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Monday, 20 April 2015
Maryland Sharps Disposal in the Operating Room:
In Maryland and other States the evolving medical environment, fiscal constraints on medical practice is becoming the norm. The new days of austerity have revived interest in the economics of medical practice. Economic measures, however, should not impinge on the quality of patient care. Maryland waste disposal, in particular, is an area without any direct patient benefit but which carries both short- and long-term ecological costs. Much of how we dispose of waste is dictated in the United States by the Joint Commission for the Accreditation of Hospital Organization, Occupational Safety and Health Administration, state regulations, and individual hospital protocols. ln an attempt to elucidate the waste in waste management, we examined the use of standard operating room sharp boxes.
Full sharp boxes from three different Maryland operating sites were randomly saved. Boxes were weighed and opened, and contents were separated into appropriate sharps: loose needles, scalpels, syringes with uncapped needles, and other. Weight and volume assessments were performed on the non-sharps. True sharp values were derived from non-sharps data. Less than 50% of the contents were appropriate for sharps disposal, with empty glass vials constituting the greatest percentage by weight of non-sharps material. We believe that encouraging the appropriate use of sharps boxes is a potential source for savings. Implications: Sharp boxes were randomly saved from university operating rooms and analyzed for content. The full boxes contained 14% appropriate sharps by weight and ~50% appropriate sharps by volume. The largest fraction of non-sharps weight was found to be glass.
In the present age of medical cost containment, clinicians must do more with fewer clinical dollars. This new practice constraint requires efforts to reduce costs in areas that have little to do directly with patient care. Medical waste management is one such area. Waste produced during clinical practice has an adverse impact on the environment.
Managers estimate that hospitals generate 3.2 million tons of waste annually, with half coming from operating rooms (ORs) (1).The generation of medical waste without consideration of its cost or disposal is an endemic problem with medical caregivers. Investigation of the impact of disposable versus reusable OR items has focused on economics (2), not waste-generating behavior. Because of its high economic and ecological cost, waste generation is an area that merits further examination.
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The mantra of waste management has become “reduce, reuse, and recycle.” relating to proper handling of medical waste arises from several sources, including waste wash-ups on beaches, concern for the proper use of landfills, and fear of infection relating to inappropriate disposal of hospital waste (3, 4). Although all infectious waste is regulated by the Environmental Protection Agency and state and local law, it is infectious sharps waste with which the public is especially concerned (5, 6). Hospitals are limited in their ability to channel the stream of waste because of government regulations, restrictions on incinerators, and the decreasing numbers of landfills that will accept medical waste. Consequently, options for the disposal of sharps waste are decreasing.
Because of their high content of plastic and metal, sharps boxes are incinerated in relatively few places because of engineering issues relating to the smokestack scrubbers (7). Thus, full sharps boxes are routinely transported cross-country to authorized incinerators, then incinerated; the ash is landfilled. At the University of Pittsburgh Medical Center (UPMC), this is done at a cost of $0.55~$1.10 per kilogram. National estimates of waste cost disposal in 1990 dollars was estimated at $480,000,000 (1). Although Occupational Safety and Health Administration guidelines (8) clearly describe what is to be disposed of in sharps boxes, personnel are often unsure of these regulations.
As a result, sharps boxes could be used inappropriately as generic garbage receptacles. To determine whether sharps boxes are used appropriately, we studied what was actually placed into sharps boxes in a busy OR setting. We hypothesized that sharp boxes are used inappropriately in Maryland. We quantified the material placed into sharp boxes and then estimated the potential ecological and economic impact of their inappropriate use. Methods Conduct of the study was approved by the Environmental Health and Safety, Infection Control and Risk Management departments at UPMC. Twenty-seven two-gallon sharps disposal containers (Sharps-A-Gator; Devon Industries, Inc., Chatsworth, CA) were randomly saved before disposal from ORs at UPMC. None of the personnel using the sharps boxes were aware of the study. The full sharp boxes were weighed and emptied into a stainless steel basin. Each empty sharp box was weighed. Non-sharps (syringes, glass vials, paper products, etc.) were separated from the sharps (Table1) and placed in a previously weighed plastic waste disposal bag. The sharps were disposed of in a new sharps disposal container. The plastic bag, with its non-sharps contents, was then weighed. Weight of the sharps was calculated by subtracting the non-sharps weight plus empty box weight from the full box weight. After the initial 10 boxes were examined, the high content of glass was noted and subsequently evaluated.
The glass items were separated into a new plastic bag and weighed. Glass weight was studied for the remaining 16 of the original 27 total boxes after the initial 10 boxes showed a high percentage of glass weight. For volume assessment, volume displacement was used because of the irregular nature of the items being assessed. The excess air within the plastic bag Table 1. Appropriate Sharps as Defined for the Study Loose needles, capped or open Syringes with uncapped needles Suture needles IV needles, Surgical staples Surgical scalpel blades Table 2. Weight and Volume Assessment of Sharps Boxes containing the non-sharps were evacuated using a standard OR suction. This bag was placed in a second bag, and the excess air was evacuated. The bag with non-sharps was then placed in a box of known volume, and water was added until the full volume was reached. The volume of water added was subtracted from the known box volume to yield the volume of non-sharps. All measurements were made in triplicate and averaged. Descriptive statistics were determined for each sharps box.
Our data indicate that the OR sharps containers held ~50% appropriate sharps by weight and volume (Table 2). The highest percentage of non-sharps by volume was found to be plastic needleless syringes. The highest percentage of non-sharps by weight was found to be empty glass vials (Tables 2 and 3). Discussion Disposal of sharps can cost hospitals hundreds of
thousands of dollars per year. The UMPC Environmental Services Division estimates that of all infectious waste, approximately 20% is from the sharps containers, which must be incinerated off site and then disposed of at landfills. Because the cost of sharps container disposal is based on weight, a reduction in sharps box misuse by 50% could save in excess of $200,000 per year at UPMC. Although some glass is “sharp,” it is primarily generated from drug vials; therefore, it is not considered infectious as defined by Occupational Safety and Health Administration or hospital infection control policies. Glass is inexpensive to dispose of and potentially recyclable. By placing glass-only disposal boxes in the OR, the high percentage of noninfectious, non-sharps weight could be significantly reduced in the sharps containers. In addition, personnel would have a safe, rational, and inexpensive option for the disposal of glass waste. The disposal of glass boxes is much less expensive than sharps waste disposal. Using sharps boxes as they are intended can be achieved with minimal alteration in personnel practice. Subsequent cost savings are realized not only through reduced disposal weight due to proper sharp and non-sharps disposal, but also the reduced need for empty boxes, reduced personnel handling costs; reduced transport costs to the incinerator and landfill site, and the result of ultimately less ash to be landfilled.
The concomitant increase in non-sharps waste is lo-fold less expensive to dispose of and at UPMC is incinerated at the institution, limiting out of pocket expenses for waste disposal. Concurrent with changes in OR disposal options, an educational program for OR personnel is to be implemented. This program will focus on appropriate sharps-related behavior as defined by federal and local regulations as well as clarification of “what goes where.” In conclusion, misuse of sharps containers has both significant ecological and economic impact. Through increased personnel awareness and education, appropriate disposal of sharps and no sharps can result in significant cost savings.
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