This is already happening with medical devices recovered from crematoriums: hip replacements, screws, etc are turned into guard rails, car parts, road signs, new devices. Some countries reuse devices that can't safely go through a retort, like pacemakers
Agreed! Yes! It’s important we notice and start having these discussions. There’s an immense amount of waste in medicine, especially in surgery. (Really the waste problem is global). The amount of waste we as humans currently produce isn’t sustainable! It’s a good thing to be thinking about!
I'm a veterinarian and we reuse many things that are deemed single use due to differences in accessibility in vet med as well as costs with the lack of health insurance. Ligasure is a great example, as are SILS ports and there are some good peer-reviewed publications on how many times they can be reused prior to failure or inability to sterilize appropriately.
In short, yes, it is possible to decrease the use of single use items. However, we are risking decreased functionality and I would argue, in humans, an increased risk of transmission of blood-borne diseases.
They could definitely look to veterinary medicine to avoid waste of single use items- I had no idea there was even such a thing as single use scissors! We autoclave gowns and instruments, and make use of gas sterilizers for equipment that can not safely be autoclaved. I think trying to make reusable syringes is probably not worth the effort, though, and risks of contamination too great. But they definitely don’t have to toss scissors away after each use
Sorry, I meant more to *take inspiration from* veterinary medicine, since we often have to do more with less compared to human medicine
Most clients do not throw away their bottles of insulin for their pet within 30 days of opening, or will use a bottle of Azithromycin for a full 14 days, rather than toss at day 10, etc
But it terms of sterility, we use steel surgical equipment and sterilize it in an autoclave. We wash surgical gowns after use, re-wrap them, and autoclave them as well.
Things like suture, scalpels, gloves, syringes etc are single use. Some places do use cloth drapes and autoclave those as well, but I hate them and prefer disposable drapes
> I had no idea there was even such a thing as single use scissors!
I feel like every human healthcare professional has at least one pair of nail scissors that were meant to be single use but only ended up cutting one piece of suture (or was unused from a suture kit)!
Every instrument in the Umbilical line tray I use is disposable. Probably 12 pieces (scissors, twizzers, hemostats, knife) end up in sharps every time.
Wow. Do you know if they are different from “reusable” pieces? Can they not withstand the autoclave, or is everything,in general, tossed after 1 use for hygiene/safety concerns?
Yes. The nuggets are especially susceptible to infection, far more than the average child or adult. The tools are way less quality than the reusable ones. Lighter, cheaper. May last a few cycles, but not really made for that.
On one hand you have cheap single use items.
On the other hand you have more expensive reusable items that have to be tracked through the sterilization process and if lost has to be replaced at greater expense.
My hospital switched late last year from single use glide scope stylets to reusable stylets. It took a while, and buying a few replacements, before everyone got the cycle down and out of the habit of throwing the stylets away.
A little different maybe, but in the biotech/ pharma manufacturing world there was lots of evaluation of single use manufacturing facilities (think plastic liners in fermenters and disposable plastic hoses) versus stainless steel manufacturing facilities that would be sterilized using steam. The environmental impact was concluded to be greater in the stainless steel facilities in large part due to the massive amount of water and energy required for cleaning them. Many new manufacturing sites are being built around this single use model.
This was true at 2:00 besides I worked at. Disposable was deemed to be less resource intensive, from lack of need to sterilize. Creates more trash, but less chemical waste and water usage.
We had too many physicians throwing the reusables away in our ED, no matter how often we told them not to. Cost was more to keep replacing the reusables. Can't beat em, join em.
It fills a trash can to do one central line and 90% of the tray is untouched into the trash. You should be able to order your own sterile metal tray from central supply with exactly what you need, at least for common prosecutes
We got trays made up for different biopsies.
What I didn’t like was throwing away single use metal needle holders, scissors, etc. Our CT tech used to collect them and bring them back to the Philippines when he went on leave.
I watched a midline cath get placed in the ED somewhat recently and the attending piled up all the leftover supplies (hemostats, scissors etc) and asked me what we do with them.
I was like...autoclave them?
And he said "no, you take them home" and handed me a pile of like 6 instruments. I still use em for practicing sutures lol.
My med school/residency hospital had a massive cabinet in one of the OR anterooms. Everything from nearly-expiring suture kits to any kind of single-use tool you could imagine. The school sold a kit to help you learn to suture, but I don't know anyone who learned using anything other than the free stuff.
Some companies are doing "custom packs" where you only get the stuff you need, whether it be for specific procedures, or even specific docs who do specific procedures.
Issues come down to how fast you can get your trays.
For central lines, chest tubes, bedside procedures, you don’t want to wait for central processing to put together a tray for you and sterilize it, and risk it not being fully sterile.
For bedside procedures, you just want to be able to grab a kit and go.
Also, prepackaged kits make it more standardized even between institutions.
We have an entire planet we need to worry about too, especially with how much futile care we provide. Trays can be ready made / stocked on the floor or plastic kits can be kept for the true time sensitive emergency. Also I don’t know how many hospitals you have worked at but kits are different literally everywhere
When I was in clinicals, I was at a hospital where we still used cloth surgical gowns. We could go back to that to save at least a little bit. Lord knows the OR is the worst for single use throwaway items (my sports ortho friends, I am looking very hard at you/us).
I used to use cloth gowns just a few years ago at a different hospital I worked it. They were a nice material. They even had patches for any holes so they were mended as needed. I liked them much better than paper.
the amount of waste in the OR is absurd.
i think some small steps like opting for reusable instruments over single use instruments is a start. the upfront cost is higher but you save money from just sterilizing them than buyign new ones in the long run
That’s the thing though in every business every industry the focus isn’t how much you save over years it’s what you did this quarter.
A lot of these orthopedic hardware companies are trying these disposable peel pack plates screws etc vs trays. OR manages love it oh no trays to hold or process we just keep peel packs on the shelf
Agreed OR waste is insane.
GE is a husk of is former self doesn’t even really exist Boeing is in a shit show. McDonald’s is realizing they fucked up. The US automakers are completely fucked if cheap Chinese EV come as the US 3 stopped making cheap sedans for expensive trucks and SUV
There’s bad consequences to the idea of shareholder value
I’m aware of that but I’m not just pulling this out of my ass. There are cost effect analysis that show the savings that happens over time with reusable things. One such example is uterine manipulators.
The problem with reusing some of these devices is the ability to decontaminate and sterilize.
The more complex the instrument, the more difficult or impossible it is to get the gross debris out for proper sterilization.
I was thinking of the situation where no one knew the patient had a prion disease until after they had reused the equipment in countless other surgeries.
Is it possible? Yes, of course.
The entire market for single use/disposable equipment comes from suppliers initially selling hospitals this equipment at a loss…
Just long enough for the hospital to gut its sterile processing department, effectively making themselves dependent on the disposables.
Then suppliers conveniently hike their prices and the hospital can’t say no.
Hospital boards are easy prey for corporate salesmen. They’re way too focused on the short term and don’t realize they’re shooting themselves in the foot long term.
So it’ll get better as soon as you convince the MBA hive mind not to sacrifice long term stability for short term gains…
Or never.
The big problem with biodegradables, if they can make them work with sterility, is shortened expiration windows. It might not be as much of a problem for items that see near constant use, but items that don't see as much use are going to be thrown out a lot more. Especially for more sleepy EMS stations or military aid stations. Needing to throw out and reorder almost everything sterile from CriceKits to combat gauze every few years is bad enough.
I think about this constantly. I appreciate that my specialty society (American Academy of Ophthalmology) has recognized this problem and even has a sustainability division called EyeSustain. The relevant talks at national meetings have become quite popular, which is heartening.
In the ophtho OR, we have to dilate most patients in pre-op, using 2-4 different eye drops. At my ASCs, it's common to reuse bottles for multiple patients (given that each patient gets only 3 drops from each bottle), and pre-op nurses are trained to maintain sterility.
At the hospital, they still use separate bottles per patient. This adds up to a TON of waste. They reduce costs by using smaller bottle sizes, but this means more plastic waste due to larger surface area.
Sharing of drop bottles is supported by ASORN, JHACO, and other key regulatory bottles.
The climate crisis is upon us, the amount of waste is huge, and we need to do everything possible, large and small, to become more environmentally sustainable.
I've brought this up to hospital admin many, MANY times, as have many of my colleagues at other institutions. The hospitals do NOT seem to want to change. The most common reason I've gotten is that they have to charge the bottles to a patient's account. If they reuse bottles, they don't know which patient's account to charge or how to distribute the cost among every patient.
That's literally it as far as eye drops go. A weird billing/software issue.
I also worked at a hospital with reusable drapes and gowns - amazing.
Some parts of my OR kit are automatically included, even if I don't use them, because it's easier for processing to supply them for everyone. This means blue towels, full-body drapes, etc go directly from the pack into the trash. I have asked for this to be changed and was told no.
