Can infection control be environmentally sustainable?

In March 2020, as hospitals across the globe were facing a new, deadly virus, the demand for personal protective equipment (PPE) skyrocketed at the same time supply chains were suddenly disrupted.

That month, Inova Health System in northern Virginia convened a Creative Solutions PPE committee, bringing together infection preventionists, supply chain experts, and front-line providers, says Lucy He, Inova's director of infection prevention and control.

One of the challenges they faced: procuring good-quality isolation gowns.

The international supplier of the raw material used to make the single-use gowns was no longer making its product because factories were shut down. Inova worked around the clock to find replacement options — but they turned out to be of varying quality, with some offering unreliable protection, she says.

That's when an emergency department physician on the Creative Solutions PPE committee reached out to the CEO of an athletic clothing company that had advertised its ability to make reusable PPE. From there, the health system's supply chain team worked with the company to design reusable isolation gowns. This solution would not only solve the procurement issues but also help Inova reduce waste and its carbon footprint. But what seemed like a commonsense solution proved difficult to operationalize.

"Sustainability and infection prevention — those two are typically at odds with one another," He says. "Usually, you want something that's single-use because of the challenges to make sure [reusable PPE is] clean."

It took much creative thinking, feedback from experts across the health system, and expertise within the manufacturer's design team — as well as trial and error — to successfully meet the three goals of making the gowns functional, safe, and environmentally friendly.

The gowns are made of a breathable, fluid-resistant fabric and can be washed more than 75 times. Inova had to think through the change, including working with a laundering service, finding storage for the gowns, and providing staff training for using them, He says. The infection prevention team led donning and doffing trainings that focused on features of the new gowns that were different, including fastening snaps, a pull-cord for easy removal, and thumb holes to keep sleeves from riding up.

"There are all these things you have to think about," she says.

From mid-2020 to mid-2021, Inova disposed of 3.1 million isolation gowns, generating about 213 tons of waste. The health system's goal is to shift to reusable gowns throughout its five hospitals, which would help dramatically reduce this waste source, He adds.

This success story, however, stands apart from the global picture.

The World Health Organization (WHO) estimates that tens of thousands of tons of PPE used during the COVID-19 pandemic have ended up as waste. And scientists from Nanjing University in China and Scripps Institution of Oceanography at the University of California San Diego created a model that projected about 8 million tons of pandemic-related plastic waste was generated globally as of August 2021, with about 25,000 tons of that ending up in the oceans. The scientists estimate that most of the waste came from hospitals.

When faced with the immediate threat of the coronavirus, health providers understandably prioritized infection control over sustainability. But with the looming climate crisis and increased efforts to make the health sector carbon neutral, some teaching hospitals are thinking creatively about how to reduce unnecessary waste while also keeping patients and providers safe.

"The most important thing is to protect human health," says Aparna Dial, senior director of sustainability and strategic services at the Ohio State Wexner Medical Center in Columbus. "We think about things holistically, in terms of resilience. If we have [a crisis, like a pandemic], how can we still manage everything appropriately while not creating undue harm by the waste we generate?"

One of the reasons health care providers generated so much excess waste in the first few months of the pandemic is that people working in health care settings treated more nonbiohazardous waste — such as PPE or regular trash — as biohazardous medical waste. Since biohazardous medical waste is regulated by state and federal agencies, it must go through processes such as sterilization or incineration, which are costly both economically and environmentally, says David Skinner, executive vice president of Daniels Health the second-largest medical waste management company in the United States.

"The pandemic was something none of us had ever lived through before," Skinner says. "Initially, [health care workers] tended to overclassify waste. They threw nonmedical waste in medical waste containers. We saw a lot of facilities where volumes went up substantially."

While it varied from setting to setting, Skinner says some facilities’ medical waste volumes went up by as much as 50% in the first months of the pandemic because many people feared that even nonbiohazardous waste could be contaminated with the virus.

According to the WHO, 85% of waste generated in health care settings is not infectious or toxic. The Centers for Disease Control and Prevention also notes that research shows most medical waste is no more dangerous than residential waste, but public misconceptions developed during the early years of the HIV epidemic fueled a fear of nonbiohazardous waste from medical facilities.

