as waste generated during medical research,

an initial solution for regulating, tracking, and treating

systems have governed medical waste regulations and

compromised less than 8% of the total hospital’s waste

testing, diagnosis, immunization, or treatment of human

medical wastes.

disposal methods. Posing a potential health hazard to

production, disposing this waste cost up to 40% of the

beings or animals. The MWTA established a cradle-to-grave

hospital’s total waste management budget. According to an

tracking system that utilized a generator initiated tracking

analysis by Reports and Data, the U.S. RMW management

form, which ensured that waste was properly accounted for

6

3

managed in a specific manner to properly disinfect its

RMW today, included:

market was valued at $3.07 billion in 2018 and was expected

and tracked from its generation to its disposal. Moreover, it

•

to grow to $5.635 billion by 2026.7 Because 60% of the total

established standards for segregating, packaging, labeling,

hospital’s regulated medical waste was generated in the

and storing medical waste before treatment. If waste

•

operating room, it was essential to understand exactly what

was found to be mismanaged or noncompliant to these

RMW was and how it was disposed.

3

medical workers and staff, RMW must be treated and

Medical waste tracked by the MWTA, and still considered

Cultures and stocks of infectious agents Pathological waste like body parts, body tissue, organs,

contents before its disposal to the landfill. Other federal agencies such as the Centers for Disease Control (CDC), the Occupational Safety & Health Administration (OSHA), and the U.S. EPA have all aided in the effort to regulate and

and bodily fluids

dispose medical wastes.

standards, then the entity in charge would be penalized

•

Human blood and blood product wastes

through the MWTA. During this time, the MWTA examined

•

Used sharps including needles, syringes, broken glass,

Based on their discretion and identification, hospital staff

and scalpel blades

would dispose RMW into bags and containers specifically

•

Contaminated animal carcasses

designed to store biohazardous waste.6 OSHA regulated

•

Waste from surgery that were in contact with infectious

management, labeling medical waste bags and containers,

different treatment technologies available at the time

The first step in RMW’s disposal process was generation.

different aspects of medical wastes such as sharps

agents such as linens, sponges, drapes, plastic

regulating sharps containers and other stored waste, and

tubing, and gloves •

even employee training.9 Following OSHA guidelines, a

Wastes from medical, pathological, pharmaceutical,

leak-resistant color-coded biohazard bag was typically

or other research that were in contact with potentially

adequate for storing RMW provided that the exterior of the

infectious agents

bag was not contaminated in the process. These bags were marked with the international infectious substance symbol

All items listed above remain categorized as regulated Figure 4: While only accounting for 8% of the hospital’s total waste, disposing regulated medical waste costs up to 40% of the hospital’s waste management budget.

and placed in matching color-coded waste receptacles, and

medical waste and all were found to have been generated

they had to be suitable for the autoclaving or treatment

in the typical operating room. Before the MWTA was

process, which will be discussed next. Additionally, the CDC

enacted, in the 1970s the single-use device (SUD) was

has published guidelines for handling sharp wastes by use

invented as the medical device manufacturing response to

of red puncture-resistant containers, like hard plastic sharps

biohazardous waste contamination worries. According to

containers and sometimes plastic-lined cardboard boxes, in

the Food and Drug Administration (FDA), SUDs were any

the point of use location to temporarily store contaminated

medical equipment, instrument, or apparatus designed

needles, syringes, and scalpel blades for treatment.⁶

for a single use on a single patient for a single procedure.8 Before SUDs, medical device materials were typically metal

The next step in RMW’s disposal process was treatment,

or glass, designed to be sanitized before and after each

and U.S. states and counties were responsible for regulating

procedure, but now plastics have been the primary material

their treatment methods before medical waste could be

used in SUDs.

disposed as solid waste. According to the Healthcare Environmental Resource Center, the most common treatment

Also, it was important to note that some facilities disposed

methods included autoclaving, or thermal treatment, and

of their operating room’s pharmaceutical wastes separately

incineration.9

from regulated medical waste, based on their respective 54

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Incineration was the most prevalent form of treatment but

3.2 Solid waste

landfill manager survey, the average fee to landfill a ton

3.3 Liquid waste

had to abide by EPA emissions standards, which had to be

Driven by the induction of SUDs, solid waste represents most

of municipal solid waste was $50.60, up 3.7% from $48.80

In the conduction of this study, surgical liquid waste

closely monitored as too much moisture or too low energy

of healthcare’s waste generation. Solid waste in the OR

in 2016. However, this increase was not an isolated event;

represented the most dangerous, infectious waste threat

input causing emission issues. Since the MWTA, other

typically included any kind of packaging, medical devices,

this was a snapshot of an upward trend. Between 2010-2016

to medical staff. Representing a significant portion of

acceptable biohazardous waste decontamination methods

paper products, plastics, and even food. According to the

there was a national average annual growth of 2% in landfill

total operating room biohazardous waste, fluid waste was

have existed such as chemical treatment, hydroclaving, and

World Health Organization (WHO), solid waste accounted

fees, but from 2016-2018 the national average landfill fee

defined as blood or bodily liquids diverted during surgery

microwaving. However, incineration, chemical treatment,

for about 85% of all healthcare waste, including wastes

grew 7% to $52.62, exhibiting an exponential increase. If

and considered regulated medical waste. These potentially

and thermal treatment were predominantly utilized in U.S.

like plastics, glass, paper, cardboard, and even food which

waste management systems were perfect, 95-97% of OR

infectious fluids were typically collected by a centrally

state medical waste regulatory programs.

were all theoretically recyclable or recoverable; this left a

waste could be properly segregated, which would provide

located or mobile vacuum and then stored temporarily in a

remaining 15% as hazardous waste.10

saving opportunities for recycling waste, landfill space, and

reusable canister or disposable suction canister before being

reduced landfill disposal fee spending.

disposed in a couple different ways.14

It was important to note that while some facilities typically

12

12

decontaminated and treated RMW on-site before disposing

Solid waste was removed by serviced municipal solid waste

as solid waste, others utilized off-site facilities dedicated

collectors in a traditional curbside collection. This service

As different areas of the country had varied demand for

The first disposal technique involved reusable canisters,

to decontaminating medical waste. On-site and off-site

collected solid and recyclable wastes in the same place at

landfill capacity, different areas charged different disposal

which were often recyclable bottles, with medical staff

were terms used to reference where the medical waste was

the same time, which was then transported to either be

costs per ton of landfill waste. In high demand areas, where

literally opening each suction canister and pouring its

treated in relation to where it was generated. On-site waste

recycled or disposed in a landfill for a fee.

solid waste collection cost sometimes twice to three times

contents down a sanitary sewer drain in a non-patient

as much as recycling collection, healthcare facilities would

area, allowing for the canisters to be reused after thorough

greatly benefit from better waste segregation practices,

disinfection. While the expelled fluids would eventually

which would reduce landfill waste and promote recycling,

be treated at a sewage water treatment plant, the real

lowering disposal costs and retaining waste from a landfill.13

danger was the splashing and aerosolization of fluid as it

treatment was typically defined as waste treated within the

The U.S. population was growing, and with it grew higher

same facility where the waste was generated while off-site

healthcare demand, incurring higher national healthcare

was anywhere outside of the generator’s facility. However,

production. According to a 2017 Waste Business Journal

one state’s on-site waste treatment was defined as waste treated and managed in a facility within 75 miles of the

was poured, which exposed the individual to potentially

Consistently generating about a third of the hospital’s

generator’s facility while off-site referred to treatment in a

infectious waste, causing this risky technique to be

entire waste output, operating room solid waste disposal

facility further than 75 miles from the point of generation.