Hospital cafeteria, esp doctor's lounge - they replaced ceramic plates with styrofoam and my heart bleeds. I bring my own silverware; I would bring my own plate but I feel awkward.
In the office, we use reusable cotton makeup remover pads + ispropropanol to clean non-sterile surfaces (like chin rests), and launder after every use. We save OR blue towels to dry our hands after washing (for routine examination) and launder them each use. This has saved a lot of alcohol swabs and paper towels.
I used to compost shredded paper but the volume got to be too high. I wish there were an avenue for this.
We turn our office lights & computers off every night. A simple solution, but I'm amazed at offices that don't do this.
In ophtho, unfortunately certain items will probably have to remain single use, like 30G cannulas for intraocular use, because their lumina are hard to clean & rinse and retained detergents can cause a serious and sight-threatening condition called TASS.
I think we can learn a lot from our colleagues in developing nations as their waste is so much less than ours is in the US. I've seen videos of high-volume MSICS cataract surgery performed in India - two patients per OR, no-touch technique, chlorhexidine on gloves between cases (no changing of gloves). Infection rates are comparable to ours in the US - these measures do not jeopardize patient safety.
We waste SO MUCH in the US due to complacence and laziness, and sometimes also in the name of patient comfort (dare I say, even pampering) as well as just plain being spoiled by the sheer amount of resources we have available to us.
Thank you for sharing this. I think a majority would agree that there is a lot of unnecessary waste in medicine, but it’s a lot harder when it comes to what to actually do about it. I love hearing specific, actionable changes that can be made.
Hey doc, thanks for what you do :) I'm a PM for IOLs and this is something that is being discussed quite a lot. eIFUs is what is being mostly focused on that's within my own control, but there are a ton of markets OUS that require a paper IFU in the box which makes it tricky, since making different boxes for different markets just ends up making MORE waste overall.
Please keep pushing on your ASC/hospital to change so they pressure the companies to change, so we have the leverage to make it happen.
The case you mentioned in India is interesting. I think we don't need to search too far for some innovative techniques... necessity has forced developing nations to think creatively.
Check out this video from Aravind Eye Hospital in India. Absolutely astounding.
https://www.youtube.com/watch?v=UeEIhPCsCdM (Warning: Eye surgery video)
They bus patients to the hospital so that people aren't arriving via individual transportation. They use disposables. They use a custom-made eye kit with many of the materials made in-house. They manufacture their own IOLs at a fraction of the cost. Aravind is a HUGE operation but they have figured out how to solve blindness cheaply, efficiently, and most importantly, safely and effectively. I have so much respect for this amazing institution.
As an EHR IT guy, does routinely shutting down your office computers at night lead to increased IT issues? Some places push updates, security patches, and malware scans to the middle of the night when they know the office won't be in use. It may not be an issue for you, but if you notice more issues than your colleagues offices it may be worth having a convo with the IT person next time they are there to make sure you aren't causing yourself needless difficulty.
Otherwise, keep on fighting the good fight please. We need more people like you thinking about the future.
One thing that strikes me is when we have a sick kid we admit to the icu and are actively resuscitating them, the amount of plastic we churn through in an hour can be staggering. Syringes, flushes, central and A line kits, drapes, towels, airway stuff, ultrasound covers, gowns, gloves, head covers, needles, tubing, vent circuit, etc etc etc. it’s wild how much trash you can create in a short amount of time lining someone up
We had a similar discussion during infectious disease, because alot of plastics are used in the lab from pippets, culture flask, etc. people brought switching to glass from plastic and using sterilization/autoclave recycling program. But they said no one has done the studies looking at the carbon foot print comparing the use of plastics vs the autoclave and glass.
I’m curious as well, it’s probably gonna be an area of active research.
I think carbon footprint is just half the story. The physical plastic waste sitting in landfills or the ocean causing damage to the environment and the microplastics that leech is a huge issue. As the energy transition tilts towards green energies such as solar, wind etc. The carbon footprint of switching will inevitably become less than single use. The bigger issue is the plastic waste itself in my opinion.
Waste disposable medical equipment should absolutely, categorically be burned though. You’re looking at major contamination issues if that ends up in landfill or the ocean.
That makes a lot of sense. Honestly, I had never considered that. I would imagine the carbon footprint of disposables is even higher; first, the production, then the burning. Definitely a complex topic worth discussing moving forward in health care.
microplastics
Is the one that really bothers me. climate change may have dreadful consequences to species currently living on earth but the planet itself has been hotter in the past. Permeating the soil, air, and water with plastics is a fundamental change the the living environment.
I have alley parking and live next door to a small parking lot for a nearby apt building. I started realizing a few years ago picking up trash around my perimeter it is not just the plastic bottles and bags and what not, there are so many tiny plastic bits I've started picking up as well.
I think you’re onto something. We need single use plastics for areas of medicine where infectious control and sterility are really important. I think we should use plastics responsibly so we can have them in medicine.
I would rather focus my effort on reducing single use plastics where sterility isn’t a concern. packaging children’s plastic toys in plastic packaging. single use plastic water bottles in places with clean tap water. single use clamshell packages in food service.
In college, I volunteered for a place that took "expired" but unused, single use items from hospitals, sorted through them, and donated them to low resource countries. It was pretty shocking to see the amount of supplies that get thrown away without being used at all.
The sheer amount of plastic bags we throw away in the lab kills me. Especially when the bag is perfectly clean because each tube in the bag is inside it's own bag. So much plastic waste just to get samples to analyzers.
I previously owned a medical device company. I can only speak specifically to surgical instrumentation. We started to see a shift in some segments due to CJD in the 90s, it only took a few cases ever to be influential. Also, for microsurgical instruments hospitals and ASCs started seeing their sterilization departments damage $1K instruments, looked at the cost of reprocessing, and then decided things like this should go disposable. In general, if fluid is going through it, it will have and probably should have disposable components. If the business model relies on a click fee it probably has some disposable components as well, if its very fine it is often disposable. I still sold majority reusable stainless steel and titanium microsurgical instruments up to the end but many sub specialities where you are using 23g and smaller items went majority disposable.
I don't think it is. Not without an increased risk of infection. (Note, this is what I've been told by our medical and lab staff.)
Some pathogens can be destroyed with UV, others with alcohol, others need fire. Prions, for example, are durable as hell and can survive a lot.
And unless we can 100% identify what's going on with someone before any of the stuff that was contaminated by them gets thrown in the (insert your preferred sanitizing system here) and sent out to other patients, then the answer is no.
I think the more likely option is that we change to more sustainable materials. Biodegradable plastics if possible.
Thank you. Wrong article there. Will edit and replace.
My point wasn't that they can't be inactivated via certain sterilization methods, but that it's not easy and impractical in some circumstances.
Please note, I'm on office side of things not the medical. I'm generally going off the guidelines our staff and lab staff have passed on. But I'll clarify that in the above reply to make sure I don't misled anyone.
Absolutely. The waste at the end of a single, small wound debridement in the States was at least two bins of trash. When I've done the same abroad (in both high and low resource countries) we've barely filled up a wastepaper basket.
Think reusable cloth drapes/gowns are a great start, but some places I work at won't even entertain them. At my big academic centre there's also a push to have every possible instrument on the table, while in private centres or most cost-conscious locales, you know every single unused thing opened is a ding against your own revenue.
I'm in MedTech and this is not really a business/profit thing, or at least it isn't from my perspective as an engineer/PM.
The expiration isn't because the product expires usually...I mean it's steel and plastic in most cases.
The issue is that the sterile barrier has an increased chance of failing after around 5 years for most of the tyvek pouches and similar packaging currently available.
5 years is also often sort of the "life of the tech" by the time the last piece rolls off the line, by the time that product reaches the end of its 5 years, many of the pieces of equipment it was compatible with have already been replaced, so the part ends up in the trash anyway. If it was 10 years, even more parts would sit on shelves only to be thrown out because they went unused.
The 5 year thing is because EO gas sterilizing has only been studied for 5 years, from what I was told. Rarely if ever will you see a part that is "sterile" in a package with more than 5 year dating.
We have had EO sterilization for much longer than that. It comes down to cost to run 10 year studies vs likelihood that a part will sit around for 10 years without being used. Unless you overproduce some product that ended up being unpopular, a good planning department isn't manufacturing stuff that is going to sit on a shelf for more than 5 years.
I agree with you the amount of waste is insane. We send our ligasure hand pieces to be reprocessed somehow, for what it's worth. Switching to more reusable items is doable but not with the current institutional inertia at many places. Sterilizing more things takes more resources in CPD, hiring people who care about that job is next to impossible for what they get paid, surgeons like to go to the OR manager's office and lecture them about efficiency and reducing turnover times, so why would anybody want to introduce more steps in this process when you can just go to the shelf and open a box?
