Introduction:
Hospitals are some of the biggest waste producers in the world, and with 6,090 hospitals in the United States alone, the amount of hospital waste generated quickly becomes overwhelming (AHA, 2021). In fact, hospitals in the United States alone produce more than 3.5 million tonnes of waste per year with an average cost of disposal of $790 per tonne (Greenhealth, 2020). It is often thought that medical waste is usually hazardous and or biomedical waste and thus there is little to be done to improve waste management in healthcare facilities. However, about 85% of the total waste generated by healthcare facilities is non-hazardous general waste (WHO, 2018). With the global population steadily increasing and medical care becoming more and more accessible, the amount of medical waste is expected to only increase (Su-Ling Brooks, Windfeld, 2015). In order to move towards a more green and sustainable future, healthcare corporations must change their waste disposal policies and the overall infrastructure of their healthcare facilities.
On a more local scale, The IU Health Bloomington hospital finally made its highly anticipated move from the ‘Legacy Hospital’ (IUHB) to the Regional Academic Health Center (RAHC) this past weekend during the early morning hours of December 5th. The RAHC is expected to serve more individuals in the South Central Indiana region and boasts 364 total beds with 198 of these being inpatient beds and 166 outpatient or ambulatory beds which is a stark increase from IUHB which only housed 278 total beds. All of the patient rooms at the RAHC are single-patient rooms with windows that overlook the beautiful IU Golf Course that surrounds the hospital. The move marks the beginning of a new partnership between IU Health and Indiana University’s Medial School. It also marks the transition into becoming more sustainable with regards to water and electricity usage and waste management in particular. The Regional Academic Health Center also includes significantly more green space which can be conducive to lower stress levels for both patients and staff who are almost always experiencing high levels of stress when in a hospital.
Below is a picture of the Emergency Department at the Regional Academic Health Center:
Methods:
For this project, I mainly did a qualitative analysis of the differences between the two facilities and conducted two interviews via email with IU Health staff who were knowledgeable about the two facilities. I, myself have also worked in the Emergency Department at IUHB for more than two years now and thus am very familiar with the way that the hospital runs and how energy inefficient it is. I also did a bit of quantitative comparison between the estimated trash production and the efficiency of some of the equipment utilized between the two facilities. To complement my own data collection, I also utilized published research about hospital sustainability in order to make comparisons and assumptions about our local facilities.
Results/Discussion:
Bloomington Hospital was first built in 1905 and has undergone many rennovoations and additions since then with the most recent major renovation taking place at the turn of the 21st century (RATIO Architects, 2019). IU Health has had plans to move the location of their Bloomington hospital for many years now and thus declined to renovate IUHB any further throughout these last 20 years. Thus, IUHB was lacking energy efficient equipment such as inefficient lighting, water usage, climate control, etc. More specifically, IUHB utilized all incandescent lightbulbs and lacked any auto-off lights, each patient room had a thermostat that could be changed to heat or cool to any temp between 50-80 degrees fahrenheit, and there were no reusable water bottle refill stations and very few water fountains. The RAHC however is a brand new facility with brand new appliances, that are often more energy efficient in general. Ms. Melanie Hamilton is the nurse educator for the Emergency Department and Medical Observation Unit who gave hospital tours to all of the staff on both of these units. She was very familiar and well versed on the in’s and out’s of the hospital and all of its new technology, particularly that of the Emergency Department. She noted that the RAHC had various equipment and infrastructure updates including auto-off lights, a water-saving flush option on most toilets, LED lighting, changes in climate control, and white walls that help to bounce light and thus decrease the amount of lightbulbs necessary (Hamilton, 2021).
Every non-patient care area at the Regional Academic Health Center has auto-off lights. This includes spaces such as staff break rooms. bathrooms, offices, and conference rooms. At IUHB, none of the lights in staff areas were EVER turned off unless by accident. The break room is not utilized for the majority of the shift (particularly on night shift) and yet all the lights are on with the TV constantly playing despite the fact that no one ever watches it. At the RAHC, however, all of the break rooms lack TV’s, have energy-efficient appliances, and lights that turn off after three minutes of inactivity. This will save a lot of energy especially when considering how much energy is saved when utilizing energy-efficient appliances and lightbulbs versus their inefficient counterparts in general.