10

discouraged.14

presented opportunities for better recycling segregation and

These off-site facilities were dedicated to decontaminating

waste avoidance techniques in order to save on disposal

RMW for solid waste disposal. Deciding between utilizing

expenditures and reduce

on-site or off-site treatment primarily hinged on dedicated

waste generation.

space in the hospital, hospital location relative to an offsite treatment facility, having available staff to perform treatment, and cost. Each had their benefits and drawbacks, and it was important to establish that each impacted the operational and environmental cost of treating medical waste.

Once RMW was treated either on or off-site it was disposed as solid waste.

Figure 5: 30% of the hospital’s solid waste is generated in the operating room.

56

Figure 6: Up to 40% of an operating room’s regulated medical waste is liquid waste, which poses the greatest threat to the health and safety of OR personnel.

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4.0 OR Waste Impacts

The next method used disposable canisters often equipped

3.4 Anesthesia waste gas

with a solidifying agent for coagulating fluid waste, filters to

Lastly, waste anesthesia gas (WAG) was the waste

seal bacteria and viruses, and backflow prevention as safety

category that most negatively impacted the world

By focusing on the staff who directly handle medical

waste bags as these wastes did not require treatment before

features. Solidifying the canister’s fluids was important for

outside the operating room. During surgeries involving

supplies, hospital managers developed strategies to reduce

disposal. Johns Hopkins Hospital’s go green initiative stated

risk prevention, as the fluids then could not splash, spill,

general anesthesia, the patient was either anesthetized

waste directly in the hospital’s largest waste generator: the

that OR waste should only be 24% RMW, with solid waste

or leak, and the canister could then either be stored or

intravenously or more commonly via inhaled anesthetics.

operating room. A 2001 study estimated about 60% of the

accounting for 59% and recyclable waste at 17%.¹ However,

disposed as either regulated or non-regulated medical

The anesthesia breathing circuit included the patient’s

hospital’s RMW was generated in operating rooms.18 The

according to Practice Greenhealth, about 50% of OR waste

waste, depending on local regulations.14 It was important to

mask, a tube, the anesthesia gas machine, a ventilator,

majority of OR generated waste, however, unless visibly

was consistently, mistakenly disposed and treated as

note that if considered RMW, these disposable containers

pumps, and even a gas scavenging device. According to the

soaked in blood or bodily fluids, belonged in clear, solid

regulated medical waste.³

added to waste disposed in RMW bags. The University

CDC, WAG was defined as small amounts of volatile gases

of Minnesota found that disposable suction canisters

that leak from the patient’s breathing circuit and into the

accounted for 25% of total hospital regulated medical

operating room air during anesthesia delivery.17 There were

waste, and another study found suction canister disposal

several causes for WAG leakage, which were primarily due to

comprised up to 40% of all operating room surgical waste.15,16

inhaled anesthetic techniques and the anesthesia machine’s delivery and scavenging systems. From poorly fitted masks

Fluid management systems could be designed to bypass

to human error and machine malfunction, anesthetic gas

the need for canisters by directly disposing the fluid waste

flow leakage was virtually unavoidable.

into a sanitary sewer, if allowed by local regulations.

This was the most desirable option as it was the most

Inhaled anesthetics involved two types of chemicals: volatile

efficient, best for the environment, and safest option for

halogenated agent vapors and nitrous oxide (N2O), which

medical staff, however, would require higher up-front

effectively carried the halogenated vapors.16 Every volatile

implementation costs.

halogenated agent was either a fluorinated hydrocarbon or a chlorofluorocarbon, which contributed to greenhouse gases and damaged the Earth’s ozone. While undergoing Figure 8: The graphic compares the composition of typical OR waste versus estimates from Johns Hopkins University.

anesthesia, patients only metabolized about 5% of

Figure 7: 95% of operative general anesthesia gas is unmetabolized by the patient, which, if left unmitigated, allows harmful gases into the atmosphere.

administered gas, which meant the other 95% was exhaled by the patient. If this gas was not scavenged, it entered the OR and ultimately the atmosphere.

An urban, midsize hospital consumed up to 1000 liters of aesthetic gases per year.

Annual greenhouse gas contributions from WAG equaled an average of 4.78 metric tons of CO2, which was the equivalent of between 100 and 1200 annual car emissions per hospital. Although these gases comprised only 6% of total greenhouse gases in the atmosphere, it was still the healthcare facility’s responsibility to minimize these exposures.16 Gas leakage exposures were not exclusively dangerous to the atmosphere, but also those working in the OR. During anesthesia administration, leaked N20 without proper ventilation posed a threat to intoxicate OR personnel.

58

Figure 9: The graphic depicts the United States’ projected increase in regulated medical waste management spending, which is expected to nearly double in eight years from 2018 to 2026, and displays the lopsided relationship of OR RMW generation compared to the whole hospital.

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The differentiating factor between RMW and solid waste

Since the EPA inducted these standards, the three forms of

Simply considering the long-term environmental impacts

was one crucial step: treatment. Before regulated medical

RMW treatment all required resources, additional filtration

of healthcare waste generation was enough motivation

waste could be disposed as solid waste, it required

or treatment to meet EPA requirements, and were relatively

to contemplate how to better management operating

treatment to disinfect any waste that would end up in

expensive to operate. Many U.S. healthcare facilities either

waste streams.

a landfill. Until the 1990s, many hospitals treated their

paid to ship their waste to a central off-site treatment

regulated medical waste by incineration with a variety of

center or have implemented their own on-site treatment

wastes. While medical incineration certainly neutralized

technologies. Additionally, off-site treatment incurred

biohazardous threats, these incinerators caused significant

additional transportation costs and required further

air quality concerns after releasing significant sources

requirements to meet the Department of Transportation’s

of mercury, dioxins, and other toxic substances into the

safety guidelines.⁹ Due to treatment and/or transportation

environment.9

costs before disposing as solid waste, RMW disposal cost six to ten times more than solid waste disposal, which justified

Incineration, being the most common and simple form

the high price for treatment and further legitimized RMW

of medical waste treatment, created several problems.

reduction efforts.

Incinerators released toxic air pollutants as well as toxic ash

According to collected data by the Waste Business Journal, by 2021 the United States’ total landfill capacity was projected to have only fifteen years before reaching maximum capacity, and some regions expected to reach maximum capacity in half that time. With such a bleak outlook on the future of domestic waste deposition, the industry which generated 13,200,200 pounds of waste per day desperately needed to reform their wasteful habits. Of those 13.2 million pounds, the operating room was responsible for nearly four million pounds of daily

in the form of dioxins, which were environmental pollutants.