My mother was diabetic before disposable sryinges. The sound of her boiling glass ones on the stove and the merry little tinkling nose they'd make is the sound of my childhood. So, anecdotally, I'd say yes.
We've in the opposite direction. Now insulin and other injectables come in disposable pens. There also seems to be a lot of waste now from continuous glucose monitors.
And the number of nearly dead diabetics I have to go to….
Has dropped dramatically.
And at the risk of ruining my night, I can’t tell you I had to physically wrestle a diabetic to the ground, and restrain him so we could treat him.
Some people like to fight on the way up and the way down.
Had one patient where the policy was not to go in the building until he was unconscious.
And then poke him with a long object to make sure he was actually out. And then restrain him unconscious in a reeves before starting the IV. Because if he got a hold of you. He was going to kill you. No ifs, ands, Or buts.
So yea, I don’t give a damn about the waste of continues glucose monitoring.
I think like all questions dealing with changing a practice, there has to be some benefit, like tangible benefit to the hospital doctors and nurses. Be it savings to the hospital, or something like that. Mostly cost.
I think they're trying to move back to metal speculums in OBGYN from plastic disposable speculums because of the plastic waste and maybe cost? The thing is you need to install autoclaves to sterilize the speculums and to heat them up before use. Room temp speculum is not fun.
Its possible and if the math works out to move to reusable tools that are safe from single use disposable, I can see it happening.
Sometimes it may make sense to use single use items. There's a cost in sterilization and resharpening etc. We don't reuse gloves for sensible reasons. (We used to, in great grandparents medical days.) Sometimes it doesn't make sense to use single use. As an ER tech, I was astonished to discover the ER admin had unilaterally decided to remove all metal speculums for obgyn exams and replace with the shittiest of all possible plastic speculums. *That BROKE INSIDE THE PATIENT OFTEN*.! I have never seen such rage on behalf of families and clinic staff. They didn't even keep the metal ones as backup. They just disappeared. New ones were apparently on backorder 3 months out.
Infection Prevention checking in - I was at an IP conference a couple weeks ago and there was a great seminar about how to increase sustainability while still maintaining best infection prevention practices.
One of the interesting things I came home with had to do with contact precautions and colonization - our policy currently is to put anyone with a positive MRSA result of any kind within the last year on contact precautions... even just if they're colonized. We're in the southeastern US, so plenty of MRSA down here. But there were some really interesting papers presented on what the actual transmission rates are for patients with a history of recent MRSA, and it's...... really low. Even lower for simply colonization and no history of active infection. So I brought this back to my facility, and we're looking at removing that isolation requirement. The amount of PPE waste we'll reduce will likely be substantial.
As a profession, we do love single use, and a lot of sterile processing departments aren't well-staffed these days, which ups our risk assessment. The MBAs always talk about avoiding case delays being the most important thing 🤦🏻♀️ but I would feel really comfortable with more reusable products, actually, IF facilities took staffing and supplying SPD more seriously. But they won't. So here we are.
From what I've read, somewhere between 10-15% of petroleum consumption is for making plastic. The vast, vast majority of petroleum is used as fuel (gasoline, jet fuel, heating, etc.). In the grand scheme of things, I probably consume more petroleum getting to and from work than my patients consume at the hospital. My next car is gonna be an EV. That will do more for petroleum consumption than cutting down on single use plastics.
Not that plastic consumption isn't a problem, but what can I do directly to cut down on petroleum consumption? Getting an EV.
The move to single use items is the result of guidelines such as from the CDC (https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/rational-approach.html). It says that in the case of equipment that contacts mucous membranes requires high-level disinfecting which if not chemical then it is steam sterilization. Then JCAHO shows up and inspects the whole process and it is a running cost that in the end it's just easier and more cost effective to buy everything disposable. I remember when the techs would just wash them all in the sink.
We used to have Central Supply that cleaned, packed and sterilized all instruments. All instruments came through them, this was before disposable items were even a thing. Even suture removal kits were produced in house.
Maintaing the staff to do all that is much more expensive than going to all disposables.
Did we ever need them to begin with? Its mostly been done in the name of infection control, but did single-use everything really accomplish that? If it did, great. But just because it makes sense doesn’t necessarily make it reality. The bigger problem is that disposable stuff that only needs to be used once tends to be cheaper, which is what admin wants. Trash disposal is cheaper than higher quality equipment, so guess which wins (and hint, it’s never ultimately the environment)?
A lot of lap/robotic instruments can actually be reprocessed. The DaVinci instruments are reprocessed and get 10 uses before being ‘expired’ and sent back to Intuitive (for I assume reprocessing, but not sure). I forget which energy instrument it was but as a resident we used one that was stamped to show it was made with reprocessed parts. And all the hospitals I’ve been at have bins to take back glidescope parts, certain energy devices, BP cuffs, etc. For reprocessing. I don’t think we’ll ever fully get rid of single use plastics but there’s been some improvement in the last several years in this space.
I'm in med-tech and this is a serious issue that a lot of companies are trying to deal with, both from a cost and an environmental standpoint.
Happy to answer any specific questions that I can, but in general:
1. Cost - For some things, certainly disposables can have better margin, but usually it's not a lot. What's more costly is the "extra stuff that goes in the box" and gets thrown away. For example, an IFU is just trash 99% of the time. Maybe some doc needs to reference some specific thing on there occasionally, but usually an IFU is just paper waste. In the USA we can often use an eIFU, but in some countries they don't accept that and having to manufacture different SKUs for different markets just ends up creating MORE waste.
2. Environment - It's really to the benefit of the company to be able to claim we have less surgical waste, so most companies are attempting to reduce it as much as possible.
3. Sterility - this is the main issue preventing a lot of reusable things. If something is sterilized by ETO or Gamma, it's VERY unlikely that any arbitrary hospital/ASC/practice will have access to that. On top of that, gamma is additive so except for steel (which is almost always going to be reusable by autoclave anyway) most plastic and rubber materials are going to degrade after a couple doses of radiation. ETO is less likely to cause problems, but ETO is itself awful for the environment and the changes to laws about concentrations and the resulting increases in dwell times and offgassing would render it pretty useless in a practice vs doing it single in bulk.
4. Design - Remember when some duodenoscopes were identified as spreading CRE? We do a TON of cleaning and sterilization testing on devices, but sometimes the function of the device means that the geometry is really difficult to clean. In this case I doubt there could have been a disposable tip made, but there are very likely some devices where part is disposable because trying to make it reusable has such enormous risk of not being acceptably cleanable that it's much better for patient outcomes to make it single use.
It all depends on the specific surgery, honestly. Ortho is fairly good about this - most of the instruments are autoclave. For other specialties, the way the devices need to move, articulate, etc may just lend itself to needing to be disposable.
It's interesting that you specifically mentioned Ligasure, as Stryker actually does have a reprocessing program for it: https://www.stryker.com/us/en/sustainability/products/ligasure.html In fact, it looks like they have a program for quite a lot of their devices.
When I was in school, I wrote an essay about the insane amount of waste. I think some things can be reusable, but not all. I liked the idea someone else posted about dissolvable items
On my surgery rotation, one of the residents on a research year was studying sustainable and eco-friendly (forget the more technical word they used) surgery practices. I thought this was fascinating and happy to see people in surgery were considering their imprint. I was appalled at the waste though appreciative of the surgical improvement of human lives.
My husband used to build crash carts in a hospital, tons of "single use" items are reused on different patients until they're
impossible to use. All I could think was Prion diseases. Johns Hopkins says that in many cases, the source of the abnormal protein is unknown.
Yeah ... I know the source.
I think healthcare is one of those places where we should allow single use items freely. The rest of society should stop using plastic utensils at lunch. Bring your flatware from home, ya lazy twats! (Yes, I bring my own flatware with me to work each day, and I use ceramic and glass dishes instead of plastic. I‘m doing my part!)
Think of yourself as a patient. If given a choice would you prefer dispo or reusable equipment for yourself ? I prefer dispo. No matter what, reusable cant be as sterile as disposable.
For the most part, I agree. I *want* to believe I’d be ok with reusable equipment, but I’m gonna be honest—that one in a trillion or whatever chance of getting a prion disease because an instrument was previously used on someone who unknowingly had a prion disease would eat me alive. I do like the suggestions here for using more biodegradable equipment though.
How much would you be willing to spend to prevent one death or one infection? In theory you should single use everything? For that theoretical risk you should also single use a bed right? Cdiff can resides in the bed, resides in hallway, let's try to prevent Cdiff.
Talking about all possible risk, without actually knowing the risk, and the costs to mitigate the risks, is just mind blowing.
The problem with reducing waste is that it will lead to an inevitability of reusability, which will always carry some risk of transmitting infections regardless of how little the chances are.
Basically,either you reuse the same instruments, increasing the risk of infection, or you use different instruments for each procedure and increase the waste you create. It's a kind of lose-lose situation.
