MedCycle Opportunities

The term "medical waste" conjures up different images for different people. For most people, it is the image of blood, needles and infectious waste. However, approximately 80% of a medical facility's waste stream can be classified as "general refuse" or municipal solid waste [msw], and is therefore similar to the kinds of waste generated in hotels, restaurants, shopping centers, office buildings, and in our own homes. The other 20% -- red bag infectious waste, nuclear, and hazardous waste -- are closely monitored throughout their collection, treatment and final disposal according to strict state and federal regulations.

To reduce confusion of terms used in this report, hospital waste refers to all solid waste [biologic or non biologic] that is discarded and not intended for further use [eg, administrative waste, dietary waste, and medical waste]; medical waste refers to materials generated as a result of patient diagnosis, treatment, or immunization [eg, soiled dressing and intravenous tubing]; and infectious waste refers to that portion of medical waste that could transmit infectious disease [eg, microbiological waste and "sharps"]. (1) In Vermont, infectious waste is treated as hazardous waste.

Over the past fifteen years the health care industry has shifted from a primarily reusable product supply system to a primarily disposable product supply system. The majority of these supplies hermetically sealed in individually-wrapped packages. This shift has dramatically increased the waste generation rates of medical facilities. A recent report in the New England Journal of Medicine credited hospitalized patients with the generation of 15 pounds of hospital waste per day. (2)

In targeting medical facilities for waste reduction programs, numerous issues surface including:

This report summarizes a pilot project, designed and conducted by Connie Leach-Bisson and Hollie Shaner, RN, that targeted the separation and reuse or recycling of the dry, non-patient contact packaging and unused supplies generated in the surgical services wing of Medical Center Hospital of Vermont [MCHV] in Burlington, Vermont. Working on the hypothesis that a significant percentage of waste generated in specialty areas, such as surgical services, is actually clean, non-infectious material -- and possibly recyclable or reusable -- Leach-Bisson and Shaner set up the pilot program to do the following:

Funding for the study came from a $13,000 waste reduction grant awarded to MCHV by the Vermont Agency of Natural Resources and $3,000 in matching funding from MCHV. The majority of the funding was used to pay for the researchers' time, but a small amount of the grant was needed for collection equipment and educational tools. A budget breakdown is attached as Appendix A. The researchers were not selected by the hospital to do this work, but rather it was they who created the project, found funding, and then selected MCHV as the medical facility where they would conduct the research. The project was a natural outgrowth of work previously undertaken at independent locations by Hollie Shaner and Connie Leach-Bisson.

Shaner had volunteered a great deal of time in the previous year assisting MCHV with the establishment of a voluntary recycling program. White office paper and corrugated cardboard recycling had been successfully implemented and steel cans were being targeted from the food services area. Leach-Bisson had created a non-profit organization [known as The ReStore] that collected clean industrial scrap from Vermont business and industry and made these materials available at low cost to daycares, schools, artists, etc. as educational materials and art supplies. Shaner learned about The ReStore and contacted Leach-Bisson to suggest that she come get materials from the hospital. Although a bit apprehensive about the source, Leach-Bisson toured the surgical services wing of the hospital and quickly saw the potential. However, she also recognized a collection system for these materials could not be implemented overnight. It had to be designed to fit into a very controlled and sanitary setting, and the redistribution would occur to a customer base [recycling markets and the general public] who generally perceived all waste from medical facilities as germ infested and drenching with blood. Hence came the MedCycle Pilot Project.

It was a unique collection of experience, connections, timing, and creativity that enabled the two researchers to launch this project so quickly and effectively. Connie Leach-Bisson has worked in the waste management field for 12 years with a strong focus on reuse and recycling. Hollie Shaner has been a nurse in a wide range of clinical settings for over 14 years and is currently a recovery room nurse at MCHV. Both were known and respected for their energy and commitment to their work. It was on this basis that they began the MedCycle project at MCHV, and they were immediately rewarded with support from department heads and Surgical Services staff to move forward with the project.

Medical Center Hospital of Vermont [MCHV] is a 500 bed teaching hospital located adjacent to the University of Vermont's medical school in Burlington, Vermont. As the state's largest medical facility, it is known for its highly qualified medical staff, up-to-date equipment, and expertise in numerous specialty areas. On a monthly basis, MCHV surgeons perform approximately 1000 surgical procedures, including open heart surgery, orthopedics, eye and dental surgery.

