Hospitals and surgery centers are under pressure to reduce operating costs, and one of the biggest potentials for payback is through improvements to fluid management systems in the operating room. Medical waste is also a leading contributor to the nation's landfills, a concern the healthcare industry is becoming increasingly aware of. A surgical facility that seeks out ways to better manage its fluid and solid wastes can have real and immediate results on its environmental impact as well as on its bottom line.

Down the drain
Some healthcare professionals are questioning why thousands of suction canisters are used and discarded every day at surgical facilities. Many facilities still empty fluid wastes from canisters and deposit them into infectious waste bins, or solidify their contents, package them for safe transport according to regulatory requirements and ship them out with red bag wastes.

A study conducted by the Minnesota Technical Assistance Program at the University of Minnesota calculated that suction canisters make up 40 percent of the infectious waste leaving ORs. In that study (available at www.mntap.umn.edu/health/91-Canister.htm) researchers advise surgical facilities to employ fluid management systems that can discharge collected wastes directly into a sanitary sewer or to reuse suction canisters once they're emptied in order to reduce waste as well as costs.

Discharging fluid wastes into your municipality's sewer system, which is recommended by both the Environmental Protection Agency and the Centers for Disease Control and Prevention, is an appropriate disposal method as long as it is permitted by your local sewer authority.

Fluid waste options
Improving your fluid waste management process depends on how your facility is equipped. Several manufacturers offer fluid waste disposal systems that eliminate the need to send suction canisters off site. They can be divided into two types: stationary, wall-mounted fixtures that drain directly to the sewer line, and portable units that are wheeled to the utility room and connected to the drain for discharge. The portable systems often offer reusable canisters with disposable lids.

A low-tech alternative to a closed suction system is, of course, manually transporting canisters to a flush sink or hopper, emptying their contents down the drain and reprocessing them for reuse. While this similarly cuts an OR's infectious waste volume, red bag hauling costs (especially if the fluid would otherwise have been solidified) and purchasing of more canisters, it raises a risk assessment issue of environmental impact versus employee safety.

Ideally, the less your employees have to handle suction canisters, the better. Closed suction systems remove all, or almost all, contact but may require significant costs in the way of dedicated plumbing. Manually pouring fluid wastes into a flush sink or hopper, on the other hand, potentially exposes employees to splashing and spattering and opens the door to the possibility of slipping and falling. These liabilities can be countered by transporting canisters from the OR to the utility room on a cart, by installing a salad bar-type shield over the sink and by requiring the staff on disposal duty to wear personal protective equipment such as gowns, masks, gloves and goggles or face shields against bloodborne pathogens.

But a facility's management may want to consider how the cost of these measures, as well as the time it takes to don the necessary protective gear and empty canisters by hand, match up against the cost of closed systems. It's a tradeoff on which each facility has to find its own balance. Conducting a cost-benefit analysis is useful in determining which option makes the most sense.

Garbage in, garbage out
By now, nearly every household in America is likely familiar with the concept of separating out the trash. The segregation of a surgical facility's refuse — solid waste items kept out of regulated medical waste, recyclable items diverted from solid waste — can help to reduce its contribution to the waste stream and also possibly lessen its waste hauling costs.

The federal Occupational Safety and Health Administration defines regulated medical waste — commonly known as "red bag" waste — as liquid or semi-liquid blood or other potentially infectious material; items contaminated with these substances which would disperse them if compressed; items caked with these substances which, while dry, could still disperse them; pathological and microbiological wastes containing these substances; and contaminated sharps. (Each state has its own definition of Regulated Medical Waste. Visit www.practicegreenhealth.org/educate/regs/srl/ for state-by-state environmental compliance information.)

Most surgical facilities that closely monitor what they throw away would discover that they produce a small amount of infectious waste in comparison to their non-infectious solid waste, and that the red bags they ship out contain a fair amount of non-infectious waste.

This is without question a cost issue, since the hauling cost for red bag waste is several times per pound more than that of conventional solid "clear bag" waste. That's why unsoiled latex gloves, caps, shoe covers, masks, gowns and packaging materials, among other items, should not be deposited in the red receptacles. It's also an environmental issue, because much red bag waste is not actually incinerated, as is commonly believed, but autoclaved and delivered to a landfill, just as clear bag waste is.

Purchasing practices
The conventional wisdom on waste management tends to focus on the materials that emerge from the end of the process. But consumers often overlook the impact that can be made by first considering the materials that are brought into it.

Product packaging is a prime example. If you minimize the waste coming into your facility by taking care to order items without extraneous packaging, that's fewer things you have to get rid of once they show up.

I remember standing on the loading dock of a California hospital the day it received a shipment of new computers. Workmen were wheeling boxes upstairs on carts, then shortly afterward wheeling the boxes back downstairs to break them down and toss them into an open-top dumpster. I remember wondering why no one had asked the manufacturer to ship the computers in a different configuration: in reusable shipping containers to be returned, perhaps.

Sterile equipment requires certain packaging, of course, but facilities might consider working with their vendors, distributors or GPOs to reduce the amount of packaging that's involved in their purchases. It's a growing option.

Your inventory and supply chain management is another area where intake can affect waste disposal. Just as your OR staff should only open the surgical supplies needed for a case in order to prevent the unnecessary wasting of unused items, you should work with your staff and buyers to establish par levels and "just-in-time inventory" for those supplies on the storeroom shelves. Only order the quantities that you need at the present time, don't keep large amounts of less-than-frequently used items on hand at any time, and be sure to track expiration dates to avoid waste.

Opened but unused products may be able to be donated to humanitarian causes. The American College of Surgeons' Operation Giving Back program (www.operationgivingback.facs.org/content76.html) suggests options for donation.

Also, ask your vendors up front about any take-back or other product stewardship programs they might offer once a purchase has reached the end of its useful life. Find out if they'll be able to properly dispose of an expired lot of pharmaceuticals, refill a printer cartridge or recycle materials for reuse.

Resources for review
One way to start improving your waste management process is to monitor, benchmarking-style, what your staff disposes of and where they throw it away. Have your staff keep an eye on regulated, recyclable and solid wastes, too. Be sure to interact with your materials manager and their inventory software to find out what's delivered, what's used and what goes to waste.

A waste management consultant can also help your facility conduct a waste audit and help you assess the ways in which you can reduce your impact and costs.

Above all, effectively educate your nurses, surgeons, anesthesia providers and housekeeping personnel. Remember, too, that if management buys in, the staff will buy in. All those components are essential to ensuring that intentions and practices result in impact.