Red Bag Reduction and Reusables

1. Red Bag Reduction and Reusables Janet Brown Director of Facility Engagement Practice Greenhealth

2. Learning Objectives Understand the value of reducing red bags. Understand how a reusable sharps container program operates. Recognize the potential for savings through transitioning away from certain disposables to reusables.

3. 3 1998 American Hospital Association & U.S. EPA Memorandum of Understanding Virtual elimination of mercury-containing waste from healthcare facilities waste streams by 2005; Reduce total waste volume by 33% by 2005, and by 50% by 2010; Identify hazardous substances for pollution prevention and waste reduction opportunities, including hazardous chemicals & persistent, bioaccumulative, and toxic pollutants. H2E: www.h2e-online.org

4. The section names in the Operations section are not based on LEED, but many of the credits in this section were modeled on LEED for Existing Buildings. In addition, the Operations section includes many pollution prevention, waste management, and environmentally preferable purchasing strategies taken from health-care specific environmental non-profits such as Hospitals for a Healthy Environment and Health Care Without Harm. There are a total of 72 credits in the Operations section. The total number of credits in both the Construction and Operations sections are 166 credits and 21 Prerequisites.The section names in the Operations section are not based on LEED, but many of the credits in this section were modeled on LEED for Existing Buildings. In addition, the Operations section includes many pollution prevention, waste management, and environmentally preferable purchasing strategies taken from health-care specific environmental non-profits such as Hospitals for a Healthy Environment and Health Care Without Harm. There are a total of 72 credits in the Operations section. The total number of credits in both the Construction and Operations sections are 166 credits and 21 Prerequisites.

6. Integrated Operations Integrated Operations Crosses Departmental Lines What makes a program stick? Structure Reporting Committees Education, Training Policy Development

7. 7 Policy & Training Committee Work, Review and Policy Development Retrain current staff with agreed upon definition of RMW. Make staff aware of facility’s RMW reduction goals. Departmental role in their own RMW generation and associated disposal costs. Develop incentives for department heads. Communication Plan, Signage

8. 8 Support Services Worker Respect Issues Employee Education Employee Recognition Respectful Break Environment Safe Work Environment Communication Listening Proper Protective Equipment

9. 9

10. 10 Learn from our waste

11. What’s Your Waste Profile?

12. 12 What percentage of your total waste is RMW? Only ~6-15% should be going into red bags. Do staff understand that RMW costs between 5-10 times MORE than solid waste? How much RMW are you currently generating?

13. 13 A typical 250 bed facility that spends about $325,000 per year – If they didn’t have a recycling program, they’d spend about $475,000 per year. Before implementing any waste initiatives, you have to have an understanding of where you’re starting from. H2E can guide you through this process of understanding your baseline. Without this, you can’t know where you are and measure your success.A typical 250 bed facility that spends about $325,000 per year – If they didn’t have a recycling program, they’d spend about $475,000 per year. Before implementing any waste initiatives, you have to have an understanding of where you’re starting from. H2E can guide you through this process of understanding your baseline. Without this, you can’t know where you are and measure your success.

14. RMW Reduction Action - Version 2.2 Operations Section - Environmentally Preferable Purchasing EP Credit 1 Solid Waste Reduction in Purchasing Examples – Reusable shipping containers, fluid management, reusable sharps containers, single use device reprocessing, reusable sterilization containers

15. Red Bag Reduction Opportunities Reusables – Shipping containers, Sharps containers, gowns, isolation gowns, fluid management, single use device reprocessing. Improved segregation - incentives, training, education, monitoring Nonincineration treatment technology Proper segregation of mercury, pharmaceuticals, formalin.

16. 16 Reusable Products Evaluation of reusable materials – Take back programs for computer and electronics, reusable tanks, storage, toter deliveryEvaluation of reusable materials – Take back programs for computer and electronics, reusable tanks, storage, toter delivery

17. 17 Suction Canisters

18. 18 Disposable vs. Reusable Sharps Containers Nurses were responsible for changing containers Containers often overfilled. Containers often removed without being closed properly. Disposable filled containers were stored in the soiled utility rooms Too many employees handling sharps containers. Beth Israel incinerated approximately 2,700 disposable sharps containers per month at one site alone! Vendor offered a full-service sharps management service. One dedicated person for handling sharps. Much fewer incidents of overfilled containers. Nicer looking container Reduced needle sticks associated with waste Elimination of 2,700 containers per month! Reduced liability Positive feedback from staff.