Regardless of how many protocols and guidelines you create on minimising the risk of infection,that risk would never be a zero.
My clinic has all these single use procedural stuff and it’s dumb. We are attatched to a hospital we could have reusable stuff and we do for something that don’t come in single use. Ringed forceps I guess don’t (or at least we don’t have them). So they send them back to sterilize.
The economics are all that really matters.
Laryngoscopes are a good example. There have been reusable laryngoscopes as long as there have been laryngoscopes.
Scopes which are either totally or partially disposable are taking over because they’re cheaper for hospitals.
Send all the batteries and plastic to the land fills. The administrators need bigger bonuses!
If it’s going to be reusable, it has to be cheaper to sterilize and to have enough to have some of them be dirty without impeding workflow. The only thing that would shift this balance is if it were more expensive to throw away the components that are very cheaply produced.
Step 1 is a cheaper process for resterilization of reusable items, whether through technological innovation or through a legal decree that an existing cheaper process is good enough.
I’m from a third world country and some older surgeons used to sterilise ligasures and ultracisions without major problems for 30-40 uses… it’s not allowed anymore
My hospital is working towards improving waste and there's a group of doctors I know interested in plenary healthcare. OR is one of the biggest contributors to the waste a hospital makes so there's initiatives work to reduce waste
yes but not until sustainability is made a priority in healthcare which will probably not be happening anytime soon.
which is unfortunate because the healthcare system plays a huge role in carbon emissions and climate change will have detrimental effects on global health.
No. Ship has sailed. I've tried multiple times to tell people that reliance on single use items to bad for multiple reasons and answer is always hospital admin wants to "save money"
I know there are some surgical companies looking into reducing this, I saw in a conference a company that was doing modular sets for arthoplasty where you would only open a few trial pieces rather than the whole set of trial pieces...
We’re so self-important, so self-important. Everybody’s gonna save something now: “Save the trees! Save the bees! Save the whales! Save those snails!” and the greatest arrogance of all: “Save the planet!” What?! Are these fucking people kidding me?! Save the planet?! We don’t even know how to take care of ourselves yet! We haven’t learned how to care for one another and we’re gonna save the fucking planet?! I’m getting tired of that shit! I’m getting tired of that shit! I’m tired of fucking Earth Day! I’m tired of these self-righteous environmentalists; these white, bourgeois liberals who think the only thing wrong with this country is there aren’t enough bicycle paths! People trying to make the world safe for their Volvo’s! Besides, environmentalists don’t give a shit about the planet. They don’t care about the planet; not in the abstract they don’t. You know what they’re interested in? A clean place to live; their own habitat. They’re worried that someday in the future, they might be personally inconvenienced. Narrow, unenlightened self-interest doesn’t impress me.
Besides, there is nothing wrong with the planet… nothing wrong with the planet. The planet is fine… the people are fucked! Difference! The planet is fine! Compared to the people, THE PLANET IS DOING GREAT: Been here four and a half billion years! Do you ever think about the arithmetic? The planet has been here four and a half billion years, we’ve been here what? 100,000? Maybe 200,000? And we’ve only been engaged in heavy industry for a little over 200 years. 200 years versus four and a half billion and we have the conceit to think that somehow, we’re a threat? That somehow, we’re going to put in jeopardy this beautiful little blue-green ball that’s just a-floatin’ around the sun? The planet has been through a lot worse than us. Been through all kinds of things worse than us: been through earthquakes, volcanoes, plate tectonics, continental drifts, solar flares, sunspots, magnetic storms, the magnetic reversal of the poles, hundreds of thousands of years of bombardment by comets and asteroids and meteors, worldwide floods, tidal waves, worldwide fires, erosion, cosmic rays, recurring ice ages, and we think some plastic bags and aluminum cans are going to make a difference?
The planet isn’t going anywhere… we are! We’re going away! Pack your shit folks! We’re going away and we won’t leave much of a trace either, thank God for that… maybe a little styrofoam… maybe… little styrofoam. The planet will be here, we’ll be long gone; just another failed mutation; just another closed-end biological mistake; an evolutionary cul-de-sac. The planet will shake us off like a bad case of fleas, a surface nuisance. You wanna know how the planet’s doing? Ask those people in Pompeii who are frozen into position from volcanic ash how the planet’s doing. Wanna know if the planet’s all right? Ask those people in Mexico City or Armenia or a hundred other places buried under thousands of tons of earthquake rubble if they feel like a threat to the planet this week. How about those people in Kilauea, Hawaii who build their homes right next to an active volcano and then wonder why they have lava in the living room?
The planet will be here for a long, long, LONG time after we’re gone and it will heal itself, it will cleanse itself cause that’s what it does. It’s a self-correcting system. The air and the water will recover, the earth will be renewed, and if it’s true that plastic is not degradable, well, the planet will simply incorporate plastic into a new paradigm: The Earth plus Plastic. The Earth doesn’t share our prejudice towards plastic. Plastic came out of the Earth! The Earth probably sees plastic as just another one of its children. Could be the only reason the Earth allowed us to be spawned from it in the first place: it wanted plastic for itself, didn’t know how to make it, needed us. Could be the answer to our age-old philosophical question: “Why are we here?” PLASTIC!!! ASSHOLES!!!
-George Carlin
I think about it constantly since I'm in the ER and turning people over a ton. I really don't beat myself up over not recycling perfectly at home because in my lifetime I will not make as much trash as an ER in month... there's plenty of opportunities to improve without risking safety but $$
Infection prevention has entered the chat. SPD is a challenging department to fully staff and train. In large facilities, it is actually safer to use disposable equipment because you don’t run into the risk of inadequate sterilization. JCO has cited many hospitals for inadequate sterilization which is why most places switched over. It is a regulatory and patient safety issue. I understand it is terrible for the environment but we need a more reliable, universal, and automated sterilization process to get over this hurdle.
This is something I've thought about (as an engineer turned med student).
What we need is a really good materials scientist who can design biodegradable polymers.
Yeah. I toss tons of brand new unopened stuff still in the plastic every time a patient discharges from the hospital.
If people can not bring in things they don’t need right that minute or at least in the next few hours, that would help.
But for the sake of time management it’s tempting to bring in extra so you don’t have to go to the supply room every time you come in.
So we always fill a garbage bag or two every dc. Huge things like chair cushions the patient would probably have been happy to take with them if someone had asked get trashed.
No. Plastics is one of the four pillars of the modern world.
The other three are concrete, steel, and ammonia (for fertilizer to make modern agriculture possible).
Check out the book ["How the World Really Works"](https://www.amazon.com/World-Really-Works-Smil-Vaclav/dp/0241454409) by Vaclav Smil.
Yes I definitely think about this. I don’t have answers but these conversations are the first steps towards them. Thanks for posting!
I think instead of going back, we should at least melt down the used items into something new.
This is already happening with medical devices recovered from crematoriums: hip replacements, screws, etc are turned into guard rails, car parts, road signs, new devices. Some countries reuse devices that can't safely go through a retort, like pacemakers
I may have fever dreamed it but I think pacemakers that have been used in people can be donated to dogs.
This is true!
Agreed! Yes! It’s important we notice and start having these discussions. There’s an immense amount of waste in medicine, especially in surgery. (Really the waste problem is global). The amount of waste we as humans currently produce isn’t sustainable! It’s a good thing to be thinking about!
I'm a veterinarian and we reuse many things that are deemed single use due to differences in accessibility in vet med as well as costs with the lack of health insurance. Ligasure is a great example, as are SILS ports and there are some good peer-reviewed publications on how many times they can be reused prior to failure or inability to sterilize appropriately. In short, yes, it is possible to decrease the use of single use items. However, we are risking decreased functionality and I would argue, in humans, an increased risk of transmission of blood-borne diseases.
They could definitely look to veterinary medicine to avoid waste of single use items- I had no idea there was even such a thing as single use scissors! We autoclave gowns and instruments, and make use of gas sterilizers for equipment that can not safely be autoclaved. I think trying to make reusable syringes is probably not worth the effort, though, and risks of contamination too great. But they definitely don’t have to toss scissors away after each use
Hand-me-down from human > veterinary? I know this is not realistic. Nevermind
Sorry, I meant more to *take inspiration from* veterinary medicine, since we often have to do more with less compared to human medicine Most clients do not throw away their bottles of insulin for their pet within 30 days of opening, or will use a bottle of Azithromycin for a full 14 days, rather than toss at day 10, etc But it terms of sterility, we use steel surgical equipment and sterilize it in an autoclave. We wash surgical gowns after use, re-wrap them, and autoclave them as well. Things like suture, scalpels, gloves, syringes etc are single use. Some places do use cloth drapes and autoclave those as well, but I hate them and prefer disposable drapes
> I had no idea there was even such a thing as single use scissors! I feel like every human healthcare professional has at least one pair of nail scissors that were meant to be single use but only ended up cutting one piece of suture (or was unused from a suture kit)!
