Solid waste... is one of the most important, growing, worldwide concerns linked to economic and technological development. Solid waste, which is defined as solid material unwanted at the time of generation (Rajor, Xaxa, Mehta, & Kunal, 2012), is one of the most important, growing, worldwide concerns linked to economic and technological development. According to the World Bank (Hoornweg & Perinaz, 2012), it is estimated that urban residents alone produced twice as much waste as they did a decade ago, and the waste production will continue to increase. By 2025, the estimated 4.3 billion, urban residents, worldwide, will generate approximately 2.2 billion tons of waste per year (Hoornweg & Perinaz, 2012). In addition, waste from households and industries, such as healthcare, play a significant role in waste generation. The management of solid waste from all producers includes both incineration and landfill, which contribute to global greenhouse gas (GHG) emissions and subsequent global warming (Hoornweg & Perinaz, 2012; United States [US] Environmental Protection Agency [EPA], 2017a). Because environmental sustainability is impacted by the amount and management of solid waste from all waste producers, the healthcare industry is obligated to examine, continuously, its solid waste production, so as to build strategies of reduction and environmentally sound management (EPA, 2017b).

In this article, the authors address the background and significance of current, solid waste practices. They also discuss the study they completed to begin to inform changes in isolation protocols and disposal processes, so as to demonstrate environmental stewardship and sustainability. They also consider their study limitations and share implications and solutions for environmental stewardship. The article conclusion identifies the critical need for further study of unregulated solid waste disposal generated in caring for infectious patients.

Background and Significance

This section will provide an overview of the challenges resulting from the large amounts of solid waste in healthcare. It will also consider the generation of unregulated solid waste from isolation procedures.

Solid Waste in Healthcare
Solid waste poses one of the most challenging concerns in today’s healthcare systems... Solid waste poses one of the most challenging concerns in today’s healthcare systems, including clinics, provider offices, and hospitals (Chandrappa & Das, 2012). Specifically, hospitals account for 71% of all reported solid waste, including food waste, that is generated through the healthcare industry (United Nations Environmental Program [UNEP], 2012). The amount of waste generated by hospitals is growing. In 1991, Rutala and Weber found that an average, hospitalized patient generated approximately 15 pounds (6.8 kg) of waste per day. In 2015, the American Hospital Association (AHA) estimated that considering total hospital waste (e.g., operating room disposables, food, pharmaceuticals, laboratory, and patient care), each patient could potentially generate 25 pounds (11.3 kg) of waste, an increase of 67% more solid waste per day since 1991. This is due in large measure to the increasing use of disposables (Hossain, Santhanan, Norulaini, & Omar, 2011).

Within the healthcare environment, there are two main classifications of solid waste: biomedical waste, which is referred to in the literature as infectious waste, and all other waste, or unregulated solid waste (EPA, 2016; Maine Department of Environmental Protection [MDEP], 2016). Biomedical waste is targeted as potentially pathogenic and requires special handling/waste disposal. This waste includes microbiology waste, blood products, bloody body fluid specimens, pathology and anatomy waste, sharps, and other items described in state specific guidelines (Centers for Disease Control and Prevention [CDC], 2013; EPA, 2016; MDEP, 2016; Sehulster et al., 2004). Biomedical waste is disposed into specified bags that are red; must be impervious to moisture and have strength sufficient to resist ripping; and are imprinted with the international biohazard symbol and words biomedical waste or infectious waste (MDEP, 2016). In addition, items that are classified as sharps (e.g., needles, glass vials) are also classified as biomedical waste and must be disposed of in leak-resistant, rigid, puncture-resistant containers, without clipping or breaking. The disposal of biomedical waste, which is regulated by state disposal management groups, includes incineration or treatment through approved non-incineration technology to render pathogens innocuous (MDEP, 2016).

