In 2020, the United States faced significant challenges in obtaining adequate personal protective equipment (PPE) and supplies for testing and treating COVID-19. As case numbers rose and vaccines were rolled out, supply management and waste reduction remained prominent issues this year.

Isolation gowns, gloves, masks, needles, syringes, and vials are discarded after use: some waste is unavoidable, but supply chain managers are looking for ways to reduce usage, reuse and recycle where possible, and adjust purchasing and packaging to benefit the environment and sometimes improve financial performance.

Sources of medical waste

Although the term "PPE" entered the public lexicon due to the COVID-19 pandemic, it has long been a staple in the healthcare system.

Isolation gowns

In healthcare settings, isolation gowns are the second most commonly used PPE after gloves, and currently 80% or more of isolation gowns used in the United States are disposable.

As hospital cases surged and healthcare workers needed to change gowns frequently, disposable gowns became more expensive and harder to procure.

"I'm shocked this is now a challenge. There's no reason they can't be reused," Howard said, by purchasing washable gowns. "Some infection control departments insist on disposable PPE, but there is research and evidence showing that disposables are not necessarily safer than reusables."

She noted that hospitals that had already used reusable PPE before the pandemic felt more prepared due to supply chain disruptions caused by the outbreak.

UCLA Medical Center began switching to reusable isolation gowns in 2012, diverting nearly 300 tons of waste from landfills within three years and saving over $1.1 million in procurement costs. A study published in the American Journal of Infection Control showed that after 75 industrial washes, medical-laundered gowns were more durable and provided better protection than disposable gowns.

Vials and needles

Howard said that for vaccines, there are fewer recycling opportunities. Glass vials and needles must be placed in sharps containers, although some containers can be decontaminated and reused after safe handling of their contents.

"Remote areas are more difficult to handle," Howard said, because these facilities may have fewer waste collection services due to their size or location.

Plastics

Plastics are a major component of waste, including flexible plastics, multi-resin products, and blue wrap (polypropylene) used to hold instruments during and after sterilization.

Recycling is only part of hospital sustainability programs, but it receives much attention, especially from employees. Howard noted that China's 2018 policy restricting or banning imports of certain recyclables slowed or halted many recycling programs.

A second life for PPE and medical supplies

During the pandemic, healthcare systems may use more reusable items out of necessity, thereby reducing waste. The global shortage of N95 masks forced hospitals to find alternatives, not just requiring staff to reuse disposable masks over multiple shifts, which led to new sterilization methods. Howard said hospitals are gaining approval from the U.S. Centers for Disease Control and Prevention to decontaminate certain disposable items, and if these methods reduce waste and are safe, they may be used long-term.

How healthcare facilities allocate supplies in patient rooms and operating rooms also affects waste volumes.

"If you calculate what you spend on disposables, it might open your eyes."

— Janet Howard, Director of Member Engagement, Practice Greenhealth

"Anything brought into a [patient's] room that the patient doesn't take is thrown in the trash," said Elizabeth McLellan, founder and president of Partners for World Health, a nonprofit that collects supplies and equipment from U.S. healthcare facilities and distributes them to developing countries.

Once items are opened in a patient room or operating room, they cannot be reused within the hospital. Her organization collects 10,000 to 20,000 pounds of unused materials daily from healthcare facilities in the Northeast (excluding durable medical equipment), ranging from unused exam gloves and wound care supplies to unneeded anesthesia machines.

"Pure medical waste goes in red bags," McLellan said. "Everything else I see as discarded but having a second life."

Managing inventory, managing waste

Hospitals may have supply chain and procurement agreements that do not allow products to re-enter the supply system. Before partnering with PWH, facilities might discard unused items, but now staff can place them in collection bins. These items are clean but not sterile and are taken to loading docks for PWH staff to pick up. PWH uses its own autoclaves to properly sterilize items, then repackages, labels, and dates them.

Operating rooms are one source of reusable supplies. A study in the Journal of Neurosurgery found that at UCSF, each neurosurgery procedure averaged $968 in unused and discarded supplies, accumulating to $2.9 million annually in that department alone.

These supplies are often included in surgical procedure kits containing items typically needed during surgery. A hysterectomy kit might include six disposable gowns, sterile gloves, plastic bowls, sutures, and three sets of 10 sponges. But if most doctors don't use all items, unused supplies may be discarded.