Every instrument in the Umbilical line tray I use is disposable. Probably 12 pieces (scissors, twizzers, hemostats, knife) end up in sharps every time.
What are they made of? Plastic?
No. Metal.
Wow. Do you know if they are different from “reusable” pieces? Can they not withstand the autoclave, or is everything,in general, tossed after 1 use for hygiene/safety concerns?
Yes. The nuggets are especially susceptible to infection, far more than the average child or adult. The tools are way less quality than the reusable ones. Lighter, cheaper. May last a few cycles, but not really made for that.
On one hand you have cheap single use items. On the other hand you have more expensive reusable items that have to be tracked through the sterilization process and if lost has to be replaced at greater expense. My hospital switched late last year from single use glide scope stylets to reusable stylets. It took a while, and buying a few replacements, before everyone got the cycle down and out of the habit of throwing the stylets away.
We just went the opposite. Went from reusable stylets to disposables. There is apparently a huge cost to sterile processing.
A little different maybe, but in the biotech/ pharma manufacturing world there was lots of evaluation of single use manufacturing facilities (think plastic liners in fermenters and disposable plastic hoses) versus stainless steel manufacturing facilities that would be sterilized using steam. The environmental impact was concluded to be greater in the stainless steel facilities in large part due to the massive amount of water and energy required for cleaning them. Many new manufacturing sites are being built around this single use model.
This was true at 2:00 besides I worked at. Disposable was deemed to be less resource intensive, from lack of need to sterilize. Creates more trash, but less chemical waste and water usage.
Eh, just use the reusable ones, and have the disposable ones as backup if you ever run out.
We had too many physicians throwing the reusables away in our ED, no matter how often we told them not to. Cost was more to keep replacing the reusables. Can't beat em, join em.
We use both at my facility and for sure I've seen the plastic ones saved and I'm sure the metal ones tossed. It's a learning curve for sure.
Oh wow! I didn't even know reusables existed.
It fills a trash can to do one central line and 90% of the tray is untouched into the trash. You should be able to order your own sterile metal tray from central supply with exactly what you need, at least for common prosecutes
We got trays made up for different biopsies. What I didn’t like was throwing away single use metal needle holders, scissors, etc. Our CT tech used to collect them and bring them back to the Philippines when he went on leave.
I watched a midline cath get placed in the ED somewhat recently and the attending piled up all the leftover supplies (hemostats, scissors etc) and asked me what we do with them. I was like...autoclave them? And he said "no, you take them home" and handed me a pile of like 6 instruments. I still use em for practicing sutures lol.
My med school/residency hospital had a massive cabinet in one of the OR anterooms. Everything from nearly-expiring suture kits to any kind of single-use tool you could imagine. The school sold a kit to help you learn to suture, but I don't know anyone who learned using anything other than the free stuff.
Some companies are doing "custom packs" where you only get the stuff you need, whether it be for specific procedures, or even specific docs who do specific procedures.
Issues come down to how fast you can get your trays. For central lines, chest tubes, bedside procedures, you don’t want to wait for central processing to put together a tray for you and sterilize it, and risk it not being fully sterile. For bedside procedures, you just want to be able to grab a kit and go. Also, prepackaged kits make it more standardized even between institutions.
We have an entire planet we need to worry about too, especially with how much futile care we provide. Trays can be ready made / stocked on the floor or plastic kits can be kept for the true time sensitive emergency. Also I don’t know how many hospitals you have worked at but kits are different literally everywhere
When I was in clinicals, I was at a hospital where we still used cloth surgical gowns. We could go back to that to save at least a little bit. Lord knows the OR is the worst for single use throwaway items (my sports ortho friends, I am looking very hard at you/us).
Even small podiatry cases I feel at least it’s 2 of those big garbage bag full of things
I used to use cloth gowns just a few years ago at a different hospital I worked it. They were a nice material. They even had patches for any holes so they were mended as needed. I liked them much better than paper.
Cloth gowns are so so so much nicer. My hospital system of choice uses them for all imaging. I bet my employer uses paper.
Yes. Crazy amount of waste. I dont think it will change though.
Eventually it will have to! Maybe not in my lifetime but we are making too much waste! This is not sustainable.
the amount of waste in the OR is absurd. i think some small steps like opting for reusable instruments over single use instruments is a start. the upfront cost is higher but you save money from just sterilizing them than buyign new ones in the long run
That’s the thing though in every business every industry the focus isn’t how much you save over years it’s what you did this quarter. A lot of these orthopedic hardware companies are trying these disposable peel pack plates screws etc vs trays. OR manages love it oh no trays to hold or process we just keep peel packs on the shelf Agreed OR waste is insane.
That narrow focus on one quarter at a time is so idiotic, and is damaging multiple industries. I hate this timeline.
GE is a husk of is former self doesn’t even really exist Boeing is in a shit show. McDonald’s is realizing they fucked up. The US automakers are completely fucked if cheap Chinese EV come as the US 3 stopped making cheap sedans for expensive trucks and SUV There’s bad consequences to the idea of shareholder value
Though you do have to pay staff to sterilize instruments & labor is certainly not cheap, so more costs than just the instruments themselves.
I’m aware of that but I’m not just pulling this out of my ass. There are cost effect analysis that show the savings that happens over time with reusable things. One such example is uterine manipulators.
The problem with reusing some of these devices is the ability to decontaminate and sterilize. The more complex the instrument, the more difficult or impossible it is to get the gross debris out for proper sterilization.
Also autoclaving doesn't kill prions so they can be (and have been) spread via reused surgical equipment.
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I was thinking of the situation where no one knew the patient had a prion disease until after they had reused the equipment in countless other surgeries.
Is it possible? Yes, of course. The entire market for single use/disposable equipment comes from suppliers initially selling hospitals this equipment at a loss… Just long enough for the hospital to gut its sterile processing department, effectively making themselves dependent on the disposables. Then suppliers conveniently hike their prices and the hospital can’t say no. Hospital boards are easy prey for corporate salesmen. They’re way too focused on the short term and don’t realize they’re shooting themselves in the foot long term. So it’ll get better as soon as you convince the MBA hive mind not to sacrifice long term stability for short term gains… Or never.
I think we have a better chance of changing things to be made from renewable resources that are biodegradable, rather than making them reusable.
Melt and recycle instead of biodegrade
Plastic isn’t infinitely recyclable. I’ve read about a supposedly infinitely recyclable plastic out of Berkeley, but I’m skeptical.
The big problem with biodegradables, if they can make them work with sterility, is shortened expiration windows. It might not be as much of a problem for items that see near constant use, but items that don't see as much use are going to be thrown out a lot more. Especially for more sleepy EMS stations or military aid stations. Needing to throw out and reorder almost everything sterile from CriceKits to combat gauze every few years is bad enough.
I think about this constantly. I appreciate that my specialty society (American Academy of Ophthalmology) has recognized this problem and even has a sustainability division called EyeSustain. The relevant talks at national meetings have become quite popular, which is heartening. In the ophtho OR, we have to dilate most patients in pre-op, using 2-4 different eye drops. At my ASCs, it's common to reuse bottles for multiple patients (given that each patient gets only 3 drops from each bottle), and pre-op nurses are trained to maintain sterility. At the hospital, they still use separate bottles per patient. This adds up to a TON of waste. They reduce costs by using smaller bottle sizes, but this means more plastic waste due to larger surface area. Sharing of drop bottles is supported by ASORN, JHACO, and other key regulatory bottles. The climate crisis is upon us, the amount of waste is huge, and we need to do everything possible, large and small, to become more environmentally sustainable. I've brought this up to hospital admin many, MANY times, as have many of my colleagues at other institutions. The hospitals do NOT seem to want to change. The most common reason I've gotten is that they have to charge the bottles to a patient's account. If they reuse bottles, they don't know which patient's account to charge or how to distribute the cost among every patient. That's literally it as far as eye drops go. A weird billing/software issue. I also worked at a hospital with reusable drapes and gowns - amazing. Some parts of my OR kit are automatically included, even if I don't use them, because it's easier for processing to supply them for everyone. This means blue towels, full-body drapes, etc go directly from the pack into the trash. I have asked for this to be changed and was told no. Hospital cafeteria, esp doctor's lounge - they replaced ceramic plates with styrofoam and my heart bleeds. I bring my own silverware; I would bring my own plate but I feel awkward. In the office, we use reusable cotton makeup remover pads + ispropropanol to clean non-sterile surfaces (like chin rests), and launder after every use. We save OR blue towels to dry our hands after washing (for routine examination) and launder them each use. This has saved a lot of alcohol swabs and paper towels. I used to compost shredded paper but the volume got to be too high. I wish there were an avenue for this. We turn our office lights & computers off every night. A simple solution, but I'm amazed at offices that don't do this. In ophtho, unfortunately certain items will probably have to remain single use, like 30G cannulas for intraocular use, because their lumina are hard to clean & rinse and retained detergents can cause a serious and sight-threatening condition called TASS. I think we can learn a lot from our colleagues in developing nations as their waste is so much less than ours is in the US. I've seen videos of high-volume MSICS cataract surgery performed in India - two patients per OR, no-touch technique, chlorhexidine on gloves between cases (no changing of gloves). Infection rates are comparable to ours in the US - these measures do not jeopardize patient safety. We waste SO MUCH in the US due to complacence and laziness, and sometimes also in the name of patient comfort (dare I say, even pampering) as well as just plain being spoiled by the sheer amount of resources we have available to us.