The amount of waste generated by hospitals is growing... due in large measure to the increasing use of disposables. In contrast, unregulated solid waste (e.g., disposable patient care pads, gloves, isolation gowns), which comprises most of hospital waste, is unregulated by the state. Disposal is handled in the same types of trash bags as those used in residential homes and managed through incinerators or landfills (Chaerul, Tanaka, & Shekdar, 2008; UNEP, 2012). Unregulated solid waste produced during routine care of all patients is in part produced as hospitals make efforts to decrease the spread of infection caused by multi-drug resistant organisms (MDROs; e.g., isolation gowns, gloves). This is a global concern (World Health Organization [WHO], 2015). According to the CDC (2013), at least 2 million people in the United States acquire antibiotic resistant infections each year, resulting in 23,000 annual deaths. MDROs have become a major threat in healthcare facilities because they are increasingly common (New Hampshire Communicable Disease Epidemic Control Committee, 2015). With 894,574 total staffed beds in nearly 5,600 U.S. hospitals registered with the AHA (2018), there is enormous potential for the spread of MDROs within care facilities where infectious patients are treated.

Generation of Unregulated Solid Waste from Isolation Procedures
To fight the spread of infection from hospitalized patients with MDROs, the CDC (2013) recommends four core actions: tracking bacterial spread; improving antibiotic use; promoting new antibiotic and tests to diagnose and treat; and preventing MDRO infection spread. Patients are screened for infection or pathogenic colonization and treated following affirmative culture results (Septimus, Weinstein, Perl, Goldmann & Yokoe, 2014; Spence, Dammel, & Courser, 2012). Part of the treatment is implementing contact isolation precautions. The vertical approach to contact isolation precautions is recommended to reduce the transmission of MDROs (Siegel, Rhinehart, Jackson, & Chiarello, 2017) and implemented for all patients with active infections or bacterial colonization (Calfee et al., 2014). This isolation practice includes the use of personal protective equipment (PPE), such as gown, gloves, and possibly nose/mouth masks or eyewear, for all people entering rooms housing isolated patients. As a result, greater volumes of unregulated solid waste are generated when these isolation precautions are implemented. This adds to the increasing volume of waste generated from disposable patient care supplies used in all care settings (Hossain et al., 2011).

As the number of MDRO infections increase, the volume of unregulated solid waste surges. As the number of MDRO infections increase, the volume of unregulated solid waste surges (Spence et al., 2012). However, the efficacy of vertical contact precautions across healthcare facilities (hospitals and nursing homes) is difficult to evaluate due to facility-specific isolation protocols, and procedural compliance as low as 21% (Clock, Cohen, Behta, Ross, & Larson, 2010; Cohen, Cohen, & Shang, 2015; Cohen, Dick, & Stone, 2017).

Studies conducted in nursing homes reporting implementation of required isolation procedures for MDRO patients are minimal (Cohen et al., 2017). Yet no significant difference in rates of infection are observed when contact isolation precautions are utilized (i.e. the use of full PPE compared with the use of gloves only) (Trick et al., 2004).

Huskins et al. (2011) conducted a rigorous, randomized trial with 5,434 admissions to 10 (intervention) adult, intensive care units (ICUs) and 3,705 admissions to 8 (control) adult ICUs. Samples from all patients in the intervention group were cultured, with patients placed in contact isolation if colonized or infected with MRSA or vancomycin resistant enterococci (VRE). Findings revealed that although patients admitted to the intervention group were placed in isolation and treated with appropriate precautions more frequently than patients in the control group, following contact isolation protocols did not reduce the incidence of MRSA/VRE colonization or infection when compared to the control group (p=0.35). Huskins et al. (2011) found that isolation precaution protocols were not strictly followed in either the control or the intervention groups; the intervention group wore gowns during 77% of patient contact with proper hand hygiene following patient care practiced just 69% of the time. Lack of compliance with isolation protocols may be attributed to several factors, including patient acuity, healthcare provider type, day of the week, and organizational culture (Yanke et al., 2015).