In fact, the difference in emissions between incandescent and LED lightbulbs alone is staggering. Incandescent lightbulbs emit 225 pounds of carbon dioxide annually whereas LED bulbs only emit 45 pounds annually (Mahmood, 2012). It is impossible to know how many lightbulbs are in each facility, but it can be extrapolated from those figures that a hospital full of LED bulbs will be emitting tonnes and tonnes less carbon dioxide than a hospital full of incandescent bulbs. There have also been some changes to climate control that should benefit the overall environmental impact of the RAHC. Aside from the obvious energy differences that come from brand new equipment, the climate control settings within patient rooms have also been adjusted. Hospitals are often kept cooler than many people keep their homes due to the sheer number of individuals occupying the facility at one time and the tendency of staff to become hot due to the fast-paced nature of the hospital. Therefore, it was not uncommon for patients to crank the heat up in their rooms to 80 degrees Fahrenheit, if their thermostat was functional of course as many in the outdated facility were not. Patient rooms at the Regional Academic Health Center have set climate control functions that only allow patients to adjust their rooms to temperatures between 65 and 75 degrees Fahrenheit. Again, it is hard to find data on just how much energy and emissions can be saved from climate control between IUHB and the RAHC, but with brand new equipment, and thermostats only allowing for adjustment within 10 degrees compared to 30, it is fair to estimate that the RACH will be considerably more sustainable when it comes to heating and cooling.
All of the toilets at the RAHC are dual flush meaning that the user can select how much water they want to flush their bodily waste with. These dual flush toilets only have to meet special EPA criteria in order to flesh with no more than 1.28 gallons of water per flush which is 20% less than the federal standard of 1.60 gallons per flush (EPA, 2021). Dual flush toilets are much more sustainable than older ‘flushometer-valve’ toilets of which there are 27 million currently still in use in the United States. There are likely the type of toilets that IUHB utilized as the facility had not been updated in almost two decades. These older toilets are so wasteful that ‘approximately 26 percent (7 million) of the old toilets have flush volumes as high as 3.0 to 7.0 gallons per flush (EPA, 2021). The EPA estimates that replacing these old inefficient toilets with EPA-approved dual flush toilets in a 10-story building with 1,000 occupants could save nearly ‘1.2 million gallons of water and nearly $10,000 per year’ (EPA, 2021). These numbers are staggering and especially surrealistic when considering how much water could be saved if all 6,090 hospitals nationwide made the switch to these more eco-friendly toilets. In fact, if commercial facilities all across the country replaced their toilets with the dual flush model. ‘it would save over 39 billion gallons per year (EPA, 2021). The simple change to a dual flush toilet will save the RAHC so much more water than the outdated toilets and plumbing models at IUHB.
Ms. Hamilton also noted how with the move to the RAHC comes with changes in the on boarding of new staff. New staff used to be given a 30+ page orientation binder that had to be filled out throughout their 6-12 weeks of training. However, all of this information has now been made virtual in order to make the process for new staff more streamlined. This will help to cut down on the use of paper as IU Health Bloomington is the third-largest employer in Monroe County and almost all of those staff at one time required an orientation binder needlessly filled with onboarding papers (Indiana Department of Workforce Development, 2021). New staff must now create a Microsoft Teams account and track all of their progress virtually (Hamilton, 2021). This is also beneficial to new staff as their orientation binders were often lost in the hustle and bustle of the Emergency Department.
