Quantifying Medical Waste at a Veterans Affairs Operating Room

Introduction

Medical waste may be defined in terms of patient care, fraud, administrative complexity, costs, and environmental impact. ¹ From a surgical standpoint, operative procedures are associated with an invariably high rate of waste that ranges from 20%–70% and is evident at the end of each case. ² The operating room is associated with the majority of a hospital’s supply costs including 60% of its regulated medical waste. Typically, operative waste includes medical equipment such as needles, syringes, suture, drapes, gauze, dressings, and surgical instruments. By optimizing instrument tray selection, several studies document a reduction in the number of instruments per case. The reduction in instruments improves medical waste through decreased sterilization and set up times and resource utilization.^3,4 In addition, the efficient use of surgical gowns, gloves, and drapes reduces medical waste associated with surgical textiles.^5,6 The reduction in surgical textiles is magnified by the decrease in waste disposal perioperatively.

Based on the data from a variety of studies, several societies published guidelines or green checklists for an environmentally conscience operating room. ⁷ Most of the guidelines emanate from orthopedic and general surgery specialties and entail an overall reduction in equipment. The reduction in equipment not only reduces waste but decreases costs associated with reprocessing or disposal. The costs analyses may be complicated by contractual agreements with industry manufacturers, supply chain logistics, billing practices, and depreciation of equipment. Moreover, patient, hospital, and societal costs are rarely discussed together. Regardless of the analysis, decreasing costs benefits individuals, groups, or payors at some point in the health care continuum. This study attempts to quantify the amount of medical waste associated with operative cases at an urban Veterans Affairs Medical Center (VAMC).

Methods

The Investigational review board at the Washington, D.C. VAMC approved this study (#1621468-9). The requisite for informed consent was waived due to the nature of this study and the lack of patient contact. This research was a prospective analysis at an urban medical center located in VISN 5.

Data obtained from this study included extraneous equipment from surgical procedures between June 19, 2024 to July 31, 2024. Extraneous equipment and medical supplies were evaluated qualitatively for cleanliness and there was no direct patient contact nor was the equipment contaminated in any manner. Items were excluded from the operating room if there was any potential for infection (eg., liquid or solid human waste). These items were disposed in the usual manner. The equipment was counted and weighed. Hospital costs for the equipment are based on the procurement price found in the Veterans Health Information System Technology Architecture (VISTA) package which represents nation-wide pricing that is established annually by the General Services Administration (GSA). The quantitative analysis is reported for the 6-week period note above.

Results

Overall, there were 81 pieces of surplus equipment and 1122 pieces of surplus medical supplies. The type and number of equipment and medical supplies are shown in Table 1. The most common piece of surplus equipment was a towel clip, and the most common surplus medical supply was a blue towel. The total weight of the equipment was 72.2 kg. The five most common pieces of surplus equipment or supplies were blue towels, suture, gloves, gowns, and gauze pads. Based on the Integrated Fund Control, Accounting, and Procurement number, the individual price for each of the five above items was $1.32, $1.84, $4.05, $5.74, and $0.13, respectively. Over the 6-week period, the total cost of the five most common items was $1,764.56. Finally, the total weight of the surplus items was 72.2 kg.

Discussion

This study identifies the surplus surgical equipment and supplies accumulated perioperatively at a single urban VAMC over a 6-week period by a single surgeon and an advanced practice provider. The most common supplies were textiles, and this aligns with previous studies that document textiles as the most common item in terms of quantity and weight. For textiles, blue towels were the most common item followed by drapes. Disposable surgical drapes, gowns, and various wraps account for 80% of the market share of operating room textiles. ⁸ These items represent an opportunity to convert disposable items to reusable linens. Prior to disposable drapes, reusable linens were customary but required laundry services, increased labor, and the ability to match the quality of disposable textiles. Interestingly, reusable gowns were rated significantly higher in terms of comfort, ease of use, and protective qualities by surgeons and surgical technicians. ⁵ Our facility is limited from a staffing perspective and does not have the capacity to increase its laundry services.

The literature documents that the weight of medical waste per procedure may range from 19.4 kg per case in myocardial revascularization and valve replacements to 3.8 kg per case in hernia repairs. This wide range reflects different draping patterns and the number of personnel participating in each case. ⁶ The majority of our cases were general surgery cases that included hernia repairs, cholecystectomies, and benign skin lesions. Although the type of case was not recorded, no cardiothoracic cases were included in this analysis. As we broaden our collection to include all service lines, the total weight and weight per case will likely increase.

The most common piece of surplus surgical equipment was a set of disposable towel clips. These items are opened on minor cases and each respective surgeon may choose to utilize them while draping. Our facility has standardized preference lists, but these lists require continual assessment. As well, disposable towel clips have been a standard piece of equipment for decades. However, these standard pieces of equipment for certain cases could easily be omitted based on this data.

The cost data reflects the public sector pricing based on government contracting. Overall, the 6-week analysis accumulated a dollar value of over $1700. At 12 months, this total would approximate $14,600. This is a conservative figure based on the activity of a single surgeon and an advanced practice provider who accrued surplus equipment and supplies through a grass roots movement.

Disposable single use surgical equipment and medical supplies remain an environmental and costly endeavor. Waste disposal may require special containers and processes that exponentially add to the costs of disposable items. In addition, using landfills for health care waste may contaminate drinking, surface, and ground water while incinerating waste may release air pollutants and generate ash residue. Moreover, incinerated materials may contain chlorine which generates dioxins and furans. These byproducts are human carcinogens and associated with a wide range of adverse health effects.^8–10

There are some potential strategies to mitigate the quantity of disposable textiles and medical equipment. Blue towels drape the surgical field and dry the surgical team’s hands. Moving forward, blue towels could still be used to drape the surgical field beneath the surgical drapes. However, after the initial case, an alcohol-based rub should be used to avoid additional blue towels. After using an alcohol-based rub, the hands air dry and do not require paper or linen towels. Furthermore, the surgical site infection rate is similar between alcohol-based rubs and aqueous scrubbing with povidone iodine solutions.^11,12 Other strategies to reduce waste include reprocessing of supplies and equipment and recycling of medical PVC (polyvinyl chloride). Medical PVC is used for intravenous fluid bags and oxygen masks. ⁵ Both reprocessing and sterilizing supplies are possible through steam sterilization (autoclaving) and thermal treatments such as microwave technologies.^13,14

Simplifying and developing a uniformed list for equipment and supplies may be one of the most important strategies to alleviate surgical waste perioperatively. A uniformed approach removes heterogeneity regardless of surgeon and simplifies the operative set up for nursing and sterile processing personnel. This type of strategy has been implemented successfully in multiple scenarios and across several disciplines.^3,4 Regardless of strategy, a health care champion is an absolute necessity and the driving force behind any endeavor to reduce medical waste. Without a champion, reducing operative waste is unlikely. The champion may be a surgeon, nurse or advanced practice provider who creates awareness and communicates the important implications of reducing perioperative medical waste. Based on this study, our next initiative entails a formal process across the Department to limit medical waste perioperatively.

There are several limitations of this study. The equipment and supplies were not stratified by service or surgical discipline. Therefore, certain disciplines or individual surgeons could account for most of the surplus items. Since this study occurred at a VAMC, the findings may not be generalized to a facility in the private sector.

Conclusion

Medical waste is prevalent in every hospital at some level. Operative waste includes equipment and supplies that increase time, effort, and costs. Quantifying the waste allows each facility the opportunity to introduce potential strategies to reduce extraneous medical equipment and supplies.