The Surgical Services wing of MCHV includes thirteen operating room suites, the post anesthesia care unit [recovery room], surgicare, and pre- op hold units. Surgical services employs approximately 200 permanent staff members and the facility is open seven days a week. Each room has several general waste receptacles along with a clearly marked container for red bag wastes and a plastic red box for the collection of sharps. A small, centrally located room in the surgical services wing [known as the dirty core] is the storage point for waste and soiled linen prior to its removal to the hospital's main waste dumpsters located on a loading dock. Housekeeping personnel are responsible for servicing the dirty core, however surgical services staff are responsible for taking waste from their units to the dirty core. White office paper and corrugated cardboard - which are part of Burlington's mandatory recycling program - are separated out for collection. Separate collection bins are strategically located throughout the surgical services wing in areas of high use of computer and office paper. Corrugated cardboard is stacked separately in the dirty core and then removed by the housekeepers.

In 1990, MCHV generated an average of three 40 cubic yard containers of compacted MSW on a weekly basis, in addition to its red bag, hazardous and nuclear wastes. 142.3 tons of corrugated cardboard and white office paper were removed through the recycling program. New target materials have been added in 1991 including tin-plated steel cans from the food service area, glass bottles from the Newborn Nursery, Nutritional Services, Pharmacy, Neonatal Intensive Care Unit, Recovery Room, Radiology, Pediatrics, and Critical Care areas, and high density polyethylene [HDPE #2] hospital wide with the largest generators being Dialysis and Nutritional Services.

Collection of PP #5 has been implemented in June 1991. A food waste compost project is about to commence as of this writing. other materials collected include ziplock pharmacy bags and foam packing peanuts. The items are reused by a variety of community organizations and local businesses. Periodic recycling drives for magazines and directories occur as well. Infrastructures are also in place to divert materials such as used equipment and durables [carpet, furnishings, etc.] to community entities for redistribution.

On January 14, 1991 the researchers, with the assistance of Jackie Clayton -- the hospital's environmental specialist, Glenn McRae -- a waste management consultant, and Loren Koss -- a nurse from surgical services, sorted through a 12-hour sample of MSW generated between 4 a.m. - 4 p.m. that day in the surgical services wing. The collection was unannounced except to Surgical Services Administrative staff so that the wastestream would be as "normal" as possible. Although 41 surgical cases were completed on this date, waste was collected from only 32 cases due to late completion of the other cases. The bags of waste from these later cases were unavailable to researchers at the time of the sort.

41 bags of waste were sorted into 24 categories. A total of 222 pounds of waste was sorted. MCHV provided a conference room for the sorting process. Researchers lined the floor with large sheets of plastic and labeled a series of boxes with appropriate category headings. The sorters wore full protective gear including tyvek suits, masks, surgical caps, shoe coverings, and double gloves. Bloody materials found in the trash bags were handled by the three sorters employed by MCHV who were professionally trained to manage these materials. A full compositional breakdown of this waste sort is included as Appendix B.

Each bag was weighed prior to sorting and then each category was weighed at the completion of the sort. All statistics of this sort are based on weight, not volume. The sort identified several important pieces of information:

The researchers were encouraged by what they saw during the sort. High quality plastics were prevalent in the waste. Unused supplies which had been opened for the case had been discarded. The "blue wraps" which had been used once in the autoclaving process were bountiful. The challenge was going to be how to collect these materials before they got contaminated with other waste generated during surgical and patient care procedures, and how to identify the composition of all these different types of materials so as to find new uses for them.

Setting up a collection system for the dry, non-patient contact waste generated in the surgical services wing of MCHV would require a change in procedure by all staff of this department as well as support from other areas of the hospital. An initial step in the design process was the establishment of a steering committee to review design parameters and the pilot project's progress. Meetings were held at a regular time on a monthly process from January through May and the majority of those individuals requested to participate on the committee were able to tend some of these meetings. The Steering Committee consisted of:

The Steering Committee was a strong sounding board, assisting in the review of the equipment and facilities needed to perform the month-long pilot separation program, and the educational campaign that had to accompany the program. They also helped obtain the cooperation necessary with other areas of the hospital including security, housekeeping, purchasing, administration, and public relations.