...some organizations... have partnered with environmental and healthcare organizations and consultants to encourage waste reduction. Study findings indicate that our current isolation practices need to be reevaluated; data is needed to make informed decisions that promote patient safety through environmentally sustainable procedures and protocols (Huskins et al., 2011; Thakur& Anbanadam, 2016). Coupled with this empirical support, practicing environmentally sound waste disposal practices through waste minimization at the point of generation is largely supported by the World Health Organization (WHO, 2017). Furthermore, some organizations (e.g., Healthcare Without Harm) have partnered with environmental and healthcare organizations and consultants to encourage waste reduction. The goal is to support both WHO goals, strategies, and focus and also the Paris Agreement to reduce greenhouse emissions (Healthcare Without Harm, 2017, United Nations [UN], 2017).

However, to date, there is a paucity of information in the literature concerning the amount and type of biomedical and unregulated solid waste that is generated specifically while caring for isolated patients. The observational, descriptive study described below focused on quantifying solid waste generated while caring for infectious patients confined in contact isolation in one of Maine’s larger regional hospitals. For this study, solid waste is defined as all waste, including biomedical waste (i.e., items in red bags and needle boxes, and unregulated solid waste care items, such as medication packages and PPE). No liquid waste disposal, such as liquid medication, was examined. Food waste was excluded from this study because food trays with leftovers were removed from patient rooms and subsequently discarded through the nutrition department, rather than in patient rooms or hospital units.

Solid waste output generated while caring for isolated patients infected with methicillin-resistant Staphylococcus aureus (MRSA) was analyzed to meet the following aims: (a) to characterize the composition of waste generated (e.g., needles, isolation gowns, gloves, and plastic syringes); (b) to measure the quantities of waste produced (e.g., number and weight of unregulated solid waste bags, biomedical waste bags, and sharps containers); and (c) to examine waste disposal practices including designation of disposal duties and sealing/securing of waste and waste bags. This study was conducted to support future development of an algorithm intended to inform changes in isolation protocols and waste disposal processes. The goal is to reduce microbial transfer through implementation of cost-effective methods that demonstrate environmental stewardship.

The Study

In this section, we will describe the subjects and setting for the study. Additionally, the study preparation, data collection and analytics used will be presented.

Subjects and Setting
All solid waste (biomedical and unregulated solid waste) generated in and collected from two patient rooms was examined for a 7-day period... This descriptive study was reviewed and designated as exempt human subjects research by the internal review boards at the participating university (2016-05-02) and the subject hospital located in Central/Eastern Maine (16-1-M-327). All solid waste (biomedical and unregulated solid waste) generated in and collected from two patient rooms was examined for a 7-day period beginning at 7:00 am on August 1 and ending at 7:00 am on August 8, 2016. Analysis was conducted only on waste generated in caring for patients who met these study inclusion criteria:18 years or older; diagnosed infection with MDRO; and prescribed treatment with contact isolation precautions. Patients subject to droplet precautions (e.g., SARS-associated coronavirus or influenza) or airborne isolation precautions (e.g., chickenpox, M. tuberculosis) or diagnosed with high-risk infections, (e.g., carbapenem-resistant Enterobacteriaceae (CRE) or H1N1) were excluded from this study.

A medical/pulmonary hospital unit was selected as the study site because patients with MDROs were frequently confined in dedicated contact isolation rooms within the unit. Patients with MRSA were assigned to the rooms in this unit by the hospital admission staff based on their pathology and healthcare needs.

Study Preparation
To ensure study reliability and facilitate consistent recording of data, the collection process was discussed, defined, and agreed upon by the primary investigator (PI) and five study team members. Waste disposal practices of healthcare providers, including registered nurse (RNs), certified nursing assistant (CNAs), and medical doctors (MDs), were observed and described by study team members. Healthcare providers were asked about waste disposal practices when the study team members could not directly observe the waste disposal (e.g., when the privacy curtain was closed). Therefore, before data collection began, the PI educated nursing leaders, staff educators, hospital nursing staff, and other healthcare providers (e.g., nurse practitioners) about the study, including data collection procedures, the purpose of the study and data collection, and their role in the data collection process.