For example, if disposing one ton of waste in 2018 cost the

generated waste. With such great opportunity for reducing

According to the WHO, dioxins could cause damage to the

average landfill tipping fee of $52.62, then disposing one

waste generation, leading with the operating room as a

human immune system, developmental and reproductive

ton of regulated medical waste might cost eight times more

space for waste reformulation would inform better waste

problems, interference with hormones, and even cancer.18 It

at $420.96. Using these numbers, if a surgical department

management practices throughout the rest of the hospital,

was not until 1997 that the EPA posted standards on medical

generated five tons of RMW in one month it would cost

which would not only benefit each individual hospital but

waste incinerator emissions, closing several thousand on-site

the facility $2,104.80 to dispose. However, if the mistaken

the industry’s sustainability as a whole.

medical facility incinerators around the U.S. that did not

50% of disposed RMW was properly disposed as solid

meet those standards.

waste at $52.62 a ton, the facility would instead spend $1,183.95, saving $920.85 a month and $11,050 per year.

Figure 11: The graphic depicts the steady climb of U.S. solid waste disposal fees per ton disposed, and knowing that healthcare waste generation will grow with the population would imply that the cost to dispose healthcare waste will grow exponentially over time.

5.0 OR Waste Reduction Strategies While understanding each waste category generated in

5.1 Fluid management systems

the OR was imperative, the degree to which these waste

Accounting for up to 25% of OR regulated medical waste,

streams impacted the hospital’s environmental footprint

and up to 40% of total operating room waste, optimized

and overall disposal cost was understood by dissecting their

fluid waste management provided a significant opportunity

contents. Some opportunities for implementing sustainable

for RMW reduction.14 According to one study, a single surgery

OR practices posed higher initial costs, however they

could produce up to 12 liters of liquid waste, and a single

provided significant long-term environmental and savings Figure 10: The graphic compares the average cost of disposing one ton of solid waste to the average cost of disposing one ton of regulated medical waste in the United States. Disposing one ton regulated medical waste cost about 8 times more than disposing one ton of solid waste.

operating room generated up to two tons worth of fluid

benefits. Ultimately, alternative long-term costs of running

waste per month.19 Provided prevalent operating room fluid

an OR were best demonstrated when comparing previous

waste generation, there were several helpful approaches

expenditures to documented examples of improvement.

that reduced both the cost and environmental burden of

Optimized savings and a minimized environmental footprint

liquid waste disposal.

were realized through alternative waste management strategies that promoted proper waste segregation,

By far the most productive strategy that required the least

encouraged recycling, reduced surgical supply demand, and

manual labor, posed the least risk to employee health,

provided a safer operating room.

most protected the environment, and offered significant cost savings was implementing an enclosed fluid waste management system.³ Notably, closed fluid waste management systems collected surgical fluid waste without manual operation, they precisely measured fluid, and most

60

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5.2 Improved waste segregation

Cardinal Health SAF-T Pump fluid management system and saved about $86,250 while diverting close to 262,000

To curb the negative impacts of mistakenly disposing solid

pounds of waste from treatment and ultimately a landfill

waste as RMW, hospitals strived to teach best segregation

by utilizing a closed-fluid waste management system. This

practices to their OR personnel. Considering that proper

resulted in a 98% reduction in liquid waste volume. These

waste segregation began at the generation source with

fluid management systems were not only less time and

the OR staff’s discretion, it proved beneficial to initiate

labor intensive, but also improved operating room turnFigure 12: Utilize fluid waste management systems.

a conversation with the OR team regarding best waste

over rate and eased the OR cleaning process. Additionally,

management practices. Facilitating communication

they no longer purchased fluid waste solidifiers, saving

between the OR team and the hospital’s infection prevention

them approximately $15,000 on supply costs per year.

and environmental services strengthened RMW and solid

Employees reported positive feedback for their fluid waste

waste segregation and began a minimization program.

management systems, and, moreover, the specific fluid

Learning how the OR team handled waste streams and

management system, the SAF-T pump system, met best

understood waste categories was an integral first step in

practice standards for the Association of Operating Room

remediating RMW waste volume.

Nursing, the CDC, and OSHA.

If RMW receptacles and solid waste receptacles were identical in size, shape, and directly adjacent, then they 5.1.2 Macro scale projections

were equally convenient for waste disposal. Providing equal

If each hospital in the U.S. implemented fluid management

convenience to both RMW and solid waste receptacles

systems, assuming each hospital saved $10,000 per year on

proved detrimental for proper waste segregation. A

importantly they directly disposed fluid into a sanitary sewer.

Necessary considerations before the implementation of

supply costs and diverted 4 tons of RMW, the U.S. healthcare

standardized approach for indicating RMW containers,

Some models even had self-cleaning capability, further

these fluid waste systems involved several variables such

system would annually save $62 million and divert 24,800

like a small kick bucket or wheeled hamper, assisted OR

decreasing staff exposure to bloodborne pathogens. These

as the volume of used suction canisters, the cost of those

tons of regulated medical waste from landfills.

team members in identifying the correct container for

systems provided an alternative to the original two options:

canisters, the cost of solidifying agents, and ultimately how

biohazardous waste. More prevalent, clearly indicated solid

disposable and reusable suction canisters. They either sat on

much the organization paid to dispose one ton of RMW.

waste receptacles in the OR provided more opportunities for

a cart that attached to a sanitary sewer docking system or

Several examples have shown cost and environmental

were hard-plumbed directly into the sanitary sewer.

benefits of fluid waste management systems, fortifying their effectiveness. Subject to vary based on the number

With an initial price tag of $20,000-$25,000 for an

of operating rooms and geographical location, by utilizing

individual system and smaller costs running an additional

a fluid management system instead of adding solidifiers

$15-$20 a procedure, these systems’ upfront cost ran on

to full suction canisters before disposal, a hospital on

the higher end, however, with a return on investment (ROI)

average could save between $7,500 and $15,000 a year on

typically spanning on average 1-3 years, fluid management

supply costs.

systems quickly paid for themselves. Moreover, without the

proper segregation.

“Bronson Methodist Hospital implemented a fluid

Different hospitals’ waste segregation programs benefited

management system in 2003. In 2010, this technology

from varying operational waste segregation strategies that

allowed Bronson to save approximately 8 tons of

best matched their management style and staff comfort.21

regulated medical waste and plastic suction canisters

Beginning with the least necessary maintenance, the first

at a savings of $7,200.³”

strategy in the OR began pre-incision during the set-up step

– Lisa Hardesty, Sustainability Manager for Bronson

of the procedure when a significant amount of packaging,

Methodist Hospital, Kalamazoo, Michigan

blue sterile wrap, and rigid plastics were disposed. In fact,

need for solidifying suction canister liquid before disposing

up to 80% of all the solid waste generated in the operating

as RMW, this system removed the cost for solidifiers,

5.1.1 Bon Secours Charity Health System case study20

which cost between $5 and $30 for each suction canister.