To verify the educational background of surgical services staff, a sampling of nursing school curriculum was done. This sampling, as well as a series of telephone inquiries to various nursing programs [ RN, LPN, Nurse Aide] indicated that medical/surgical asepsis is an early and integral part of these health care workers' education. This extra step was undertaken as an added assurance for recycling haulers and processors who had expressed concern about handling materials generated in the hospital setting. Since it is the nursing staff who are most apt to be opening the medical supplies and equipment, it will be their responsibility to differentiate between the materials appropriate for the Medcycle program and those materials which should be discarded because of contamination.

During April, Shaner and Leach-Bisson began training staff for the pilot separation project which would run from May 1 - May 31st. Control of contamination would be essential to the success of this program and its potential transferability to other areas of the hospital and other medical facilities. The educational campaign included a 4 minute video explaining the project, the equipment to be used, and the procedure to be followed as a participant. Individual memos were sent to all affected staff [Appendix C], and live presentations were given at staff meetings with an endorsement from Department heads. The program was voluntary and emphasis was placed on the slogan, "When in Doubt, Throw it Out". Only dry, non- patient contact supplies and packaging were to be included in the MedCycle collection containers.

A kick-off breakfast celebrating the beginning of Medcycle was held between 6 - 8 A.M. on May 1st in the employee's lounge of the Surgical Services wing. Nutrition Services provided coffee, pastries, and fresh fruit. MedCycle buttons were given to all staff, a sample MedcycleTM toter was on display in the lounge, and Leach-Bisson and Shaner were available to answer questions. Toters were then placed throughout the Surgical Services wing and the pilot separation program was underway.

During the first week, a number of questions arose about certain materials. It was invaluable to the project to have Shaner on staff to respond to these questions and comments. When she was not present, messages were left for her. A 24-hour, round the clock information contact number was given to all staff through a memo and on the training videos. As a result, essentially no contamination occurred during the entire project. Staff felt an ownership to the project and were grateful for the opportunity to divert such a significant amount of material from the waste stream. According to visual estimates from the management staff of Surgical Services, the MSW waste stream was reduced by 80% during the month of May. They also estimated that more than 75% of the staff participated in the program on a regular basis during the month. To validate this observation, Dick Redmond, Head of Housekeeping, supplied the hospital-wide weights of MSW picked up from January through June.

Infectious waste generation rates hospital-wide during the same time period did not vary, but the researchers did not include in this pilot a separate weighing of the red bag material generated in the Surgical Services wing during a MedCycle program. This factor will be studied in a future Medcycle project.

Employees willing to participate in the MedCycle collection began on May 1st to segregate wastes generated in the Surgical Services wing of the hospital. Blue-tinted trash bags [with 20% post-consumer recycled plastic resin] were used as the identifying color of bag liner for the Medcycle program. The hospital currently uses red bags for infectious waste and clear or green bags for MSW. 39-gallon wheeled toters, purchased from a local discount chain, were used as the receptacle to hold the blue MedCycle bags. The word "Medcycle" was prominently displayed on the toter, and ample supplies of blue bags were left on the supply shelf outside the OR suites.

The MedCycle toters were located in 18 locations as follows: 1 in each of the 13 operation rooms, and 1 in surgicare, pre-op hold unit, anesthesia work room, perfusionist space and the recovery room. A sign was affixed to the side of each toter listing examples of the types of materials acceptable in the Medcycle bin. The sign emphasized the unacceptable items in bold letters. [See Appendix C]

In the operating room suites, the design was to use the MedCycle bins only during the set up procedures before the patient entered the room. During this time, operating room technicians and nurses are opening a myriad of different packages of supplies for the case and throwing them onto a sterile field for quick access during the surgical procedure. The packaging from the set up of any case normally filled at least one MedCycle bag, but the more complex cases -- such as heart and orthopedic cases -- filled at least three Medcycle bags before the case even began. Just before the patient entered the room, the MedCycle bags were closed, lids were placed on the Medcycle toters and the toters were pushed to the corner or removed from the room.

Additional non-patient contact packaging and materials meeting MedCycle criteria were generated during the case and Circulating Nurses requested permission from the MedCycle Team and Department Head to be allowed to continue to fill the MedCycle bag during the surgical procedure. Permission was granted as long as the Circulating Nurse was willing to be responsible for the materials entering the toter. The procedural change was successful and no contamination occurred.