Data Collection and Analysis
Study team members collected data describing the volume and type of solid wastes generated in caring for patients that occupied 2 patient rooms during the week-long study (168 hours). The first author of this article served as the PI; the data collectors were nursing students who had completed the health-related research course and their junior year of nursing courses. Data collection was conducted outside patient rooms; study team members did not enter patient rooms or handle solid waste. To ensure efficient and optimal data collection, the PI collected data on Day 1 and Day 2 from 7:00am – 7:00pm; made site visits once per day on Days 3 – 7; and was available by telephone 24 hours/day for the duration of the study.

At the time of the study, the designated hospital site utilized four container types for disposal of solid wastes generated during patient care. Patient rooms featured sharps containers for needles and other items that can puncture skin, red bags used to collect biomedical waste, and clear bags used for unregulated solid waste, such as paper towels discarded after handwashing. Black bags located just outside the door to patient rooms were dedicated to disposal of single-use isolation gowns and gloves (i.e., unregulated solid waste PPE items).

Data was not associated with patient rooms or hospital records, and was cataloged in dedicated, password protected iPads loaded with a HIPAA-compliant, iFormBuilder data collection tool, customized for this study. Descriptive analysis was used to examine the study data which included limited patient demographics; composition and quantity of solid waste generated; and the weight of disposal bags (biomedical and unregulated solid) and sharps containers used in, and collected from, patient rooms. SPSS v. 24 (IBM, Armonk, N.Y.) was used for data analysis.

Findings

This section presents the demographics and collection setting. We will also describe the solid waste composition and practices, and the waste weight and waste removal.

Demographics and Collection Setting
Patients assigned to these rooms during the study period included two females and one male, all medically stable and ranging in age from 34-68 years. Admitting diagnoses included urinary tract infection, peripheral vascular disease, and gastrointestinal bleeding. Time periods monitored varied by patient during the study based on their admittance and departure from isolation, and ranged from 28 hours (Patient 1) to 168 hours (Patient 2).

Solid Waste Composition and Practices
Over the course of the study, two patient care isolation rooms, housing three patients, yielded a combined 3,322 solid waste items generated and disposed of through 418 waste deposits. These solid waste items were classified in 37 categories (See Table 1 for item descriptions). The wastes were deposited in the previously described designated containers: black bags (located outside patient rooms), unregulated solid waste bags (clear), biomedical red bags, and sharps containers (inside patient rooms) (See Table 2 for Solid Waste Composition and Disposal). Study team members directly observed nearly 70% of all solid waste disposals completed during this study.

RNs deposited 55% of the wastes, while certified nursing assistants (CNAs) deposited 21%; other healthcare providers and service personnel together deposited 24% of the wastes generated in these rooms. Care provided between the hours of 7:00 am and 7:00 pm yielded 61% of the total waste volume; 39% was generated between the hours of 7:00 pm and 7:00 am. The most commonly deposited waste items were disposable, non-latex gloves (n=1028, 31%), single-use isolation gowns (n=467; 14%), gown packaging (n=467, 14%), and medication packaging (n=267, 8 %). Thirty-three additional waste items account for the remaining 33% of waste (See Table 2 for Solid Waste composition).

Table 1. Solid Waste Items Discarded during Study (n=37)

Table 2. Solid Waste Composition and Disposal (n=3,322)

Waste Weight and Removal
Approximately 65 kilograms (kg) of solid waste in 80 waste bags/containers was removed... during the study. Approximately 65 kilograms (kg) of solid waste in 80 waste bags/containers was removed to the unit waste holding room by the hospital’s environmental services (EVS) staff during the study. Sixty kilograms or 92% of this volume was deposited as unregulated solid waste (in clear or black bags); biomedical bags (3 kg) accounted for 5% of the waste, and sharps containers accounted for 3% (2 kg) of the total waste. Approximately 96% of the solid waste bags utilized during this study (including clear and black waste bags and biomedical waste bags) were sealed by tying the ends of the bag together. Between 6:00 am and 11:30 am, 40% of the bagged solid medical waste was removed from the rooms (see Table 3 for additional disposal details). Isolation, protocol-related waste items alone (i.e., gowns, gown packaging, and gloves) accounted for approximately 28 kg of the total disposed solid waste (See Table 4 for weight data).