19. Reusable Sharps Containers – Metro Hospital Implementation – FY 2006 Prior to implementation – 6 tons of disposables that were incinerated. Incineration fees were $2,520.00 In FY 2008 Metro avoided over nine tons of plastic from going to incineration at a savings of $3,8345. The program was cost neutral. The program is safer, due to less individuals handling sharps containers. The program prevents waste, in line with Metro’s environmental commitment. Reusable Needle Box Containers (RNBC): Metro implemented the use of RNBC in FY 2006 for its hospital. Prior to reusable needle box containers Metro was using six tons of needle boxes that were incinerated along with the sharps. The cost for incineration of the needle box containers alone was $2,520.00 dollars. In FY 2008 Metro’s RNBC allowed Metro to avoid over nine tons of plastic from going to incineration at a savings of $3,845.00 dollars. The total cost of Metro’s RNBC program was cost neutral compared to its previous program. Reusable Needle Box Containers (RNBC): Metro implemented the use of RNBC in FY 2006 for its hospital. Prior to reusable needle box containers Metro was using six tons of needle boxes that were incinerated along with the sharps. The cost for incineration of the needle box containers alone was $2,520.00 dollars. In FY 2008 Metro’s RNBC allowed Metro to avoid over nine tons of plastic from going to incineration at a savings of $3,845.00 dollars. The total cost of Metro’s RNBC program was cost neutral compared to its previous program.

20. Operating Room Waste Reduction Blue wrap prevention at Boulder Community Hospital Boulder Community Hospital worked with EPA on a zero waste program. Conducted a waste audit and identified “blue wrap” as a significant portion of the waste stream. Invested in durable, reusable containers for sterilization of instruments in the OR Setting.

21. Hard Cases Instead of Blue Wrap

22. Reusable Containers Invested in hard cases - $120,000 one time cost. Reduced disposable blue wrap purchase from $250,000 in 2003 to $60,000 in 2005. This does not include waste removal fee reduction. Manufacturers of surgical equipment are now required to provide the durable container as part of the equipment purchase.

23. Hard Cases Instead of Blue Wrap at Metro Rigid containers selected in FY 2007 for surgery and central sterile departments. Reduced use of sterile blue wrap Phasing in over time. As of Fall 2008, 50% are reusable. So far, blue wrap reduction is estimated at 2.5 tons. Metro’s estimated savings in purchase and disposal of blue wrap is $62K per year. Rigid Containers (RC): Were selected in FY 2007 as a means for the surgery and central sterile departments to minimize RMW. The RCs allowed Metro to begin reducing the amount of blue sterile wrap required for surgical packs-most of which would end up in the RMW containers following a surgical procedure. Metro is phasing in the use of RCs over time. As of this writing, 50% of Metro’s surgical packs come in the RCs. Estimates, of blue sterile wrap reduced due to the RCs, are at two and half tons. Metro’s estimated savings 62K per year. Rigid Containers (RC): Were selected in FY 2007 as a means for the surgery and central sterile departments to minimize RMW. The RCs allowed Metro to begin reducing the amount of blue sterile wrap required for surgical packs-most of which would end up in the RMW containers following a surgical procedure. Metro is phasing in the use of RCs over time. As of this writing, 50% of Metro’s surgical packs come in the RCs. Estimates, of blue sterile wrap reduced due to the RCs, are at two and half tons. Metro’s estimated savings 62K per year.

24. Reprocess-able devices: . EP Catheters . Compression Sleeves: PACU and floor collection . OR items - Cardiovascular, Orthopedic/Arthroscopic, Endoscopic/Laparoscopic External Fixation Devices Open/Unused and ExpiredReprocess-able devices: . EP Catheters . Compression Sleeves: PACU and floor collection . OR items - Cardiovascular, Orthopedic/Arthroscopic, Endoscopic/Laparoscopic External Fixation Devices Open/Unused and Expired

25. Reduction of waste in pounds, cost savings, Positive outcomes: increased awareness of environmental concerns Negative effects: OEM backlash Next steps: Celebrate success and keep up communications Reduction of waste in pounds, cost savings, Positive outcomes: increased awareness of environmental concerns Negative effects: OEM backlash Next steps: Celebrate success and keep up communications

26. GGHC Red Bag Reduction Waste Management Section – 1 point WM 2.1-2.2 – RMW Reduction Develop Facility Policy in collaboration with infection control and environmental services. RMW Segregation training for staffers New Training and Annual Training Achieve a less than 10% RMW rate Annually provide DOT training to relevant staff Provide RMW info, newsletters, posters etc..

27. RMW Continued WM 2.2 – 1 point in addition Demonstrate nonincineration for waste, where possible. Incorporate steps into overall waste plan Documentation Reference Standards Potential Technologies and Strategies

28. 28 Waste Segregation – Best Practices Implement an Infrastructure Conducive to Waste Minimization- Color coded, strategically placed and well labeled containers for: Solid Waste Infectious Waste Hazardous Waste Recycling Universal Wastes Others Desk side containers Recycling bins by copiers NO RMW containers by sinks on basic exam areas.Desk side containers Recycling bins by copiers NO RMW containers by sinks on basic exam areas.