The RAHC also features water fill stations which promote the use of reusable water bottles, or the reuse of plastic, disposable water bottles at the very least. It is estimated that approximately 30 million plastic water bottles end up in landfills each year in the United States alone (Budzaj, 2012). The implementation of filling station however encourages staff to drink more tap water and makes opting to purchase plastic water bottles less attractive. Aside from the outright cost, reusable water bottles do not cost anything to refill, they can be refilled time and time again, and they are often easily identifiable by their owner. Plastic water bottles often all look very similar and in hospital settings where there are a bunch of people, who may be harboring pathogens, in close quarters with one another, it is easy to confuse your water bottle for someone else’s. There is even a lot of energy required to produce plastic water bottles with the EPA even estimating that if a person chooses tap water over one liter of bottled water each time they drink water, they could save up to 46 gallons of gas per year (2010). The water filling stations at the RAHC keep a record of how many plastic bottles they have saved, and it will be interesting to analyze that data in the years to come and consider implementing water fill stations not only at other hospitals, but in all commercial businesses and facilities.
Another big change for the patient’s who visit the RAHC will be the inclusion of windows in each and every inpatient room. Windows not only provide natural light which can help cut down on energy costs, but they also provide the patients the ability to look out on to nature which can be therapeutic. In fact, there is a substantial amount of research that indicates that being able to look out on to green space ‘has a positive influence on the physical and mental well being of users, especially patients’ (Shukor, 2012). The RAHC has also included two outdoor green spaces in which individuals can sit, relax, and eat in an outdoor setting. One of these green spaces is designated specifically for staff who would otherwise likely not see the sun for the entirety of their twelve hour shift. The building of new green spaces is a wonderful addition to the hospital as natural landscapes have many benefits amongst individuals such as ‘reduction of stress, improvement of mood, and the provision of recreational activities’ (Shukor, 2012). It would be beneficial for me personally to have a space to step out of the department and get some fresh air. We only get 30 minutes for a break during our twelve hour shift if we are lucky. It would make a world of difference for me to be able to step off of the unit, away from all of the stressors and into a beautiful green space even if just for a few minutes. Hospitals are very high stress settings for not only patients, but also staff and visitors. Thus, the inclusion of outdoor spaces can help to foster a better, calmer mindset for everyone involved which could potentially lead to better patient outcomes.
While there have been many minor changes to the interior of the RAHC that make day to day operations more sustainable, arguably the biggest difference in environmental impact will come from changes in waste management. I interviewed Mr. Ojwang Wilson is head of Environmental Services for IU Health Bloomington (at both locations) and provided some insight into just how much waste IUHB was producing. He estimated that IUHB was producing 1000 various sized bags of trash each and every day (Wilson, 2021). These bags of trash include biomedical waste (noted by distinct, red bags), food waste, plastic/general waste, as well as ‘sharps/ bio-hazardous waste. This equates to 365,000 bags of trash being produced annually by a single hospital building. These 1000 bags of trash are picked up by Republic Trash service, an outside company that serves many states (Wilson, 2021). After Republic picks up the trash, Mr. Wilson is unsure of where it goes/how it is disposed, but presumes that all non-hazardous waste is disposed of in a landfill. The improper disposal of medical waste in landfills can result in contamination of the water supply which can negatively effect the health and wellbeing of a community (Su-Ling Brooks, Windfeld, 2015). This is what waste production at IUHB looks like on a departmental scale:
This is a photo of the trash room of the 29 room Emergency Department at IUHB:
This photograph was taken at approximately 7 am. The trash from this room is emptied and hauled away down to the basement where it is compiled with the waste from the rest of the hospital at approximately 5 am. Thus, all of the waste seen in this photo has been collected in an approximately two hour period from a single department that only hosts 29 beds, of which most of them are occupied and thus cannot have their trash emptied from them. This small trash room is often entirely filled with waste. These massive amounts of waste come from the widespread use of single use items, lack of an option to recycle materials, and high demand for packaging within healthcare in order to decrease risk of infections (Fråne, Lindberg, Nordin, 2019). It is a common misconception that hospitals infectious waste and thus there is there is little room for alternative waste disposal methods such as recycling. However, according to the WHO only 15% of hospital waste on average is infectious leaving a lot of room and necessity for improvement with regards to waste disposal (WHO, 2018). Luckily, IU Health recognized the negative impact its improper forms of waste disposal were having on the community and took major steps to remediate this problem when designing the RAHC.