At the end of each case, employees sealed all MedCycle bags and carried them to one of two large blue gondolas that had been labelled MedCycle Depot. One was located in the hallway outside of Operating Room 4, and the other was located in a hallway on the other side of the surgical services wing. When the Medcycle Depots were full, a housekeeper was called to transport the gondolas to a holding area in another part of the hospital. An empty gondola from this holding area replaced the filled one. Four gondolas were in circulation during the pilot phase.

No sorting space was available in the main building of the hospital. However, a basement room in an adjacent building was made available for the study. Since this was not in the main building, it was the responsibility of the researchers to pick up the filled MedCycle Depot gondolas from the holding area and transport them to the basement sorting room in the adjacent building. Because the study was done in May, inclement weather only resulted in damp researchers and raindrops on the outside of a few MedCycle bags. These facilities would not be usable in the winter time. Approximately 3 gondolas were filled daily during the week, with much smaller amounts generated on the weekend dependent on the emergency surgeries conducted.

Once in the basement, blue bags from the gondola were stacked onto the floor in an outer room, weighed, and then brought into an inner room for sorting. 21 categories were used during the sorting process. When a category bag filled, it was weighed, the weight recorded, and the bag moved into a third room for storage.

802 bags of MedCycle materials were collected from 982 cases during the month of May. This does not represent one bag per case. Since this was a voluntary program, there may have been instances during May when the medical staff chose not to participate in the Medcycle project. Also, OR staff were responsible for controlling contamination. Any bag suspect of contamination was discarded by OR staff as either MSW or red bag, depending on the contents. The total weight of the material diverted by MedCycle was 3565 pounds or 1 3/4 tons.

KimGuard 'blue wraps' (sheets for sterilization)	37.5%
Plastic	23.0%
Polycoated/EVA materials	17.0%
Paper	11.0%
Reusable Medical Supplies	4.5%
Garbage	3.5%
Other	3.5%
TOTAL	100.0%

The segregation of the MedCycle materials into more specific components was hampered, particularly in the plastics category, by an inability on the part of the researchers to identify the plastics by resin types. Only one type of packaging, the Sodium and Sterile Water irrigation solution bottles sold by Abbott Laboratories, was labelled according to the SPI coding system. Contacting vendors to assist in the identification process of these products and packaging is a task of magnitude similar to that of identifying all the types of packaging present in a major grocery store. Any given medical facility may purchase medical supplies from more than 100 vendors and has a store room as big as a large grocery store filled with this inventory. This identification process has begun, and several vendors have been helpful in identifying the resins and components of their packaging. Since that information is not complete, this report will reference the composition of the MedCycle material stream by the categories developed by the researchers.

The categories used are listed below. Some categories were established several days into the sort because of a prevalence of the material in each bag sorted and because the researchers felt a recycling or reuse market would be available for the material as a single item. Some materials were separated out because of their reuse potential, particularly some of the rigid plastic trays. However, until more information is obtained from the vendors or plastics engineers, most plastics fall under two categories: rigid plastics, and films and plastic bags.

PLASTIC	PAPER	POLYCOATED/EVA	OTHER
Kim Guard blue wraps	Virgin boxboard	Packaging	Resusable medical supplies
Irrigation solution bottles	Corrugated cardboard/boxboard	Plastic lined sheets	Garbage
Rigid plastic	White paper	Colored paper 'wraps	Other (reusable bags)
Film and plastic bags	Tissue paper glove packaging		Samples to markets
Polystyrene foam and blocks	Colored paper		Foil
IV bags
Outer IV bags
Polystyrene packaging
White wraps

The table below provides the total weight of each component and its percentage in relation to the entire amount of Medcycle materials separated during May. Separate columns give general volume estimates for the materials based on the number of bags generated during the sorting process. This is not an accurate measure of the volume, nor is it representative of space saved in a landfill due to unknown compaction rates. However, it is provided to give the reader a reference point on the volume, as well as the weight, of material handled during the month. In the sorting of the entire 3565 pounds of materials, the only contamination found were 5 unused needles [unopened in their original rigid plastic protective packaging], two polypropylene solution bottles still partially filled with sterile water, a few pharmaceuticals, and a HDPE gallon jug container one quarter filled with Betadine Solution.