Table 3. Solid Waste Disposal

Table 4: Weight of Large Volume Solid Waste Items

Discussion

This study revealed that substantial waste was generated by medically stable patients with MDRO being treated with contact isolation protocols in a medical/pulmonary unit of a regional hospital in Maine. Based on our findings, caring for one patient in this unit generated nearly 5 kg of solid medical waste in one day (65 kg/7days/2 patients). Extrapolated over one year, caring for one low-acuity patient using contact isolation standards could generate approximately 1,690 kg of unregulated solid, biomedical, and sharps waste. Current hospital trends reflect increasing use of disposables in treating patients of low and high acuity to limit cross-contamination and enhance patient safety (Hossain et al., 2010) This trend has a significant impact on the medical waste stream. In 2015, the AHA reported generation of greater waste volumes than measured in this study, estimating that treating hospitalized patients in all patient care areas (operating rooms, emergency departments, and multiple critical care units) can generate, on average, 11.3 kg of solid waste per person, per day.

In this study, items required by contact isolation treatment protocols (disposable gowns and packaging and single-use gloves), comprised 28 kg (43% of the generated weight). While the volume of waste generated in caring for low acuity patients in this study is less than the per patient volume reported by AHA, it is clear that low acuity patients require less intense nursing care and fewer bedside procedures, effectively reducing the production of patient-care solid waste. However, the care for low acuity isolation patients for 168 hours during this study generated 37 different solid waste items that included a considerable volume of personal protective equipment (PPE) requiring disposal.

The waste data collected in this study (approximately 500 non-latex gloves per patient per week, and more than 230 gowns per patient per week) adds 26,000 gloves and 11,960 gowns per patient each year to the unregulated solid waste stream to be disposed of via incineration or landfill. High acuity patients with multiple, specialty healthcare provider visits during their hospital stay could generate a significantly larger volume of unregulated solid waste just from PPE. For example, an unstable MRSA-infected patient treated in a contact isolation intensive care room could have multiple healthcare provider visits per hour. Just doubling the number of gloves and gowns used per patient each year would amount to 52,000 gloves and almost 24,000 gowns. Considering the 77,000 U.S. critical care beds (Society of Critical Care Medicine, 2017), there is potential for vast amounts of unregulated solid waste generation from critically ill, isolated patients, which would add to environmental pollution through solid waste production and disposal processes.

Limitations

Limitations inherent in this study include those presented by a small study site, such as one having minimal data volume and reduced variability. Isolated patients with greater acuity, such as those in intensive care units, labor and delivery, or the emergency department, could produce a much larger volume of wastes. Additionally, this study was conducted in a regional hospital, and may not accurately reflect the type and quantity of isolation waste produced in other hospitals. One critical drawback in executing this study was the reliance on indirect reports of waste disposal. Approximately 30% of the disposal data were not recorded by the study team but were self-reported by on-duty hospital staff, increasing the likelihood of recording, quantification errors, and potential study bias.

Nursing Implications and Solutions for Environmental Stewardship

A horizontal isolation approach could be employed to decrease waste generation... Given the mixed support of the efficacy of current isolation protocols to limit the spread of MDRO in acute care settings (Huskins et al., 2011), and the volume of wastes generated in caring for medically stable, low acuity isolated patients in the current study, alternative isolation approaches to containing MDRO infection should be considered. A horizontal isolation approach could be employed to decrease waste generation as well as the cost of care (Septimus et al., 2014; Spence et al., 2012). This horizontal approach differs from the vertical isolation approach in that each patient is individually assessed for isolation appropriateness. For example, patients with MRSA infections are individually assessed for contact isolation needs based on level of active infectiousness (i.e., draining wounds) rather than microbial presence (i.e., MRSA positive or colonization screens).

However, care for all patients (i.e., isolated and non-isolated) could focus on vigilant hand hygiene and environmental cleaning. For all high-risk patients, topical decolonization of with chlorhexidine gluconate could also be employed (Septimus et al., 2014). Policy changes would reflect a prescriptive horizontal contact isolation protocol, hand hygiene emphasis, aggressive environmental cleaning procedure, and topical decolonization for targeted patients. Follow-up studies could be conducted to test and promote the efficacy of horizontal isolation techniques, which could then encourage other health institutions to change isolation procedures.

