27 pounds of waste from one operation. Healthcare has a huge sustainability problem

Three young men in white coats, wearing gloves, rummage through garbage in silence. They bend over a sea of ​​white, blue, green and translucent plastics, pipes, cloths and clamps. Some stuff is soaked with blood, but most of it is just a bit wrinkled or completely intact. One of them shakes out new garbage bags, and the garbage heap grows, until the brightly colored hospital Crocs are no longer visible at their feet.

There is a total of 27 kilos of waste. It is intended for the incinerator, but now the subject of study. Everything that is there comes from one operating room in the Radboud hospital in Nijmegen. And it’s not saved up for a week, it’s not even a whole day.

“It’s impressive when you’re right in the middle of it,” says Hugo Touw, intensive care physician, “and you realize that it all comes from one operation of a few hours.” He nods sideways. “The three bags that are there must also be on this mountain.”

Healthcare has a huge sustainability problem. In the pursuit of efficiency, hygiene, cost savings and convenience, even the smallest medical act involves throwing things away. Without any hesitation, gloves, IV bags, jackets and aprons disappear in the trash, even if they are not necessary for patient safety. Cleaning and reusing items is often expensive, difficult and little attention is paid to it.

Trash cans

They don’t even know exactly how polluting hospitals are. Touw is now trying to find out with his fellow researchers through the wastepaper baskets. They investigate four common care pathways: eye surgery, open heart surgery, trauma surgery (major accidents) and patients with blood poisoning. For example, during an average open heart surgery (from four to six hours), five hundred different products are used. The vast majority is destined for the incinerator.

The fieldwork of the men, which has been going on for several months, is a curiosity within the hospital. They put blue notes on waste bins and bags: “Don’t throw it away!!” After an operation, they roll the waste in large containers through the corridors to their research room in the basement, where they pour out bag after bag on a tarpaulin. They sort, they tally and they weigh everything. “We wanted to do thorough research into the environmental impact of what we do,” says Touw. “Because that knowledge is still lacking. As a result, hospitals do not know how to become more sustainable most effectively.”

The study is being carried out in collaboration with, among others, the Leiden University Hospital LUMC, health insurer Menzis, Philips, waste processor PreZero and receives several hundred thousand euros in support from research organization ZonMw.

Washable mattress

Tim Stobernack, postdoctoral researcher in sustainability, squats in the trash to pull a large green plastic cover out of the mound. He holds it up with both hands. “This is where the mattress is for during the operation. Warm air is blown in to warm up the patient.”

“So that weighs almost nine hundred grams,” shouts Egid van Bree, student researcher, squatting in a rubbish heap.

“To high-quality plastic, yes,” says Stobernack. He puts the cover aside. „This is quite a fancy thing. It is discarded after each patient. You could easily make a washable mattress, or put a plastic cloth in between. That you just throw those away.”

His colleague Van Bree has just swept all the gauze into one heap – “at least eighty” – and is now fishing plastic gloves out of the mess. “On average, it’s 50 per operation,” he says, “and 113 for one day in intensive care, per patient.”

“Jesus,” says Touw.

“That’s average, isn’t it, there are also outliers.”

„The NHS [National Health Service] in England they are working hard to reduce the use of plastic gloves, but that is hardly an issue here,” says Touw. “I also notice in myself an ease with which I always pull gloves out of the closet and throw them away. For example, if I come into contact with blood, I have to. But when I measure the patient’s blood pressure or listen to the heart, it is enough to just wash my hands well. The patient is then really not at risk.”

Climate crisis

Radboudumc shows that even a progressive hospital still has a long way to go. In terms of sustainability, it is one of the frontrunners in the sector: the hospital runs on wind energy, and more projects are underway, such as reducing medication waste. But until recently, many hospital rooms did not segregate waste, despite the staggering amount of plastics thrown away.

Hospitals and other healthcare institutions have concluded two national agreements with each other in recent years: the green deals of care. The sector is therefore on the move, for example with the more frequent reuse of plastics. But until now, the agreements have always been without obligation – there is no sanction for not or hardly any sustainability. Talks are underway about a third version, due in October. It is unclear whether this time there will be consequences for not complying with the agreements.

