The hidden cost of plastic in healthcare

Fossil fuel plastic causes death, disability, and disease at every stage of its lifecycle; impacting upon the health of the planet and the many species, including humans, which call it home. Plastic is comprised of complex polymers and thousands of chemicals which can be persistent, bio accumulative and toxic including endocrine disrupters, a particular concern for the food and medical industries. Plastic is designed to be durable and in 2018, it was reported that 6.3 of the 8.3 billion tonnes produced persists as waste in landfill or the environment. Human health impacts are predominantly experienced by those in lower Human Development Index countries, fence line communities, the vulnerable and extremes of age.

Healthcare organisations must be cognizant of their footprint; otherwise, the products and services procured and used with good intention will, through contributing to climate change and environmental ill health, fuel further demand for services at a time when they themselves are trying to reduce their own environmental impact. It is therefore welcome to see the NHS Standard Contract requiring action to be taken by the whole value chain to reduce the avoidable use of single use plastic which comprises 23% of the waste produced by the NHS, most of which is ultimately incinerated whether it sees clinical action or not.

The UNEP Global Plastic Treaty aims to ‘turn off the tap’ on single-use plastics and whilst healthcare may fall into the category of ‘essential use’, we must still aim to first, do least harm by reducing use whenever possible. Despite innovations in material science, bioplastic, reduction in medical device plastic mass, use of less-toxic polymers, reintroduction of reuseable products and recycling, we must be honest that for the foreseeable future, healthcare will remain dependent on many single-use plastic products.

One of the most important decisions a healthcare professional can make is when to open the packaging of a single-use device as once opened, the item becomes waste whether used or not. It’s therefore essential to move from a ‘just in case’ to a ‘confirmed required’ mindset. Staff responsible for preparing clinical areas like anaesthetic rooms must check the requirements of anaesthetists before items are opened. An equally important decision is how to dispose of used items safely with the least environmental harm. Healthcare waste is deemed non-hazardous until proven or suspected otherwise and appropriate containers must therefore be available to accommodate all potential waste types for the specific clinical area.

Safe and sustainable management of healthcare waste provides clear guidance and its essential clinical, sustainability and waste management leads create supporting materials to help staff segregate waste correctly. Ensuring waste is disposed through the correct waste stream using the most sustainable containers has a significant, measurable impact on the amount of plastic consumed, distance transported, method of treatment, whether the energy created can be utilised by the national grid and cost.

Mapping these pathways and calculating metrics for our different waste streams led to several changes. By moving to Sharpsmart reuseable sharps bins, our 11-bedded critical care unit reduced the amount of (single-use sharp bin) plastic incinerated by 2.3 tonnes per year and through introducing blue Bio-bin containers into every bedspace, redirected 6.4 tonnes of medicinal waste (predominantly used fluid bags, syringes and giving sets) to the less environmentally harmful, non-hazardous waste stream.

This waste redirection followed an analysis of Health and Safety Executive Regulations, a local risk assessment and agreement the risk to staff from a giving set ‘spike’ which remained embedded in an intravenous bag was minimal. We communicated that all giving sets along with their attached bags of intravenous fluids/residual pharmaceuticals could be disposed of in Bio-bins and since making this change several years ago, no associated injuries have been reported. The only pharmaceuticals not disposed through the blue waste stream are those with cytotoxic or cytostatic properties, hazardous sharps, or items contaminated during use. These are placed in the purple or yellow sharp waste streams respectively.

This ‘balance of probabilities’ approach to theoretical harm from a shielded giving set spike compared to the known increased environmental harm from overly cautious classification of healthcare waste as hazardous is a great example of a pragmatic approach to sustainability. Challenging existing processes which we continue to do because we’ve “always done it that way” is essential when plotting a path to truly sustainable healthcare. Concerns over the space required for these additional waste containers were quickly allayed by the positive feeling arising from a visible reduction of the environmental impact of care. Demands on staff time reduced through fewer container exchanges and cost savings amounted to thousands from just one clinical area.

Reducing the demand pull for single-use items can be challenging if the infrastructure to support the re-introduction of reuseable devices has changed and whilst supporting and pursuing the principles of circularity, it’s essential to consider service demands and patient needs. For example, a reuseable bronchoscope on critical care is of little value when in transit for cleaning or being repaired which in our experience, can take weeks. Every additional day a patient spends on the unit comes with an energy, plastic, drug and pollution cost; factors not always included in product life cycle assessments. Our approach is therefore to ensure continued availability of single patient use bronchoscopes and to support environmentally-ambitious companies in making devices as sustainable as possible.

Despite the use of composite materials and distinct lack of clues on packaging, we continue to separate plastic from paper never sure what can or will be recycled. Whilst items contaminated with a body fluid will primarily be directed toward the offensive waste stream (tiger bin), questions are often asked of why we do not recycle non-hazardous plastic waste. Is there evidence this poses a higher risk than a random plastic drinks bottle destined for recycling following a beach clean? As material complexity may currently preclude this pathway, future products and packaging must be designed to be reused, recycled or disposed of with minimal environmental impact whilst as an industry, we must be pragmatic about risk.

My personal journey exploring healthcare plastic and waste has thrown up all sorts of emotions. Plastic is simultaneously harmful and beneficial, but with the benefits received by those in countries with accessible healthcare system and the harms externalised to the planet and those less fortunate. With the increased knowledge we now possess, we should at least acknowledge the harm, use products responsibly, communicate why, educate our peers and first, do least harm whenever possible.

Everyone has an equal right to the highest attainable standard of physical and mental health and from a climate and environmental perspective, health is everything; it’s why we care. The trusted voices of healthcare professionals can, as we saw during the COVID-19 pandemic, cut through the noise and by including climate, environment and their impacts on health within our own professional development, we can become effective communicators inspiring others to act both in their personal and professional lives.

Richard Hixson.