There were also less expensive, higher maintenance fluid management systems which started around $5,000

The Bon Secours Charity Health System, which included

a fluid management system that reduces its

three hospitals, served over half a million people in the

regulated medical waste by 5,400lbs each year at an

New England area, and generated a significant amount

but these required suction canisters, which somewhat

of waste.20 In fact, about 16,120 canisters in medical waste

contradicted the system’s intent as canisters were still used.

from surgical practices were being generated per year.

This less expensive system may not have reduced as much

Their largest hospital, the 377-bed Bon Secours Good

waste as possible, but still offered waste reductions.

room were generated before the patient even entered the

“In 2007, St. Mary’s Hospital Medical Center instituted

room.19 Since this process generated no infectious waste, this first strategy involved either replacing the RMW receptacle’s bag with a clear, solid waste bag or removing the RMW

annual cost savings of over $10,000 dollars.³”

receptacle all together, which considerably cut back on

- Ronald VanSchyndel, EVS 1st Line Supervisor,

waste mistakenly disposed as RMW. The next strategy

St. Mary’s Hospital Medical Center,

focused on post-surgical waste segregation. After the

Green Bay, Wisconsin

procedure, items such as mayo stand covers, surgical drapes

Samaritan Hospital in Suffern, New York, implemented the

that were not soaked in blood, remaining packaging, sterile wrap, and non-sharp instruments that could not be reused 62

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generated RMW per day. This daily 170lbs reduction provided cost savings of over $15,000 in six months. Across

5.3 Recycling blue sterile wrap

the Inova Health System’s five hospitals, over one million pounds of regulated medical waste was diverted from

The induction of SUDs into the operating room came as

2009 to 2010.

a result of infection and sterility concerns in the surgical practice, and the growth of the U.S. healthcare system

Figure 13: Implement operating room waste management best practices.

has continued to drive for more SUD production. With this

“In 2010, our Waste Management Team achieved a

demand, blue wrap and packaging plastics were used for

47% reduction in regulated medical waste, reducing

these individually wrapped SUDs, which added a significant

28,795 pounds of waste by initiating a targeted focus

amount of recyclable plastic to the OR waste stream. Blue

on RMW reduction in our ORs and Labor & Delivery.

wrap effectively protected medical devices, surgery kits, and

Cost savings due to red bag waste reduction were in

instruments for sterilization. This blue wrap was sometimes

excess of $89,000.³”

recyclable or reusable as it was super strong and resistant

- Judith Focareta, Coordinator, Environmental

to both moisture and tearing, which made it such a popular

Health Initiatives, Magee-Womens Hospital of

wrapping product for SUDs and desirable for other purposes.

UPMC, Pittsburgh, Pennsylvania

Additionally, according to Practice Greenhealth, the environmental impact of reducing 1 million pounds of blue sterile wrap was the equivalent of removing 250 cars from the road.23

or reprocessed for another surgery should be either disposed

their operating rooms’ waste stream. Then they performed

as solid waste or recycled. The last strategy required the

post-operative audits of generated waste and found most

most amount of effort of the three strategies as it occurred

of the waste disposed as RMW was packaging material.

during the surgical procedure. This critical surgical stage

Weighing the generated waste, they discovered that the OR

generated all the procedure’s RMW so the OR team’s

was producing 907lbs of RMW a day. Realizing there was a

understanding of what constituted as biohazardous waste

problem, management held an “In-Service” review to help

was critical. During this process, the RMW receptacle had to

educate OR staff about how their waste disposal practices

be easily accessible to operating staff, which increased the

critically impacted the hospital’s budget, human health, and

probability of improper segregation. This strategy hinged

ultimately the environment. Part of this In-Service included

most on the OR staff’s education and understanding of

a review of the facility’s waste disposal policies, describing

segregation guidelines.

proper waste disposal techniques regarding RMW and solid waste. This training pointed out how non-infectious

5.2.2 Macro scale projections

Certain U.S. locations offered great benefit for recycling

Utilizing the Inova Health System as a large scale model,

waste as opposed to disposing solid waste based on landfill

if hospitals across the United States implemented proper

tipping fees versus recycling fees. With several waste haulers

RMW segregation techniques as successfully as Inova Fairfax

implementing better recycling techniques, the possibility to

Hospital, the U.S. healthcare system would save $186 million

divert plastics generated in the OR to recycled waste streams

and divert 192,355 tons of RMW over one year.

Figure 14: Recycle or redistribute operating room blue sterile wrap.

wastes were being disposed in RMW containers, educated 5.2.1 Inova Fairfax Hospital case study22

staff about cost savings offered by recycling, and ultimately

The Inova Fairfax hospital in Falls Church, Virginia was

reminded OR staff that their action was critical in waste

a 900-bed facility with 29 operating rooms, performing

segregation.

nearly 19,500 inpatient and 16,400 outpatient surgeries in

Six months after the In-Service training, the hospitals’

2010.22 In 2007, their environmental committee targeted the

sustainability manager, Seema Wadhwa, once again

operating room’s waste production and implemented an

audited the OR’s waste. The training was a success: staff

OR waste disposal and segregation educational program

decreased the amount of packaging and non-infectious

accompanied with a bolstered recycling program as part

materials disposed in the RMW bags, and the recycling

of their new waste reduction and minimization efforts.

program diverted additional waste from the landfill.

Beginning with a survey of OR staff, a further conversation,

Operating room regulated medical waste was reduced

and even a survey of practices and procedures, the

by an astounding 19%, from 907lbs to 738lbs of one OR’s

committee sought to better understand the logistics of 64

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has become much more prevalent, benefitting both disposal expense and providing the opportunity for less waste

“Fletcher Allen Medical Center achieved a 38%

production. When blue wrap could not be recycled, it could

recycling rate in 2010. The nursing staff in the OR have

have been sold to local buyers, such as moving companies,

been initiators of Fletcher’s OR recycling program

for a variety of purposes.

which collects approximately 50 tons of recycling annually at a savings of approximately $6000.3”

Figure 15: Substitute blue sterile wrap with rigid sterilization containers.

- Louis Dinneen, Director, Facilities Management, 5.3.1 Harbor Hospital blue wrap recycling case study24

Fletcher Allen Medical Center, Burlington, Vermont3

Harbor Hospital in Baltimore, Maryland was a 203 bed hospital with 11 ORs. Partnered with Maryland Hospitals for Healthy Environment (MD H2E), who provided healthcare

The Overlook Medical Center (Atlantic Health) in

facilities with waste reduction assistance and a local

Summit, N.J., estimates that their recycled blue wrap

Baltimore recycler, Cdm eCycling, Harbor Hospital sought

tote bags prevented the use of 100,000 plastic bags

to improve their environmental footprint and save money

and saved the hospital $30,000 in waste handling

through sustainable practices. According to a study from MD

costs in 2019. In addition to making tote bags,

H2E, blue plastic wrap comprised about 19% of all operating

they recycled blue wrap into sleeping bags for the

room waste.24 With this knowledge, Harbor Hospital’s goals

homeless, putting the “purpose” in “repurpose” in the

were to capture at least 50% of their blue wrap from the

best kind of way.22

waste stream, determine the potential savings acquired by saving this blue wrap, and to exhibit their stewardship to their employees and patients.

disposal fees, which would more greatly benefit hospitals in more densely populated regions.