COMPONENT	POUNDS	%	# OF BAGS	% OF VOLUME
KimGuard blue wraps	1340.0	37.5	152	38.0
Polycoatred EVA	480.0	13.5	47	11.5
Solution bottles	292.0	8.0	36	9.0
Rigid plastic	263.5	7.5	10	2.5
Reusable medical supplies	153.0	4.5
Virgin boxboard (white)	143.0	4.0	24	6.0
Garbage	123.0	3.5	18	4.5
Corugated and boxboard	118.0	3.5	18	4.5
Plastic film and bags	82.0	2.5	14	3.5
Outer IV bags	69.0	2.0	10	2.5
Polystyrene foam and blocks	64.0	2	18	4.5
White paper	63.0	1.5	4	1.0
Colored paper wraps	63.0	1.5	10	2.5
Tissue paper glove pkg.	60.0	1.5	13	3.0
Other	58.0	1.5
Plastic blue sheets	57.5	1.5	9	2.0
Samples	55.0	1.5	5	1.0
IV bags	26.0	1.0	2	0.5
White wraps	21.0	0.5	4	1.0
Foil	18.0	0.5	5	1.0
Polystyrene	16.0	0.5	3	1.0
TOTALS	3565.0	100.0	402	100.0

During the last few days of May, Surgical Services staff were given MedCycle evaluation forms to complete. The results were 100% supportive of the project and many were disappointed that the Medcycle toters were going to be removed.

The pilot separation offered some unexpected findings beyond the successful recycling system. The private laundry service contracting with MCHV, although unaware of the MedCycle project until reading about it in the local paper in late May, had noticed a considerable decrease in the quantity of waste items mixed in with the soiled linen they were receiving from the hospital in May. In a letter to the researchers, the General Manager of the linen service noted, "Any kind of reduction in this waste flow has a direct reduction in the probability of exposure to our employees and equipment to sharps and other foreign matter."

On a tour of the Medcycle sorting area, the Purchasing Director for MCHV noted his displeasure at the numerous yellow stickers with identification numbers he saw. Until his visit, the researchers had merely noted the stickers with questions. Upon learning through the purchasing agent that many of the stickers should have been removed at the time the supply was used and attached to the patient's card in order to capture the charge the patient appropriately for supplies used, the researchers began to collect the stickers to help the hospital isolate the procedural problem. Some of the stickers represent items with built in charges. However, many stickers slipping through the system were a direct expense to the hospital. More than 100 stickers were collected during the last two weeks of the sort. MedCycle uncovered a problem with an existing system which may eventually, when corrected, save the hospital thousands of dollars.

Project Haiti -- Reusable medical supplies Last fall, several MCHV surgeons travelled to Third World countries to volunteer their expertise. Upon their return, they made a presentation and told MCHV staff of the terrific need for medical supplies in other countries. They suggested that MCHV could collect its excesses -- sutures, supplies, etc. -- which were currently being discarded as MSW due to product liability issues. Labelled boxes were set up in the OR where staff could collect the medical/surgical supplies not used in the course of surgery. In spite of the existence of this program at MCHV, an additional 153 pounds of usable medical supplies were diverted through the Medcycle project. These materials will be added to the upcoming shipments of materials headed for Haiti and Ecuador.

MedCycle offers a new strategy in managing certain components of medical facility wastes. The pilot project answered a few questions and raised a thousand more.

A roadblock encountered in this study was that of public perception concerning the safety of handling waste generated in a medical facility setting. Recycling markets and end-users were initially reluctant to work with the material for fear of health risks from biological contamination. Once educated about the separation process, these fears diminished, but more work and documentation about infection control is necessary to truly open up marketing opportunities for these materials.

Lack of information exists on the compositional breakdown of the diverse wastestream generated in the medical realm. There is also a very limited understanding of the potential for separating waste streams prior to the point of contamination, thereby segregating the infectious and potentially infectious components from the materials which are similar in form and content to materials found in any other manufacturing, retail, or service setting.