29. 29 RMW Reduction Reduce volume of RMW. Switch to a reusable sharps container. Switch to reusable shipping containers for RMW. Reusable Sterilization Containers

30. 30 Step by Step to RMW Reduction Infection Control Committee – Policy Development Gather baseline data – Project savings Reduce red bags BEFORE evaluating onsite treatment technologies Review waste contracts – non-incineration treatment of RMW. Consider on-site versus off-site. Review sharps contracts.

31. 31 Waste Segregation – Implementation Present Plan Form a team Define waste streams Survey Facility Develop Materials Purchase equipment, supplies. Issue Memo Container placement Properly Labeled, Signage Proper placement Training (never ends.) Monitoring and reporting Continue!

32. 32 Container Placement Red bags containers should be covered to reduce solid waste casually tossed in. Remove red bags from under hand-washing sinks, non-critical care patient areas, hallways and other areas where people are likely to dispose of solid waste. Where there ARE red bags, locate a solid waste container directly adjacent so staff make conscious disposal and segregation decisions.

33. 33 Container Placement and Signage

34. 34 What goes in a red bag anyway?* Blood, Products of Blood Anything caked, soaked or dripping in blood Tissues from surgery and autopsy Cultures and stocks of infectious agents and discarded vaccines. Suction canisters with any fluid. Hemovac and pleurovac drainage. Operating room waste saturated with body fluids as defined by OSHA. Waste from patients isolated with HIGHLY communicable diseases. (These are CDC Class IV definitions including Ebola, Lassa Fever, Marburg and Small Pox. NOT such conditions as AIDS< Hepatitis or TB.) Sharps, including syringes and unused sharps. IV Bags, tubing, foley bags Non bloody gloves Packaging, Urine-soaked waste, feces, vomit Blood-tainted waste (Note distinction between blood-soaked and blood-tainted. A little bit of blood on an item can go in the regular waste stream.)

35. 35 New Employee Training Train new employees about waste segregation procedures as part of employee orientation. Consider making “compliance with hospital waste management policies” part of every job description.

36. 36

37. 37 Employee Buy InEmployee Buy In

38. 38 Obstacles Fear of Waste Lack of training Old habits No clear can available Overfilled clear lined can Ran out of clear bags! Housekeeper collecting clear bags into red bag. Use closest can Change of Staff No time No can available Confusion of Isolation rooms Confusion over body fluids Let’s talk a little about reality: Space Finances Employee Buy In Construction Worker – Using red bags for waste, chute, using chemicals near air intake, MSDS, appropriate elevator, EMPLOYEE RESPECT – SPACES FOR CHANGING, EATING LUNCH, ARE THEY ACCEPTABLE? WOULD YOU USE THEM?Let’s talk a little about reality: Space Finances Employee Buy In Construction Worker – Using red bags for waste, chute, using chemicals near air intake, MSDS, appropriate elevator, EMPLOYEE RESPECT – SPACES FOR CHANGING, EATING LUNCH, ARE THEY ACCEPTABLE? WOULD YOU USE THEM?

39. 39 Problem Identification and Resolution Plan You WILL encounter mistakes. Conduct tours of trash areas monthly. Develop a mechanism to report concerns or issues (e.g. photo along with written report of issue and responsible floor/dept/unit) Re-educate promptly. Hold in-service with responsible unit to explain problem and proper segregation technique. Engage a nurse leader to help communicate program.

40. 40 Track Progress, Report Successes and Reward Staff! Make sure to track waste generation rates in a reliable spreadsheet. Track cost-savings. Let staff know how they’ve done… Reward staff for their efforts- create incentives such as movie tickets, catered lunches, pizza parties Apply for an award from H2E. Use results as a Performance Improvement Initiative for JCAHO.

41. 41 Change… requires shift in mindset and enlightened leadership A typed policy in a binder does not make change in an institution or any business setting. The key to success is simplicity, tools and education. Without support for the efforts, programs will not sustain themselves. These programs, while viable and achievable, do not happen by themselves. Someone must be dedicated to coordinating the work, which spreads across all departments and levels of management. A dedicated staff person can cross department lines, educate throughout the house, and pull together the programs. And don’t forget to reward front-line workers. The front-line workers make the programs and their participation and buy-in will make or break the program. A typed policy in a binder does not make change in an institution or any business setting. The key to success is simplicity, tools and education. Without support for the efforts, programs will not sustain themselves. These programs, while viable and achievable, do not happen by themselves. Someone must be dedicated to coordinating the work, which spreads across all departments and levels of management. A dedicated staff person can cross department lines, educate throughout the house, and pull together the programs. And don’t forget to reward front-line workers. The front-line workers make the programs and their participation and buy-in will make or break the program.

42. Review & Program Maintenance Team Development Data Collection Data Review and Goal Setting (short, medium, long) Policy/material Development Monitoring Waste data tracking Ongoing Education, New Employee Orientation Report, reassess and repeat

43. Thank you Janet Brown jbrown@practicegreenhealth.org 413/253-0254 www.practicegreenhealth.org www.gghc.org