Sterilization packaging for operating room instrumentation

alternatives to blue sterile wrap as a cost-saving method

had to allow for sterilization, remain sterile during storage

and discovered reusable hard instrument containers, 211

and transport, and protect instruments from damage upon

containers worth $75,000 were purchased to offset 66%

5.4 Replacing blue sterile wrap

accidental drops. These rigid, reusable, vacuum sealed

of its surgical instrumentation to these reusable hard

the hospital diverted nearly 1,700lbs, or 75%, of its blue wrap

Unfortunately, recycling blue wrap was not always a

sterilization containers were typically made of aluminum or

containers. In just one year, approximately $30,000 was

generation from the solid waste stream. In this area, Harbor

possibility as not all recycling centers accepted the sterile

stainless steel and met all container requirements.

saved in sterile wrap purchases and disposal fees, and

Hospital paid $380 per ton in RMW and solid waste disposal

packaging. In the case where recycling was not a possibility,

Before purchasing reusable sterilization containers, there

costs. Avoiding the disposal fees and allowing Cdm eCycling

some hospitals have transitioned from the recurrent

were several necessary considerations. Collaborations were

to redistribute their blue wrap, Harbor Hospital saved $320,

purchasing of blue wrap to a one-time purchase of rigid

necessary between the sterile processing department,

but most importantly helped divert 1,700lbs of plastic waste

hard cases, which served the same purpose but could be

operating room personnel, and infection control staff

from the landfill and regulated medical waste disposal.

used, sterilized, and reused repeatedly.25 Removing the

regarding the containers’ compatibility with current

need for replenishing blue wrap supply removed more

From May 2007 to December 2007, Cdm eCycling collected all of Harbor Hospital’s diverted blue wrap on a monthly basis for free. Over those six months, after staff were educated about this program’s blue wrap recycling effort,

5.3.2 Macro scale projections While recycling blue wrap may not have been an area providing the most amount of cost savings, it proved incredibly helpful in the effort to reduce both solid and RMW.

over two tons of landfill waste were avoided with almost a 40% return on investment. They found that the new cases benefitted their workflow, reduced OR waste volume, and

“Mills-Peninsula Medical Center, a 413-bed hospital

sterilization equipment, container material and type,

in Burlingame, CA purchased rigid sterilization

one-time use medical supplies from the supply chain and

and storage. Utilizing this reusable container system

containers for the organization in 2006 at a cost of

waste stream.

virtually guaranteed tremendous savings and massive

Unlike blue wrap, which required two separate payments

waste diversion in the long run but did require a hefty up-

for purchasing and disposal costs, reusable hard

front investment.

$34,987. They were able to avoid blue wrap purchases of $25,173 and save $26,000 in rewrapping costs for torn blue wrap sets, making the payback 8.2 months with an additional cost-savings of $16,186 in one year

instrumentation containers only incurred a single purchase.

Utilizing Spectrum Health’s blue wrap recycling program as

This provided an opportunity for hospitals to calculate how

a typical model, if all hospitals in the United States recycled

many containers they may need for their operating rooms

or redistributed their OR’s blue sterile wrap, then the U.S.

only once, which removed recurring cost, saved exorbitant

healthcare system would annually save $8 million in disposal

amounts of money in the long term, and eliminated

fees and divert 131,750 tons of blue wrap from the landfill.

thousands of tons in blue wrap waste a year.

This number widely varied based on the region’s RMW 66

without even tallying waste avoidance costs into the 5.4.1 MetroWest Medical Center case study26

equation.³”

MetroWest Medical Center was a 269 bed health system

- Gail Lee, past Director, Environmental Health &

in the Boston, Massachusetts area with 16 operation

Safety, Mills-Peninsula Medical Center, Burlingame,

rooms performing over 10,500 surgeries in 2010. After their

California³

sterile processing department leader began searching for 67

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Reducing waste in the operating room

From a cost-savings perspective, purchasing reprocessed The St. Cloud VA Healthcare System in St. Cloud,

SUDs in lieu of new SUDs was an obvious choice, providing

MN, avoided the burdens of waste handling and

savings of 50% or more on commonly reprocessed medical

transportation costs by switching from disposable

devices.27 This posed massive savings potential as operating

to reusable items wherever possible. By switching

room used the most expensive medical devices in the

to reusable sterilization containers, St. Cloud VA

Figure 16: Reprocess single-use medical devices.

hospital. Environmentally speaking, SUDs that were not

Healthcare System reduced waste by 7,350 pounds in

collected for reprocessing ended up joining the RMW

the first three months while maintaining the highest

stream, eventually populating a landfill. In fact, a single

standards for staff and patient safety.

hospital could reprocess over a ton of SUDs in one year,

22

which meant huge cost-savings for the facility and relief for of course provided cost-savings by avoiding blue sterile

the landfill.27

wrap purchasing.

Examples of reprocessed SUDs included catheters, endoscopic instruments, orthopedic surgical instruments, and many other devices, in fact the United States currently

5.4.2 Macro scale projections

reprocesses more than 100 kinds of SUDs.19 With more than

Replacing blue sterile wrap from the operating room supply

60% of operating room single-use devices capable of being

chain provided massive cost-savings and potential for tons

reprocessed per the FDA’s list, OR supply management

of diverted solid waste from the landfill. If each hospital in

greatly advantaged partaking in reprocessed SUDs. Most

the U.S. were to adopt hard sterilization containers in their

hospitals have discovered the noteworthy cost-saving and

OR department and experienced results like MetroWest,

environmentally friendly benefits to reprocessing SUDs;

the 6,200 hospitals in its healthcare industry could expect

however, some were weary of purchasing refurbished

annual cost-savings of $186 million and divert the same

SUDs out of contamination and underperformance fears.

131,750 tons of blue plastic wrap as recycling would save

However, according to the United States Government

from the landfill.

Accountability Office, the FDA had increased their oversight of reprocessed SUDs and found them no more dangerous than purchasing brand new equipment from

5.5 Reprocessing medical devices

manufacturers.28

Another powerful waste reduction, cost-saving strategy involved the collection and reprocessing of FDA-approved single-use devices (SUDs). Defined by the Medical Device User Fee and Modernization Act of 2002, a reprocessed

5.5.1 Metro Health Hospital case study30 Located in Wyoming, Michigan, the Metro health Hospital was a 208 bed facility with 10 operating rooms performing

““The University of Washington Hospitals in Seattle,

over 12,700 surgeries in 2010. After evaluating numerous

WA diverted 5.8 tons of waste and saved the

30

organization $496,123 in 2008 by reprocessing more

techniques and strategies for minimizing their environmental footprint and cost-savings, Metro Health viewed SUD

than 100 different single-use medical devices.³”

reprocessing as a key strategy. Once they had selected and

- Sheila Jobe-Lockwood, Compliance Outreach

Practicing medical device reprocessing was comprised

partnered with a third-party vendor for reprocessing their

Coordinator, Environmental Health & Safety,

of two methodologies: collection of devices bound for

SUDs, Metro Health saved an annual average of $78,600

University of Washington Medicine, Seattle,

reprocessing and the following repurchase of reprocessed

and diverted 1.84 tons of waste from the RMW stream.