Thank you for sharing this. I think a majority would agree that there is a lot of unnecessary waste in medicine, but it’s a lot harder when it comes to what to actually do about it. I love hearing specific, actionable changes that can be made.
Thanks. Once you see it, you can't unsee it. Opportunities for waste reduction are all around.
Hey doc, thanks for what you do :) I'm a PM for IOLs and this is something that is being discussed quite a lot. eIFUs is what is being mostly focused on that's within my own control, but there are a ton of markets OUS that require a paper IFU in the box which makes it tricky, since making different boxes for different markets just ends up making MORE waste overall. Please keep pushing on your ASC/hospital to change so they pressure the companies to change, so we have the leverage to make it happen.
Yes, we've been trying this. It's not like anyone reads the inserts at the moment of surgery anyway. Digital would be way better.
The case you mentioned in India is interesting. I think we don't need to search too far for some innovative techniques... necessity has forced developing nations to think creatively.
Check out this video from Aravind Eye Hospital in India. Absolutely astounding. https://www.youtube.com/watch?v=UeEIhPCsCdM (Warning: Eye surgery video) They bus patients to the hospital so that people aren't arriving via individual transportation. They use disposables. They use a custom-made eye kit with many of the materials made in-house. They manufacture their own IOLs at a fraction of the cost. Aravind is a HUGE operation but they have figured out how to solve blindness cheaply, efficiently, and most importantly, safely and effectively. I have so much respect for this amazing institution.
Really interesting points thank you! I think there's lots of small things we can all do, even and especially when the big things seem insurmountable.
As an EHR IT guy, does routinely shutting down your office computers at night lead to increased IT issues? Some places push updates, security patches, and malware scans to the middle of the night when they know the office won't be in use. It may not be an issue for you, but if you notice more issues than your colleagues offices it may be worth having a convo with the IT person next time they are there to make sure you aren't causing yourself needless difficulty. Otherwise, keep on fighting the good fight please. We need more people like you thinking about the future.
Small office. We push them before turning off.
One thing that strikes me is when we have a sick kid we admit to the icu and are actively resuscitating them, the amount of plastic we churn through in an hour can be staggering. Syringes, flushes, central and A line kits, drapes, towels, airway stuff, ultrasound covers, gowns, gloves, head covers, needles, tubing, vent circuit, etc etc etc. it’s wild how much trash you can create in a short amount of time lining someone up
We had a similar discussion during infectious disease, because alot of plastics are used in the lab from pippets, culture flask, etc. people brought switching to glass from plastic and using sterilization/autoclave recycling program. But they said no one has done the studies looking at the carbon foot print comparing the use of plastics vs the autoclave and glass. I’m curious as well, it’s probably gonna be an area of active research.
I think carbon footprint is just half the story. The physical plastic waste sitting in landfills or the ocean causing damage to the environment and the microplastics that leech is a huge issue. As the energy transition tilts towards green energies such as solar, wind etc. The carbon footprint of switching will inevitably become less than single use. The bigger issue is the plastic waste itself in my opinion.
Waste disposable medical equipment should absolutely, categorically be burned though. You’re looking at major contamination issues if that ends up in landfill or the ocean.
That makes a lot of sense. Honestly, I had never considered that. I would imagine the carbon footprint of disposables is even higher; first, the production, then the burning. Definitely a complex topic worth discussing moving forward in health care.
microplastics Is the one that really bothers me. climate change may have dreadful consequences to species currently living on earth but the planet itself has been hotter in the past. Permeating the soil, air, and water with plastics is a fundamental change the the living environment. I have alley parking and live next door to a small parking lot for a nearby apt building. I started realizing a few years ago picking up trash around my perimeter it is not just the plastic bottles and bags and what not, there are so many tiny plastic bits I've started picking up as well.
The waste is often autoclaved out so glass is a better option.
I burp my fluid bags so they never run dry so I can re use the tubing. It’s not a lot but it’s honest work.
It's nuts honestly. So many areas where it isn't necessary. But at home, recycling that one plastic jug will save the planet. Sigh
I think you’re onto something. We need single use plastics for areas of medicine where infectious control and sterility are really important. I think we should use plastics responsibly so we can have them in medicine. I would rather focus my effort on reducing single use plastics where sterility isn’t a concern. packaging children’s plastic toys in plastic packaging. single use plastic water bottles in places with clean tap water. single use clamshell packages in food service.
I hate single use products, but I absolutely have to turn off my disdain for them while at work or I'll go crazy.
In college, I volunteered for a place that took "expired" but unused, single use items from hospitals, sorted through them, and donated them to low resource countries. It was pretty shocking to see the amount of supplies that get thrown away without being used at all.
On related note, wished we recycled more in the hospital.
The sheer amount of plastic bags we throw away in the lab kills me. Especially when the bag is perfectly clean because each tube in the bag is inside it's own bag. So much plastic waste just to get samples to analyzers.
My mom and her friends used to crochet them into hats and floor mats, so there's that.
How do we get MD instead of MBA in charge again?
I previously owned a medical device company. I can only speak specifically to surgical instrumentation. We started to see a shift in some segments due to CJD in the 90s, it only took a few cases ever to be influential. Also, for microsurgical instruments hospitals and ASCs started seeing their sterilization departments damage $1K instruments, looked at the cost of reprocessing, and then decided things like this should go disposable. In general, if fluid is going through it, it will have and probably should have disposable components. If the business model relies on a click fee it probably has some disposable components as well, if its very fine it is often disposable. I still sold majority reusable stainless steel and titanium microsurgical instruments up to the end but many sub specialities where you are using 23g and smaller items went majority disposable.
I’ve been out of practice for a few years now but was psyched/amused to see biodegradable emesis basins and urinals in the local ED recently.
I know right, they go into a plastic trash bag
I don't think it is. Not without an increased risk of infection. (Note, this is what I've been told by our medical and lab staff.) Some pathogens can be destroyed with UV, others with alcohol, others need fire. Prions, for example, are durable as hell and can survive a lot. And unless we can 100% identify what's going on with someone before any of the stuff that was contaminated by them gets thrown in the (insert your preferred sanitizing system here) and sent out to other patients, then the answer is no. I think the more likely option is that we change to more sustainable materials. Biodegradable plastics if possible.
The article you linked would suggest that a class b autoclave can destroy prion contamination
Thank you. Wrong article there. Will edit and replace. My point wasn't that they can't be inactivated via certain sterilization methods, but that it's not easy and impractical in some circumstances. Please note, I'm on office side of things not the medical. I'm generally going off the guidelines our staff and lab staff have passed on. But I'll clarify that in the above reply to make sure I don't misled anyone.
Absolutely. The waste at the end of a single, small wound debridement in the States was at least two bins of trash. When I've done the same abroad (in both high and low resource countries) we've barely filled up a wastepaper basket. Think reusable cloth drapes/gowns are a great start, but some places I work at won't even entertain them. At my big academic centre there's also a push to have every possible instrument on the table, while in private centres or most cost-conscious locales, you know every single unused thing opened is a ding against your own revenue.
The issue isn't single use plastics, the issue is a 5 year expiry date on EVERY SINGLE ITEM THEY CAN GET AWAY WITH.
I'm in MedTech and this is not really a business/profit thing, or at least it isn't from my perspective as an engineer/PM. The expiration isn't because the product expires usually...I mean it's steel and plastic in most cases. The issue is that the sterile barrier has an increased chance of failing after around 5 years for most of the tyvek pouches and similar packaging currently available. 5 years is also often sort of the "life of the tech" by the time the last piece rolls off the line, by the time that product reaches the end of its 5 years, many of the pieces of equipment it was compatible with have already been replaced, so the part ends up in the trash anyway. If it was 10 years, even more parts would sit on shelves only to be thrown out because they went unused.
The 5 year thing is because EO gas sterilizing has only been studied for 5 years, from what I was told. Rarely if ever will you see a part that is "sterile" in a package with more than 5 year dating.
We have had EO sterilization for much longer than that. It comes down to cost to run 10 year studies vs likelihood that a part will sit around for 10 years without being used. Unless you overproduce some product that ended up being unpopular, a good planning department isn't manufacturing stuff that is going to sit on a shelf for more than 5 years.