One option to reduce unused surgical supplies is to reconfigure procedure kits. Hospitals can determine the items and quantities they want and work with suppliers to reconfigure them.

Some of the savings can be used to purchase more environmentally friendly products. The additional cost of these green products ranges from a few cents per item to 40% more per item, said Kimberly Ludy-Chase, co-founder and vice president of marketing at NewGen Surgical, which sells products made from agricultural waste materials. While that may sound high, she said hospitals view it in the context of total spending per pack.

Why not put unused items back in supply cabinets? "I think it would be difficult for hospitals to establish a completely different service to reprocess these items," McLellan said.

It would be costly, require additional personnel and tracking, and could interfere with accreditation standards. Nevertheless, some hospitals now use supply cabinets outside patient rooms so they can take just one gauze pad or diaper rather than bringing the entire package into the room.

"Pure medical waste goes in red bags. Everything else I see as discarded but having a second life."

— Elizabeth McLellan, Founder and President, Partners for World Health

Organizations like the Cleveland Clinic separate waste into 37 different categories, seeking the best ways to reuse or recycle. The clinic estimates its organization generates 6,000 tons of waste daily. It sorts by bag color: red for regulated medical waste, orange bags for plastics, blue bags for mixed recyclables, purple bags for clinical plastics, and clear bags for non-regulated waste.

The Cleveland Clinic's main campus uses an underground tunnel system where 100 robotic automated guided vehicles transport waste bags to their destinations, whether to the health system's autoclaves or to collection docks for recycling and medical waste.

Small operational changes bring big impacts

Hospitals can decontaminate some products like metal emesis basins, but the cost of collecting, transporting, sterilizing, and repackaging these items may be higher than buying new ones, especially when they are contaminated with patient bodily fluids. "It's not worth the supply chain cost," Ludy-Chase said.

Ludy-Chase said operating rooms account for up to 35% of hospital waste, but there are opportunities to reduce waste without changing current workflows.

"You don't want to make huge changes to how perioperative staff work because it takes time, training, and cost," she said.

Through NewGen Surgical's "Small Change, Big Impact" program, Dignity Health Network replaced traditional plastic needle counters used in operating rooms with counters made from plant-based materials. Although these poker-card-sized boxes are still discarded after surgery, Dignity Health eliminated 10 tons of single-use plastic in two years.

Blue wrap (made of polypropylene) is commonly used in hospitals to wrap instruments for sterilization. According to Practice Greenhealth, the healthcare industry discards about 255 million pounds of blue wrap annually.

Previously, hospitals used rigid sterilization containers.

"We would rather hospitals go back to reusable sterilization containers than recycle blue wrap," Howard said. It is bulky and difficult to recycle. While investing in containers costs money, "if you calculate what you spend on disposables, it might open your eyes," Howard said.

Key performance indicators for measuring and reducing waste

Key performance indicators depend on the healthcare system's goals. McLellan said PWH provides each hospital annually with an accounting of how many pounds were collected from their organization, so hospitals can calculate savings from avoided disposal costs.

She can also tell hospitals where their durable medical equipment went, because hospitals like to share this information in annual reports. "I can tell them 20 beds went to Ethiopia, and their anesthesia machines went to Syria," she said.

Ludy-Chase said NewGen Surgical can calculate how many tons of plastic waste customers save annually by using products like plant-based trays, because trays are included in many surgical kits. Unlike traditional polystyrene surgical trays, NewGen Surgical's trays can be recycled with paper products. The organization estimates that one kit manufacturer purchased enough trays to fill seven football fields knee-deep.

The Cleveland Clinic charts its waste profile quarterly, dividing waste into more than thirty categories, including pulse oximeters, X-ray film, ice packs, and batteries. The clinic also tracks landfill diversion rates annually.

Howard said every healthcare facility should have someone leading sustainability efforts. "The most successful hospitals are those that have dedicated positions," she said, noting her organization has seen hospitals create more waste management manager and energy management manager roles.

The sustainability process requires ongoing education and employee engagement strategies. "Whether hospitals are interested or not, if they don't address these waste issues, they will be left behind," Howard said.

This article first appeared in the weekly newsletter Supply Chain Dive: Operations.Subscribe here。