Washington³

devices.28 The collection of SUDs offered the most

single-use device was any “original device that has

opportunity for diverting waste tonnage, while the bulk of

previously been used on a patient and has been subjected

cost-savings and environmental stewardship occurred when

to additional processing and manufacturing for the purpose

facilities bought these reprocessed devices back. Between

of an additional single use on a patient.1” After use, SUDs

2007 and 2010, reprocessing SUDs became common practice

were collected and reprocessed either within the hospital

as the industry reprocessed more than 50 million devices

or more likely by third-party vendors, then the reprocessed

and diverted 10,000 tons of regulated medical waste, and,

device could be sold either to a separate facility or

as of 2016, 70% of U.S. hospitals practiced with reprocessed

repurchased by the same facility.18 Regulated by the FDA,

SUDs.27 Hospitals participating in Practice Greenhealth’s

reprocessed SUDs met the same standards as an originally

5.5.2 Macro scale projections

““Through reprocessing of medical devices, Advocate

Utilizing Metro Health Hospital’s success as a micro scale

Christ Medical Center was able to save $400,000

model projected upon the macro scale of all U.S. hospitals,

and avoided sending almost 5 tons of waste to the

if the entire U.S. healthcare system practice reprocessing

incinerator or landfills in 2010.³”

single-use devices, then hospitals across the country

-Mary Larsen MS, Environmental Stewardship

would save at least $487.3 million and avoid over 11,400

Manager, Advocate Health Care, Chicago, Illinois³

tons of RMW.

sustainable practices survey enjoyed a collective savings

manufactured SUD, and in some cases their standards were

of $30.5 million between avoided disposal fees and lower

more stringent than the original equipment manufacturers.27

purchase costs, averaging individual annual savings over $295,000.29

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5.6 Anesthetic gas reduction and reclamation Every day, operating rooms around the U.S. practiced general anesthesia with inhaled anesthetic gases, which contained environmentally damaging chemicals. In fact, just one hour of administering desflurane, a commonly used anesthetic gas, contributed the greenhouse gas emission equivalent of driving an automobile 400 miles.31 Just within

To reduce the leakage of these damaging gases, researchers

manufacturer’s price. This incorporated a reprocessing-like

5.6.2 Macro scale projections

experimented with new methods of capturing anesthetic

system for anesthetic gas, which both provided healthcare

If the 6,200 hospitals in the U.S. reduced anesthetic gas

gas before they were released into the OR, and eventually

facilities with cost-savings and saved the environment from

emissions through low flow anesthetic gas scavenging

the atmosphere. Many medical companies have since

leaked volatile gases. Healthcare facilities could subscribe

and reclamation, then the national healthcare industry

developed scavenging systems in this effort. One system

to this anesthetic gas capturing service with a monthly fee

might save $250 million and sequester about 125,000lbs of

called the Dynamic Gas Scavenging System captured

that covered the cost of Deltasorb’s canisters and provided a

anesthetic gases from entering the atmosphere.

and recycled 99% of anesthetic gas without altering or

monthly report of how much gas was captured.

diluting the anesthetic agents.17 This system was tested

the United States, 500,000 gallons of anesthetic were

5.7 Reusable sharps containers

and developed four Vanderbilt University Medical Center

released in 2008, and each gallon of anesthetic cost about

operating rooms. Priced at $20,000 with the ability to serve

5.6.1 Lexington Medical Center case study

up to eight operating rooms, the system was designed to

The Lexington Medical center, located in Columbia, South

work with any anesthesia machine, and provided significant

Carolina, was a 414 bed general hospital with 22 operating

energy savings because the vacuum pump ran only 10%

rooms. Conducting more than 21,000 procedures the

of the time, only when the patient exhaled an anesthetic

hospital was searching for savings opportunities with long-

Several strategies have been implemented in the effort

appeared.17 Another company, Blue-Zone Technologies

term positive economic effects. Finding that their anesthesia

to mitigate these gases effect on the environment and

Ltd, utilized a canister system, called Deltasorb, which

gas purchasing accounted for about 10% of their total $18

reduce costs including: educating anesthesia providers on

specifically captured inhaled anesthetics through a

million annual pharmaceutical expenses, Lexington Medical

the cost and environmental effects of waste anesthesia

filtration process before escaping into the atmosphere.17

Center implemented a waste anesthesia gas scavenging

gas, utilizing low fresh gas flows, administering anesthesia

The anesthetic gases were then extracted from the

system called the Dräger Apollo Low Flow Wizard in all 22 of

intravenously, and investing in high energy-efficiency

canisters, liquefied, and finally processed for bulk anesthetic

their operating rooms. Not only did the ten anesthesiologists

equipment that could scavenge, destroy, or sequester gases

drug production, which could either be sold back to the

and 50 CRNSAs report high satisfaction for this system

from escaping outside.

hospital or another third party for less than the original

because of its universal effectiveness and efficiency, the

$2,000.32 With these gases having high global warming potential and their increased prevalence over the last thirty years, it was imperative that the healthcare industry reduced and reused anesthetic gases.

33

FDA-approved sharps waste containers in operating rooms were typically lined with a plastic bag that was commonly discarded along with its contents, which not only added volume to the waste stream, but also required continuous replacement, adding additional cost to an occupational need. However, like SUDs, a movement to reduce single-use medical devices pushed for the creation of reusable sharps containers. Instead of removing and disposing the plastic bags from the containers, the containers were entirely removed and replaced with another sharps container for disposing its contents. Unlike SUDs, these containers were used and reused hundreds of times. These reusable sharps containers temporarily stored sharp waste before

hospital realized cost savings of more than $100,000 in the

collection, which was done by a third party who emptied

first year of implementation. Because the system utilized

their contents, processed the waste, cleaned and disinfected

an optimized low fresh gas flow, patients reported quicker

them, and then returned them to the hospital for reuse.

recoveries and left the hospital sooner than previously

Reusable sharps containers have existed in operating

reported. By using this system’s low fresh gas flow and

rooms and healthcare facilities for many years, and the

anesthetic reclaiming system, the facility reduced their

implementation of these containers resulted in numerous

anesthetic gas supply costs by 25%.