As part of its mission to make waste disposal safe, efficient, and environmentally sustainable, Daniels Health audits health care facilities’ disposal practices and educates staff on how to properly categorize waste.

"As time has gone on, what we have seen is that the volumes have settled down," Skinner says. "People now understand what is truly medical waste and what isn't; things have settled back to what we saw pre-pandemic."

But even pre-pandemic, there was room for improvement.

There are "a lot of things that can be recycled that, today, get [thrown] out," Skinner says.

The medical waste industry is currently moving toward a greater focus on environmental sustainability, including using innovative ways to eliminate plastic waste, he adds.

One example in use at facilities that work with Daniels Health is the reusable sharps disposal containers that can be washed up to 500 times and do not require a plastic liner. Since 2003, the reusable containers have reduced greenhouse gas emissions by nearly 119,000 tons and have diverted nearly 78 million pounds of plastic from landfills, according to the company's website.

Teaching hospitals face particular challenges when it comes to diverting waste that can be recycled from ending up in landfills, explains Lauren Koch, a sustainability program manager at the Ohio State Wexner Medical Center. The logistics to coordinate waste disposal and recycling from the medical center's research laboratories and multiple campuses are complex and require education for and compliance from staff members at every step of the process — from clinicians to maintenance and facilities workers.

"It takes multiple systems to move that waste where it needs to go," Koch says. "We must bring them all together to create a symphony — a process that ensures [the waste is] going to stay segregated and make its way to the right place."

While many people are "aspirational recyclers," as Dial calls them, they can often unintentionally harm efforts when they contaminate recycling receptacles by putting items in the wrong bins or attempting to recycle items with food residue. These errors can mean that whole bags can end up trashed.

"Education is really, really key," Dial adds, explaining that their staff receive training on proper disposal and recycling procedures and that the team conducts audits when there's a failure in the system to see what went wrong and where there can be improvement.

This focus on sustainability and waste diversion began to gain traction at the medical center in 2017, and within the last decade, the medical center's diversion rate has increased from about 6% to 37% in 2022, despite an overall increase in waste associated with the pandemic, Dial says.

The staff interest in sustainability has also markedly increased.

The medical center's "green team," a coalition of staff members interested in sustainability at the institutional level, increased from about 50 in 2017 to more than 800 presently, Koch says.

Much of the enthusiasm for sustainability is coming from medical students and residents — the next generation of clinicians who are passionate about the issue and are driving forces at their institutions. A medical resident is leading the charge to do a quality improvement project focused on the Ohio State Wexner Medical Center's medical waste segregation, Koch says. And medical students are engaged in curricula focused on environmental justice, Dial adds.

At Washington University School of Medicine in St. Louis (WUSTL), medical students have taken the lead in pushing the medical school to focus on sustainability by starting with small but impactful projects.

Joshua Perez-Cruet, a second-year medical student who co-leads the WUSTL School of Medicine sustainability group, directed an effort to transition from single-use anatomy lab gloves to durable, reusable ones.

"A quick calculation comparing the waste produced by both options over 20 lab sessions made it clear that, from a sustainability lens, reusable gloves were the way to go," Perez-Cruet says. He and other students from the sustainability group successfully convinced about 80% of their classmates to opt for heavy-duty janitor gloves that could be washed. "It was relatively easy to get student buy-in and implement this initiative."

Perez-Cruet is also leading an optional lecture series where students can learn about climate and health issues, including a session on proper waste segregation, and he worked with the school's administration to design a session that is now a required component of their medical school curriculum.

He's hoping that the sustainability group can continue to make a difference through education by implementing simple solutions that, in the long term, can have a big impact.

"There's so much that can be done that's quite simple before we need to turn to high-tech interventions," he says.

Caellagh Catley, a third-year medical student at WUSTL School of Medicine and a co-leader of the sustainability group, says that, though the waste generated by the health care industry can be a daunting problem in the face of the worsening climate crisis, she is hopeful that the next generation of health care providers will create more solutions.

"A lot of people assume being sustainable and running a hospital system that is efficient and cost-effective and best for patients are not the same," Catley says. "I believe that those goals can be aligned. When we look at reducing waste as something that can amplify patient care and really improve the way that we practice medicine, as well as improve the health of patients in the long term, there are a lot of places for innovation."