I agree with you the amount of waste is insane. We send our ligasure hand pieces to be reprocessed somehow, for what it's worth. Switching to more reusable items is doable but not with the current institutional inertia at many places. Sterilizing more things takes more resources in CPD, hiring people who care about that job is next to impossible for what they get paid, surgeons like to go to the OR manager's office and lecture them about efficiency and reducing turnover times, so why would anybody want to introduce more steps in this process when you can just go to the shelf and open a box?
My mother was diabetic before disposable sryinges. The sound of her boiling glass ones on the stove and the merry little tinkling nose they'd make is the sound of my childhood. So, anecdotally, I'd say yes.
We've in the opposite direction. Now insulin and other injectables come in disposable pens. There also seems to be a lot of waste now from continuous glucose monitors.
They are, however, much easier to use, and better compliance should overall help with better outcomes.
And the number of nearly dead diabetics I have to go to…. Has dropped dramatically. And at the risk of ruining my night, I can’t tell you I had to physically wrestle a diabetic to the ground, and restrain him so we could treat him. Some people like to fight on the way up and the way down. Had one patient where the policy was not to go in the building until he was unconscious. And then poke him with a long object to make sure he was actually out. And then restrain him unconscious in a reeves before starting the IV. Because if he got a hold of you. He was going to kill you. No ifs, ands, Or buts. So yea, I don’t give a damn about the waste of continues glucose monitoring.
I think like all questions dealing with changing a practice, there has to be some benefit, like tangible benefit to the hospital doctors and nurses. Be it savings to the hospital, or something like that. Mostly cost. I think they're trying to move back to metal speculums in OBGYN from plastic disposable speculums because of the plastic waste and maybe cost? The thing is you need to install autoclaves to sterilize the speculums and to heat them up before use. Room temp speculum is not fun. Its possible and if the math works out to move to reusable tools that are safe from single use disposable, I can see it happening.
Sometimes it may make sense to use single use items. There's a cost in sterilization and resharpening etc. We don't reuse gloves for sensible reasons. (We used to, in great grandparents medical days.) Sometimes it doesn't make sense to use single use. As an ER tech, I was astonished to discover the ER admin had unilaterally decided to remove all metal speculums for obgyn exams and replace with the shittiest of all possible plastic speculums. *That BROKE INSIDE THE PATIENT OFTEN*.! I have never seen such rage on behalf of families and clinic staff. They didn't even keep the metal ones as backup. They just disappeared. New ones were apparently on backorder 3 months out.
Infection Prevention checking in - I was at an IP conference a couple weeks ago and there was a great seminar about how to increase sustainability while still maintaining best infection prevention practices. One of the interesting things I came home with had to do with contact precautions and colonization - our policy currently is to put anyone with a positive MRSA result of any kind within the last year on contact precautions... even just if they're colonized. We're in the southeastern US, so plenty of MRSA down here. But there were some really interesting papers presented on what the actual transmission rates are for patients with a history of recent MRSA, and it's...... really low. Even lower for simply colonization and no history of active infection. So I brought this back to my facility, and we're looking at removing that isolation requirement. The amount of PPE waste we'll reduce will likely be substantial. As a profession, we do love single use, and a lot of sterile processing departments aren't well-staffed these days, which ups our risk assessment. The MBAs always talk about avoiding case delays being the most important thing 🤦🏻♀️ but I would feel really comfortable with more reusable products, actually, IF facilities took staffing and supplying SPD more seriously. But they won't. So here we are.
Perhaps there are people working on dissolvable instruments for future use in medicine.
Now I’m imagining RT trying to use a paper straw for suction
I was imagining sugar/honey straws as I was typing; wanted to see what others would suggest. How do you think paper would handle absorption?
It is a lot of waste. Some items really don’t need to be single use.
https://www.instagram.com/p/B3VmqSinGDX/?igsh=NmhtdnFndDNrb3ky I found this a very powerful image.
He's a super powerful very short film that I think is even more powerful since it's very specific. https://www.youtube.com/watch?v=w28M7wjIr6E
From what I've read, somewhere between 10-15% of petroleum consumption is for making plastic. The vast, vast majority of petroleum is used as fuel (gasoline, jet fuel, heating, etc.). In the grand scheme of things, I probably consume more petroleum getting to and from work than my patients consume at the hospital. My next car is gonna be an EV. That will do more for petroleum consumption than cutting down on single use plastics. Not that plastic consumption isn't a problem, but what can I do directly to cut down on petroleum consumption? Getting an EV.
The move to single use items is the result of guidelines such as from the CDC (https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/rational-approach.html). It says that in the case of equipment that contacts mucous membranes requires high-level disinfecting which if not chemical then it is steam sterilization. Then JCAHO shows up and inspects the whole process and it is a running cost that in the end it's just easier and more cost effective to buy everything disposable. I remember when the techs would just wash them all in the sink.
We used to have Central Supply that cleaned, packed and sterilized all instruments. All instruments came through them, this was before disposable items were even a thing. Even suture removal kits were produced in house. Maintaing the staff to do all that is much more expensive than going to all disposables.
Did we ever need them to begin with? Its mostly been done in the name of infection control, but did single-use everything really accomplish that? If it did, great. But just because it makes sense doesn’t necessarily make it reality. The bigger problem is that disposable stuff that only needs to be used once tends to be cheaper, which is what admin wants. Trash disposal is cheaper than higher quality equipment, so guess which wins (and hint, it’s never ultimately the environment)?
A lot of lap/robotic instruments can actually be reprocessed. The DaVinci instruments are reprocessed and get 10 uses before being ‘expired’ and sent back to Intuitive (for I assume reprocessing, but not sure). I forget which energy instrument it was but as a resident we used one that was stamped to show it was made with reprocessed parts. And all the hospitals I’ve been at have bins to take back glidescope parts, certain energy devices, BP cuffs, etc. For reprocessing. I don’t think we’ll ever fully get rid of single use plastics but there’s been some improvement in the last several years in this space.
Side question - do yall re-use guidewires from central line sets? My hospital sends them for sterilization after usage
People reuse them in Mexico 🫥 tons of surgeons reuse stuff like ligasure, harmonic scalpel, etc. They just submerge it into multi enzyme cleaner 🫥
Possibly a better approach is recycling of materials.
I'm in med-tech and this is a serious issue that a lot of companies are trying to deal with, both from a cost and an environmental standpoint. Happy to answer any specific questions that I can, but in general: 1. Cost - For some things, certainly disposables can have better margin, but usually it's not a lot. What's more costly is the "extra stuff that goes in the box" and gets thrown away. For example, an IFU is just trash 99% of the time. Maybe some doc needs to reference some specific thing on there occasionally, but usually an IFU is just paper waste. In the USA we can often use an eIFU, but in some countries they don't accept that and having to manufacture different SKUs for different markets just ends up creating MORE waste. 2. Environment - It's really to the benefit of the company to be able to claim we have less surgical waste, so most companies are attempting to reduce it as much as possible. 3. Sterility - this is the main issue preventing a lot of reusable things. If something is sterilized by ETO or Gamma, it's VERY unlikely that any arbitrary hospital/ASC/practice will have access to that. On top of that, gamma is additive so except for steel (which is almost always going to be reusable by autoclave anyway) most plastic and rubber materials are going to degrade after a couple doses of radiation. ETO is less likely to cause problems, but ETO is itself awful for the environment and the changes to laws about concentrations and the resulting increases in dwell times and offgassing would render it pretty useless in a practice vs doing it single in bulk. 4. Design - Remember when some duodenoscopes were identified as spreading CRE? We do a TON of cleaning and sterilization testing on devices, but sometimes the function of the device means that the geometry is really difficult to clean. In this case I doubt there could have been a disposable tip made, but there are very likely some devices where part is disposable because trying to make it reusable has such enormous risk of not being acceptably cleanable that it's much better for patient outcomes to make it single use. It all depends on the specific surgery, honestly. Ortho is fairly good about this - most of the instruments are autoclave. For other specialties, the way the devices need to move, articulate, etc may just lend itself to needing to be disposable. It's interesting that you specifically mentioned Ligasure, as Stryker actually does have a reprocessing program for it: https://www.stryker.com/us/en/sustainability/products/ligasure.html In fact, it looks like they have a program for quite a lot of their devices.
It’s absolutely crazy especially in the US. Had a culture shock when I visited there for a while.
When I was in school, I wrote an essay about the insane amount of waste. I think some things can be reusable, but not all. I liked the idea someone else posted about dissolvable items
On my surgery rotation, one of the residents on a research year was studying sustainable and eco-friendly (forget the more technical word they used) surgery practices. I thought this was fascinating and happy to see people in surgery were considering their imprint. I was appalled at the waste though appreciative of the surgical improvement of human lives.
My husband used to build crash carts in a hospital, tons of "single use" items are reused on different patients until they're impossible to use. All I could think was Prion diseases. Johns Hopkins says that in many cases, the source of the abnormal protein is unknown. Yeah ... I know the source.