“I myself did not realize for a long time that we cause a large part of the climate crisis with healthcare,” says Touw. He refers to research agency Gupta Strategists, which calculated that the healthcare sector would account for 7 percent of CO.₂footprint of the Netherlands. That calculation has not been verified elsewhere. It therefore remains unclear exactly how polluting hospitals are.

Also read: Erasmus MC wants to reuse ‘contaminated’ hospital waste

Research into this is scarce in any case, as are incentives to become more sustainable. Insurers pay hospitals per treatment, not for sustainability policies. Medical disposables (disposable items) are so cheap that it rarely pays to wash them or look for a reusable variant.

In the corridor of the intensive care unit, Touw unfolds a white-blue plastic mat. “This is among patients to collect some urine, for example.” He rubs the mat. “It looks harmless, but research by Erasmus MC shows that a lot of trees have to be cut for such mats because of the cellulose they contain.”

The mat comes from China and costs 16 cents. There is also a reusable variant on the market, which is four times as expensive. “We, in healthcare, are always under pressure to make cutbacks,” says Touw. “It is very complicated to swim against the current and use the expensive mats.” At the moment, the hospital uses both reusable and non-durable mats.

IV bags

The Nijmegen study already shows that not only heart surgery itself produces bags full of waste. They are also investigating the 24 hours in intensive care following the operation. Another five kilos of waste is produced there. In less than a day and a half, the patient in the hospital is therefore good for 32 kilos of waste.

“Look, this has changed,” says Touw, pointing to a hook with IV bags in an intensive care room. “Until yesterday, there were bags available here that are specifically for intensive care. A different type of IV bag was used in the operating room, so the bag was usually changed when the patient came here. The bag is now traveling with you.”

Infusion bags are also very polluting, the researchers discovered. Stobernack: “The plastic contains a plasticizer and the hoses are made of PVC. We calculated the environmental impact and arrived at one kilogram of CO₂emissions for such a small bag. About fifteen of these are already used during one operation.”

The bags are also packed in sometimes three layers of plastic, says Van Bree. And often things come from far away. “These bags come from Spain. That’s not too bad: surgical aprons come from Thailand or Cambodia. And I always see a lot of unused stuff back in the garbage. For example, they have been unpacked in advance by an operating assistant, but have not been used, and thrown away.”

asbestos suits

For Touw, sustainability only came into existence in corona time, when he had to slalom through the hospital corridors between wheelie bins with waste to get to the patient rooms. The insulation coats, hairnets, gloves and mouth caps flew through his hands. And every time there was a shortage.

Touw: “Then this apron was gone, then that medicine again. We’ve had six or seven varieties of protective clothing, at one point we even wore asbestos suits. Me and my colleagues then felt: we should look for reusable items. We cannot continue like this, for ourselves and for the planet.”

The Nijmegen hospital has recently introduced reusable insulation jackets for use with corona patients. It is a large, green wrap over coat that can be safely reused a hundred times after washing. “I thought: that would save plastic, but all that washing will cost more water,” says Touw. This appeared to not be the case. “Washing uses less water than is needed to produce disposable coats.”

The jacket resembles the type that was in use a few years ago, for disposables came into vogue. Touw: “I often hear people who have been working here for twenty years say: ah, so we’re really just going back to the past.”

Touw believes that it was a problem with disposable products that the healthcare sector should be responsible for itself. “We often point to the industry, but we have also asked for it ourselves. Reuse requires separation, removal, cleaning, etcetera. So yes: life is easier if you can just grab a new article.”

Some security measures have now turned out to be unnecessary. Rope takes a wafer-thin, see-through apron and hangs it around his neck. “Every time I visit a patient here, I’m expected to grab such an apron,” he says. “But that measure comes from the time when the intensive care unit was one room, where eight people were. Then you don’t want micro-organisms to move from one patient to another. Now they are separate rooms and research shows that the apron is not necessary. We are now in the process of letting go of that apron.”

The researchers also want to look at travel movements of hospital staff and patients. “A total of about twenty men are involved in such an operation and the first day in intensive care,” says Touw. “It makes a big difference if people come by train as much as possible.”

When the study is completed in January 2024, there should be a database detailing how polluting each part of the four interventions studied is. The researchers will then tour with their results to as many hospitals and conferences as possible. Touw: “We do that by bicycle.”

A version of this article also appeared in the newspaper of August 4, 2022