Gathering additional solid medical waste data could facilitate development of an algorithm-based, horizontal approach to modifying isolation precautions... Gathering additional solid medical waste data could facilitate development of an algorithm-based, horizontal approach to modifying isolation precautions, one that mitigates waste handling and sustainability challenges. Updated, isolation techniques could ideally be applied to a diverse array of microorganisms ranging from common human flora to more serious pathogens, such as Ebola virus or the emergent fungus, Candida auris (Sherry et al., 2017). The algorithm could be updated periodically as new MDROs develop.

Another practice that could be emphasized to decrease the amount of unregulated solid waste (e.g., PPE) in isolated patient rooms is task bundling. This decreases the number of room entries, thereby decreasing the amount of PPE. Environmental work designs and changes could be employed based on the psychology of human factors (i.e., designs that focus on minimizing room entries based on how healthcare providers interact with their environment). This practice essentially promotes work efficiency and has been found to be a predictor in task compliance, (Arnetz et al., 2011 β = .22, p<.01). Increased hand-hygiene practices and strict isolation compliance for isolated patients may result from more efficient isolation processes. To sustain the importance of work efficiency and task bundling, formal educational sessions (e.g., continuing educational offerings) could be provided for healthcare professionals.

Conclusion

Isolation precautions utilized in larger healthcare facilities are being examined to determine the effectiveness of existing protocols for preventing microbial spread (Schweizer, 2013). Disposal of wastes generated in caring for isolated patients must be investigated to evaluate potential for transmitting disease through improperly focused disposal guidelines or staff non-compliance. This study revealed that much of the solid waste produced in hospital rooms housing medically stable patients subject to isolation precautions was disposed of as solid waste. Considering the widespread use of dated medical waste disposal protocols, growing interest in sustainability, and continuing efforts to reduce the costs of healthcare, it is critical for investigators to study unregulated solid waste disposal, including the significant and increasing amount of wastes generated in caring for infectious patients.

Authors

Deborah A. Saber, PhD, RN, CCRN-K
Email: deborah.saber@maine.edu

Dr. Deborah Saber has had extensive clinical experience caring for infectious patients in hospital environments. Through this experience, she has developed a working knowledge of isolation and waste disposal processes and procedures. She became interested in solid waste disposal while working with patients who were under isolation precautions, as she noted the continuing spread of microorganisms and increasing waste disposal with current isolation procedures. She is part of the interdisciplinary Materials Management research team with members in anthropology, food science, environmental/civil engineering, economics, and psychology at the Senator George J. Mitchell Center for Sustainability Solutions at the University of Maine. The team conducts research and informs policy makers regarding both solid and food waste issues and solutions so as to enhance environmental sustainability and a circular economy. Dr. Saber teaches both nurses and students about waste disposal processes with infectious patients.

Brandon Howlett, BSN, RN
Email: Brandon.howlett@maine.edu

Mr. Brandon Howlett is a newly licensed registered nurse. As a senior nursing student, he recognized the need to reevaluate our hospital solid waste disposal processes, especially as they concern isolation practices. He became increasingly interested in this matter as he recognized that although healthcare sustainability, waste disposal, and the environment have seldom been explored together, they could have a major impact on health systems worldwide.

Timothy Waterman, BSN, RN
Email: twaterman@une.edu

Mr. Timothy Waterman, a newly licensed registered nurse, became interested in this topic because of the environmental and federal financial implications of the changing healthcare policy. In addition, working to improve policies pertaining to infectious diseases was something he viewed as critical for saving many lives in the event of a highly infectious disease outbreak. This knowledge, coupled with a fascination for infectious diseases, motivated him to contribute to this research.

Lila de Tantillo, BSN, MS, RN
Email: l.detantillo@umaimi.edu

Ms. Lila de Tantillo’s research focuses on best practices for patient outcomes, including management of infectious disease in a clinical setting. She became interested in solid waste disposal of infectious patients while studying as a PhD student.