Figure 17: Practice anesthetic gas scavenging and reclamation.

environmental and cost-savings benefits. Because of this, implementing reusable sharps waste containers was an easy strategy to reduce both supply costs and the hospital’s

““The new Dräger machines feature a software

environmental footprint.

platform that allows our CRNAs and anesthesiologists to adjust the flow rate of the anesthetic, which led to a cost savings of more than $100,000 in the first year in reference to 21 machines. The fact that the anesthesiology department had the opportunity to implement this was a wonderful development for the hospital.33” -Harriet Horton, Lexington Medical Center, Columbia, South Carolina33

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supplies to developing countries. However, in most cases hospitals typically disposed these unused supplies, which

“In collaboration with its vendor, Mayo Clinic Surgery

unfortunately often ended up in the regulated medical

in Rochester, MN reviewed and reformulated its

waste stream.

custom packs in the OR in an effort to reduce both waste and cost, saving nearly $125,000 in avoided supply costs with the new kits since April of 2009.³”

5.8.1 University of Minnesota Medical Center (UMMC) Figure 18: Implement reusable sharps containers.

- Kevin T. Hovde, C.P.M., Supply Chain Mgmt

case study35

Performance Consulting Lead Senior Analyst –

Located in Minneapolis, Minnesota, the University of

Surgery, Mayo Clinic, Rochester, MN Thomas J.

Minnesota Medical Center was a nearly 2,000 bed hospital

Louks, Hospital Surgical Services Finance Specialist,

with 21 operating rooms and performed over 6,100 surgeries

Mayo Clinic, Rochester, Minnesota3

in 2010. A surgeon at UMMC, Dr. Rafael Andrade, was concerned with the volume of waste exiting the facility’s operating rooms and decided to systematically reform the facility’s OR kits. Dr. Andrade reviewed the facility’s most

5.8.3 Macro scale projections

used OR kit and reduced its contents from 44 items to 27. Not

Averaging these three cases’ savings and projecting their

only did this reduction save $50 per case, but it also reduced

outcomes, if the U.S. healthcare industry applied OR kit

the waste production by one pound per case. Performing

reformulation across the board it should expect $588.4

this kit reduction technique, Dr. Andrade saved the facility 5.7.1 Macro scale projections Collectively utilizing reusable sharps containers, and

“Borgess Medical Center, a 450-bed hospital in

averaging savings from Advocate Illinois Masonic Hospital

Kalamazoo, MI made the switch to reusable sharps

and the Borgess Medical Center, the U.S. healthcare industry

containers in 2007. The transition has enabled

would save $74.4 million and divert 62,000 tons of waste

Borgess to reduce its regulated medical waste by 10.5

from the RMW stream per year.

tons at savings of $11,000 dollars annually.3” - Eric Buzzell, Executive Director, General Services & Property Management, Borgess Medical Center,

5.8 OR Surgical kit reformulation

Kalamazoo, Michigan3

Operating room surgical supplies were typically dictated by surgeon preference. Each procedure typically had several prepackaged kits full of a variety of supplies that

“The reusable sharps container program at Illinois

million in supply costs and avoid about 29,500 tons of both

$2,000, 64lbs of CO2 emissions, and 80lbs of waste.

solid and regulated medical waste.

Realizing significant savings, he presented his findings to the rest of UMMC’s operating room staff and worked with several others to systematically review an additional 38 OR

5.9 Reusable linens

kits, identifying unused items like plastic basins, Styrofoam trays, plastic cups, gauze dressings, and syringes. This

Many health systems across the country who were dissecting

subsequently prompted coordination with their OR kit

waste streams and analyzing their contents began to

vendors, which allowed for them to request fewer supplies

rethink their treatment of OR gowns and drapes. Similar to

and ultimately lower OR kit cost. This OR kit reformulation

the migration from reusable medical devices to single-use

reduced the UMMC’s waste production by over 10,500lbs

devices, surgical linens and basins were once laundered

and saved the hospital over $116,200 per year in avoided

and reused but transitioned to disposable textiles in a

supply and disposal costs.

response to infection and protection concerns. These textiles included towels, gowns, and mayo stand covers, which were

the surgeon may or may not need for accomplishing that

Masonic Hospital (an affiliate of Advocate Health)

procedure. For each procedure, the surgeon would submit

reduced its regulated medical waste by 10 tons and

preferences on the composition of devices, equipment,

saved the organization $13,000 dollars in 2010.³

and kits in the operating room. However, some of these

- Steve Verzi, Safety Coordinator, Advocate Illinois

supplies were not always needed for every procedure. When

Masonic Hospital, Chicago, Illinois³

the supplies placed within these kits were provided for a procedure but not used, under FDA guidelines any item prepared for one patient’s procedure could not be used for a separate patient’s procedure, which deemed even unused supplies as unsterile and unacceptable for alternative use.34 In some cases, healthcare facilities would collect these opened but unused and clean supplies for donation to third party organizations who would then distribute these 72

classified as medical devices by the FDA, and as a result 5.8.2 Other Success

were typically disposed as regulated medical waste after

Seattle Children’s Hospital worked with OR leadership to

just one procedure.37 The Association for the Advancement

reduce their operating room waste.36 Every one to two years,

of Medical Instrumentation provided performance

the facility reviewed the supplies within their OR kits and

standards for each of these textiles, and found that both

adopted a sustainable approach to decide which supplies

reusable and disposable products met all levels of necessary

would stay in their OR kits. Upon review of the supplies, the

performance. Attracted to lower up-front costs, about

team utilized an 80/20 rule in which only items used 80% of

80% of U.S. healthcare facilities in 2001 chose disposable

the time would remain in the kit. This 80/20 rule resulted in

linens as opposed to considering long-term cost benefits of

over $43,500 of annual savings from supply and disposal

reusable linens.19

costs, and avoided the disposal of about 8,500lbs of waste,

However, one study discovered that replacing disposable

most of which would have been disposed as RMW.

gowns, surgical basins, and table and Mayo stand covers 73

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2019–2020 Yearbook

Reducing waste in the operating room

5.9.2 Macro scale projections

regulated medical waste by about 20%. This could divert

Assuming a similar average rate of success as UMMC and

approximately 31 tons of annual waste from the RMW stream

Kaiser Permanente, if the U.S. healthcare industry utilized

per OR, saving about $30,000 a year per operating room

reusable linens in the operating room setting, it should

simply by implementing best waste segregation practices.

expect savings of $240.5 million in disposal fees and divert 306,900 tons from the solid waste and RMW streams.