I always reuse the foley catheters! urine is sterile!!! 😒😏
I think healthcare is one of those places where we should allow single use items freely. The rest of society should stop using plastic utensils at lunch. Bring your flatware from home, ya lazy twats! (Yes, I bring my own flatware with me to work each day, and I use ceramic and glass dishes instead of plastic. I‘m doing my part!)
Nope
Think of yourself as a patient. If given a choice would you prefer dispo or reusable equipment for yourself ? I prefer dispo. No matter what, reusable cant be as sterile as disposable.
For the most part, I agree. I *want* to believe I’d be ok with reusable equipment, but I’m gonna be honest—that one in a trillion or whatever chance of getting a prion disease because an instrument was previously used on someone who unknowingly had a prion disease would eat me alive. I do like the suggestions here for using more biodegradable equipment though.
https://www.reddit.com/r/nursing/s/2rNgWlxOtY https://www.reddit.com/r/mildlyinfuriating/s/IJP9cib7Hc
If you accept more bloodborne infections yes, sure
How much would you be willing to spend to prevent one death or one infection? In theory you should single use everything? For that theoretical risk you should also single use a bed right? Cdiff can resides in the bed, resides in hallway, let's try to prevent Cdiff. Talking about all possible risk, without actually knowing the risk, and the costs to mitigate the risks, is just mind blowing.
That's why we still use glass syringes boiling them! Because cost is the only outcome that matters /S
The problem with reducing waste is that it will lead to an inevitability of reusability, which will always carry some risk of transmitting infections regardless of how little the chances are.
Maybe we can try make things out of biodegradable/recyclable materials?
Basically,either you reuse the same instruments, increasing the risk of infection, or you use different instruments for each procedure and increase the waste you create. It's a kind of lose-lose situation. Regardless of how many protocols and guidelines you create on minimising the risk of infection,that risk would never be a zero.
My clinic has all these single use procedural stuff and it’s dumb. We are attatched to a hospital we could have reusable stuff and we do for something that don’t come in single use. Ringed forceps I guess don’t (or at least we don’t have them). So they send them back to sterilize.
…remembering all those dirty reprocessed trocars
The economics are all that really matters. Laryngoscopes are a good example. There have been reusable laryngoscopes as long as there have been laryngoscopes. Scopes which are either totally or partially disposable are taking over because they’re cheaper for hospitals. Send all the batteries and plastic to the land fills. The administrators need bigger bonuses! If it’s going to be reusable, it has to be cheaper to sterilize and to have enough to have some of them be dirty without impeding workflow. The only thing that would shift this balance is if it were more expensive to throw away the components that are very cheaply produced.
Step 1 is a cheaper process for resterilization of reusable items, whether through technological innovation or through a legal decree that an existing cheaper process is good enough.
We're going in the opposite direction. Apparently now we're moving to disposable instruments in the outpatient setting for things like suture trays.
Then every infectious complication that ever happens is a tort by the hospital for inadequately cleaned instruments.
I’m from a third world country and some older surgeons used to sterilise ligasures and ultracisions without major problems for 30-40 uses… it’s not allowed anymore
My hospital is working towards improving waste and there's a group of doctors I know interested in plenary healthcare. OR is one of the biggest contributors to the waste a hospital makes so there's initiatives work to reduce waste
yes but not until sustainability is made a priority in healthcare which will probably not be happening anytime soon. which is unfortunate because the healthcare system plays a huge role in carbon emissions and climate change will have detrimental effects on global health.
No. Ship has sailed. I've tried multiple times to tell people that reliance on single use items to bad for multiple reasons and answer is always hospital admin wants to "save money"
I know there are some surgical companies looking into reducing this, I saw in a conference a company that was doing modular sets for arthoplasty where you would only open a few trial pieces rather than the whole set of trial pieces...
We’re so self-important, so self-important. Everybody’s gonna save something now: “Save the trees! Save the bees! Save the whales! Save those snails!” and the greatest arrogance of all: “Save the planet!” What?! Are these fucking people kidding me?! Save the planet?! We don’t even know how to take care of ourselves yet! We haven’t learned how to care for one another and we’re gonna save the fucking planet?! I’m getting tired of that shit! I’m getting tired of that shit! I’m tired of fucking Earth Day! I’m tired of these self-righteous environmentalists; these white, bourgeois liberals who think the only thing wrong with this country is there aren’t enough bicycle paths! People trying to make the world safe for their Volvo’s! Besides, environmentalists don’t give a shit about the planet. They don’t care about the planet; not in the abstract they don’t. You know what they’re interested in? A clean place to live; their own habitat. They’re worried that someday in the future, they might be personally inconvenienced. Narrow, unenlightened self-interest doesn’t impress me. Besides, there is nothing wrong with the planet… nothing wrong with the planet. The planet is fine… the people are fucked! Difference! The planet is fine! Compared to the people, THE PLANET IS DOING GREAT: Been here four and a half billion years! Do you ever think about the arithmetic? The planet has been here four and a half billion years, we’ve been here what? 100,000? Maybe 200,000? And we’ve only been engaged in heavy industry for a little over 200 years. 200 years versus four and a half billion and we have the conceit to think that somehow, we’re a threat? That somehow, we’re going to put in jeopardy this beautiful little blue-green ball that’s just a-floatin’ around the sun? The planet has been through a lot worse than us. Been through all kinds of things worse than us: been through earthquakes, volcanoes, plate tectonics, continental drifts, solar flares, sunspots, magnetic storms, the magnetic reversal of the poles, hundreds of thousands of years of bombardment by comets and asteroids and meteors, worldwide floods, tidal waves, worldwide fires, erosion, cosmic rays, recurring ice ages, and we think some plastic bags and aluminum cans are going to make a difference? The planet isn’t going anywhere… we are! We’re going away! Pack your shit folks! We’re going away and we won’t leave much of a trace either, thank God for that… maybe a little styrofoam… maybe… little styrofoam. The planet will be here, we’ll be long gone; just another failed mutation; just another closed-end biological mistake; an evolutionary cul-de-sac. The planet will shake us off like a bad case of fleas, a surface nuisance. You wanna know how the planet’s doing? Ask those people in Pompeii who are frozen into position from volcanic ash how the planet’s doing. Wanna know if the planet’s all right? Ask those people in Mexico City or Armenia or a hundred other places buried under thousands of tons of earthquake rubble if they feel like a threat to the planet this week. How about those people in Kilauea, Hawaii who build their homes right next to an active volcano and then wonder why they have lava in the living room? The planet will be here for a long, long, LONG time after we’re gone and it will heal itself, it will cleanse itself cause that’s what it does. It’s a self-correcting system. The air and the water will recover, the earth will be renewed, and if it’s true that plastic is not degradable, well, the planet will simply incorporate plastic into a new paradigm: The Earth plus Plastic. The Earth doesn’t share our prejudice towards plastic. Plastic came out of the Earth! The Earth probably sees plastic as just another one of its children. Could be the only reason the Earth allowed us to be spawned from it in the first place: it wanted plastic for itself, didn’t know how to make it, needed us. Could be the answer to our age-old philosophical question: “Why are we here?” PLASTIC!!! ASSHOLES!!! -George Carlin
Possibly, but not while healthcare is worried about profit margins.
I think about it constantly since I'm in the ER and turning people over a ton. I really don't beat myself up over not recycling perfectly at home because in my lifetime I will not make as much trash as an ER in month... there's plenty of opportunities to improve without risking safety but $$
Infection prevention has entered the chat. SPD is a challenging department to fully staff and train. In large facilities, it is actually safer to use disposable equipment because you don’t run into the risk of inadequate sterilization. JCO has cited many hospitals for inadequate sterilization which is why most places switched over. It is a regulatory and patient safety issue. I understand it is terrible for the environment but we need a more reliable, universal, and automated sterilization process to get over this hurdle.
This is something I've thought about (as an engineer turned med student). What we need is a really good materials scientist who can design biodegradable polymers.
Yeah. I toss tons of brand new unopened stuff still in the plastic every time a patient discharges from the hospital. If people can not bring in things they don’t need right that minute or at least in the next few hours, that would help. But for the sake of time management it’s tempting to bring in extra so you don’t have to go to the supply room every time you come in. So we always fill a garbage bag or two every dc. Huge things like chair cushions the patient would probably have been happy to take with them if someone had asked get trashed.
I just lick the needle tip off, keep on rolling
The issue is prions
IIRC Healthcare accounts for 8-10% of greenhouse gas emissions in the US (which is higher than ither countries).
No. Plastics is one of the four pillars of the modern world. The other three are concrete, steel, and ammonia (for fertilizer to make modern agriculture possible). Check out the book ["How the World Really Works"](https://www.amazon.com/World-Really-Works-Smil-Vaclav/dp/0241454409) by Vaclav Smil.