Much of the material collected through the MedCycle project is still in storage as of September 1991. The sorting and identification process has taken time, but the materials are now being prepared for recyclers. Markets have been located for the polypropylene, polystyrene, high density polyethylene, white paper and corrugated cardboard. The virgin boxboard and brown boxboard are about to become part of a pilot community compost project. Discussions are being held with hydropulpers concerning the composite materials. The rigid plastics will be added to existing plastics streams as resins are identified. The ReStore is handling plastic trays, reusable bags, and some of the polypropylene solution bottles.

Reusable medical supplies are being sent to Schweitzer Hospital in Haiti. Discussions are underway to add the virgin boxboard to a local compost pilot project. Blue wraps have been given to Vermont and New York veterinarians for reuse, to local schools and daycares, and to area painters.

As a result of this project, MCHV has established a half-time waste reduction specialist position. MCHV has made a commitment to re-institute a permanent Medcycle system at MCHV in the near future, possibly targeting the collection to specific components identified through the pilot such as the KimGuard "blue wraps", the polypropylene solution bottles, rigid plastics, and a few other high volume materials. Mini- versions of the collection program will be implemented in the Emergency Room, Labor & Delivery, and Radiology. Upon completion of the evaluation, some form of MedCycle will continue in the Surgical Services wing.

The new waste reduction specialist, in addition to setting up systems to comply with the Burlington Mandatory Source Separation ordinance, is also working with other areas of the hospital to collect styrofoam packing peanuts, empty ziplock bags generated from in-house packaging of pharmaceuticals, metal film canisters, twisties, colorful paper cuttings from the print shop, and other reusable items which are being sent to The ReStore. Each Department is offered an opportunity to scrutinize its wastestream and to launch measures that will minimize its waste generation rate without jeopardizing quality health care.

Although the pilot project is now complete, Medcycle is far from over. The researchers have established a company from which they will continue to pursue answers to the questions raised by this study, while seeking new opportunities to further this research. For more information about this company contact:

CGH Environmental Strategies, Inc.
P.O. Box 1258
Burlington, VT 05402 US
Phone: (802) 878-1920; Fax: (802) 878-9507

1 Rutala, William A.; Odette, Robert L.; Samsa, Gregory P. Management of Infectious Waste by US Hospitals. JAMA 1989. Vol 262, No 12, 1635-40.

2 Rutala, William A.; Weber, David J. Infectious Waste -- Mismatch between Science & Policy. The New England Journal of Medicine 1991. Vol 325, No 8: pp 578-581.

MATERIAL	POUNDS	PERCENTAGE
PAPER	8.5	4.0
White	2.0	1.0
Colored	1.0	0.5
Virgin paperboard	4.5	2.0
Recycled content Pboard	1.0	0.5
PLASTICS	95.7	43.0
Blue wrappers	41.5	19.0
Foam	2.0	1.0
Rigid plastics	9.5	4.0
PVC plastics	9.2	4.0
IV bags	8.0	4.0
Film wrap	11.5	5.0
Soft plastics	6.5	3.0
Syringes	3.5	1.5
IV bag tubing	1.0	0.5
Misc. bottles	3.0	1.0
RUBBER PRODUCTS AND GLOVES	7.0	3.0
POLYCOATED EVA	40.0	18.0
Products	24.0	11.0
Packaging	16.0	7.0
OTHER	71.0	32.0
Reusable Products	9.0	4.0
Linens	3.5	1.5
Cafeteria Waste	4.0	2.0
Bandages	24.5	11.0
Trash	15.0	6.5
IV urine & liquid	8.0	4.0
Infectious red bag	7.0	3.0
TOTAL	222.0	100.0%

This report is based on a pilot study conducted by Hollie Shaner, R.N. and Connie Leach-Bisson-Bisson for the Medical Center Hospital of Vermont in Burlington, Vermont. The pilot study was funded by a waste reduction grant from the Vermont Agency of Natural Resources.

This report may not be reproduced in part or in whole for any purpose without permission of the authors.

Medcycle is a registered tradename. Any use of this tradename without permission of CGH Environmental Strategies, Inc. is strictly prohibited.

January	6.1 tons
February	6.6 tons
March	6.9 tons
April	7.1 tons
May	5.9 tons
June	6.7 tons
July	6.5 tons
August	6.9 tons

General Surgery	248 cases
Orthopedic	223
Gynecology	138
Ear, Nose, & Throat	119
Cardiothoracic	91
Genitourinary	69
Neurosurgery	41
Eye	31
Dental	22
TOTAL	982