6.3 Recycling blue sterile wrap Figure 19: Convert back to reusable operating room linens.

Recycling or redistributing blue sterile wrap, which

6.0 Client takeaways

depended on local recycling vendors, provided vastly varied outcomes directly related to the hospital’s locality. Hospitals

Admittedly, the necessary management coordination

in more densely populated regions like the northeast would

between several teams of hospital staff, influencing

benefit significantly more from diverting blue sterile wrap

their workflow and sometimes altering their operations

waste than less populated regions. However, even in lesser

completely, in order to remediate operating room waste

populated areas a hospital should expect to at save at

management was certainly no small undertaking. The

least $1,500 in disposal fees from annually diverting over

aforementioned strategies of reducing OR waste required

half a ton of blue sterile wrap per OR from the nationwide

focused interest from all parties and the cooperation of

diminishing landfills.

each member in an interlocked system of highly trained, highly intelligent individuals. Retraining these individuals with reusable products resulted in a 65% reduction of

were annually generating about 5 million tons of waste

for improving operating room waste outcomes was no small

regulated medical waste generated in the operating

and spending $1.35 million on disposing that waste. After

feat. Also, most healthcare facilities did not have the ability

room.38 This was likely because disposable linens generated

performing a waste audit, they discovered that their

to implement each of these waste reduction strategies, so

packaging waste, which was avoided when utilizing

operating rooms were generating millions of pounds in

illustrating a matrix of projected savings and environmental

reusable linens that could be used and reused 75 times or

waste per year, and that items such as gowns, towels, and

benefits per each reduction strategy provided hospital

more. Beyond their negative environmental performance,

basins were all being disposed. With this knowledge, UMMC

management with the opportunity to pick and choose which

disposable linens received negative feedback from OR

collaborated with a third-party vendor who provided them

strategies, no matter how small, were most appropriate for

surgeons and staff who complained about thermal comfort

with reusable sterile surgical gowns, drapes, and basins.

their operating rooms.

issues, tearing table covers, and their small size.

The vendor would collect used items, returning them to their

6.4 Replacing blue sterile wrap Replacing the majority of the operating rooms use of blue sterile wrap with rigid reusable instrument containers incurred an up-front cost in the tens or hundreds of thousands of dollars. Purchasing rigid sterilization containers reduced annual OR blue sterile wrap purchases by 76%, which in some cases made the return on investment endeavor less than one or two years considering direct supply costs and disposal fees. Per operating room, cost-

plant where they were cleaned, sorted, packaged, sterilized,

Today’s reusable textiles were both technologically and compositionally advanced compared to what they were before the transition to single-use, disposable textiles.

Today’s circumstances allowed hospitals to choose between cleaning these textiles through an onsite laundry operation

and redelivered back to UMMC. Utilizing this vendor and

6.1 Fluid waste management system

tracking their progress, UMMC avoided over 69 tons of

Provided the opportunity, and if hospital management

waste and about $38,800 in waste disposal fees in one year

considered the long-term benefits of up-front costs, the

as a result of reusing their linens.

implementation of a fluid management system in an

or a third-party vendor. Choosing a vendor for providing

operating room should produce cost-savings anywhere

reusable textiles was more desirable in hospitals lacking the

between $4,000 and $10,000 in supply and disposal costs

“Kaiser Permanente’s use of reusable surgical gown

infrastructure for running an onsite laundry operation.

and basin sets reduced the organization’s regulated medical waste by 30 tons, at a savings of 3.8% in

savings were estimated to be at least $1,500 and divert half a ton of wrap in one year.

6.5 Reprocessing medical devices Reprocessing single-use medical devices was a practice heralded as one of the most impactful strategies for cost-

and avoid about six tons of liquid waste per operating

savings and environmental stewardship. An individual

room, per year.

hospital should expect cost-savings between $50,000 and $90,000 per ton of single-use medical device waste

2010.3

5.9.1 University of Maryland Medical Center (UMMC)

- Andrew Knight, Senior Sourcing Director, Kaiser

case study39

Permanente, San Diego, California³

The University of Maryland Medical Center was a 757

of at least $4,000 per operating room and diverting about

Training OR personnel the industry’s best waste

bed hospital with 31 operating rooms and performed

management practices, while following local regulations,

21,500 surgeries in 2010. In 2007, UMMC found that they

posed the possibility of reducing each operating room’s

74

diverted from the landfill. On an annual basis, cost-savings

6.2 Improved waste segregation

500lbs of waste.

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6.6 Anesthetic gas reduction and reclamation

6.8 OR surgical kit reformulation

By practicing anesthetic gas scavenging and reclamation,

By reviewing absolutely necessary surgical supplies in OR

an operating room equipped with one of these machines

surgical kits and reducing the need for unused supplies that

should expect an annual savings of at least $4,750 and a

could not be used for another surgery, each operating room

25% reduction of waste anesthetic gas generation.

would save over $5,000 and 500lbs of solid and regulated medical waste per year, per OR.

7.0 Conclusions

Resources

With the exponential increase of healthcare medical waste

Greening the OR Initiative: Practice Greenhealth developed

generation, financial and environmental concerns sparked

the Greening the OR Initiative (GOR), which offers tools and

an interest in revamping healthcare waste management

resources for sustainability efforts in the OR.

and recycling programs. Representing a shockingly large

Healthier Hospitals Initiative: A 3-year challenge to

percentage RMW in typical ORs, fluid waste management

engage the nation’s hospitals in adopting a basic set of

alternatives proved highly beneficial to RMW reduction.

6.7 Reusable sharps containers

environmental best practices, Healthier Hospitals Initiative

Beyond an effort to generally reduce waste generated

6.9 Reusable linens

Implementing reusable sharps containers in ORs presented annual cost-savings between $10,000 and $15,000 and

Historically speaking, utilizing reusable linens in operating

commonly reduced regulated medical waste streams by 10

rooms had once been widely practiced, but since a move

tons per year, per OR.

to single-use devices had become popularized, so did disposable linens. However, by converting back to reusable linens that could be cleaned onsite or laundered through a third-party provided annual cost-savings opportunities of over $1,200 per operating room and avoided over 2 tons of solid and regulated medical waste per year, per OR.

(HHI) offers a series of free webinars, implementation guides.

in the operating room, the proper waste segregation of

Learn more at www.healthierhospitals.org.

RMW, solid waste, and recyclables provided surprising possible savings. Blue sterile wrap would likely always

Association of periOperative Registered Nurses: Association

have a presence in the hospital, but the treatment of blue

of periOperative Registered Nurses (AORN) has an updated

wrap waste and the possibility for replacing it in operating

position statement on environmental responsibility and

rooms posed the possibility for significantly positive

has launched a “Going Green” discussion forum. Visit

environmental and expenditure outcomes. Reprocessing

www.aorn.org.

and reusing sharps containers, medical devices, and linens were common operating room practice, but still benefitted the OR’s sustainability. Removing unnecessary supplies from

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[38] Conrardy, RN, J, et al. (2010). “Reducing Medical Waste”, AORN Journal, Vol. 91, No.6, pp: 711-721

files/upload-files/casestudy_uofmd_r6_web.pdf

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Below and bottom right: SoLe Mia, a medical office building for the University of Miami! This is a project Chris has been working on during his fellowship at the Los Angeles studio.

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“Chris is very engaged in our studio events, and has a very good work ethic! He is very well versed in all technical aspects of project delivery and is always included as an integral team member on healthcare projects at our studio.” ―TINA GIORGADZE, IIDA, LEED AP ID+C, CHID, RID, LEAN BLACK BELT, SENIOR INTERIOR PROJECT DESIGNER, SENIOR ASSOCIATE, LOS ANGELES STUDIO

↑ Top and Bottom Left: Chris in his Los Angeles studio environment.

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