The Regional Academic Health Center will have an onsite Ozonator. An Ozonator is a machine that grinds most trash and leaves it in lint size pieces. It can reduce the amount of waste by up to 90%. Using Mr. Wilson’s estimate of trash production at around 365,000 bags of trash being dumped in a landfill annually, the Ozonator should reduce this to around only 36,500 bags of trash being dumped annually. The Ozonator is an integrated system that consists of a loader, shredder, ozone reactor, treatment chamber, and disposal tank (Corum, Demir, and Ökten, 2015). To begin the process, the waste is dumped into the receiving hopper of the ozonator. The machine then increases the ozone levels within the treatment chamber and once the proper ozone level is reached, the shredding process begins. The amount of ozone necessary and the amount of time needed is dependent on the amount and type of waste being treated. Once the shredding process is complete, the waste is transferred to the disposal container (Corum, Demir, and Ökten, 2015).
There are a lot of incentives for a hospital to purchase an Ozonator. For starters, it is a much more sustainable alternative to incineration methods which risk releasing pollutants such as polychlorinated dibenzo-dioxin/furan and toxic metals into the air and thus decreasing the air quality (Jones, 1999). It also has a greater hourly treatment capacity than similar alternatives such as autoclaves and waste convertors. It is the most economically advantageous option as it can be implemented on site and thus allows the hospital to avoid the costs of building a temporary trash storage room and paying for waste pickup/treatment fees from outside companies (Corum, Demir, and Ökten, 2015). The Ozonator is also a great disinfectant as ozone promotes the oxidation carbon carbon double bonds which are found in many organic molecules. Thus, it is is able to kill almost all pathogens that may be present in the waste (Al-Ghamdi, 2011). Furthermore, the amount of ozone that they produce does not have a negative environmental impact as the ozone produced is converted back to oxygen in 30 minutes under atmospheric conditions (Corum, Demir, and Ökten, 2015). Mr. Wilson also noted that the Ozonator was rather easy to operate and that anyone of his staff after proper training could operate the machine with ease (2021). He is particularly excited about the change to onsite waste disposal mechanisms as well as the inclusion recycling bins, as he was also concerned about the sheer amount of waste being produced at IUHB.
Hospitals are also huge producers of plastic waste in their general facilities, laboratories, operating rooms, and cafeterias in particular (Ellenbecker, Lee, Moure-Eraso, 2002). The majority of the recyclable waste is plastic waste due to the fact that single use products are used in order to minimize infection risks and cross contamination between patients themselves and between patients and their healthcare providers (Fråne, Lindberg, Nordin, 2019). Most medical equipment also comes in a lot of plastic packaging and if it has been shipped in bulk, it will also come in humongous boxes both of which have the potential to be recycled. IUHB has >5 recycling bins in the entire facility as they are only located in waiting rooms. Hospitals have relatively few waiting rooms nor are they where the majority of the recyclable waste is being produced. At the RAHC, there will be recycling bins present within each department in order to cut down on the overall amount of trash produced. This will also help to cut down the costs of disposing of waste and will also decrease the RAHC’s environmental impact as less trash will end up in a landfill. There was concern that recycling bins would be hard to implement as it would be the responsibility of the nurses and techs on the floor to sort waste that did not need to be sorted prior. It is not uncommon for hospital staff to have to turnover a room on a moments notice leaving little time for them to throw away waste in general, much less sort out recyclable material. However, a study of over 600 hospital employees in Germany found that 90% of those individuals reported that recycling disposable plastics was sensical from both and environmental and economic standpoint and easy to implement (Nunes, Vogt, 2014). Similarly, in the few days that the RAHC has been open, patients, visitors, and staff have been opting to utilize the recycling bins instead of the trash can when disposing of recyclable waste.
Hospitals are large facilities jam packed with monitors, ventilators, all kinds of energy sucking machinery that are constantly running all day every day 365 days a year, and yet the research on their environmental impact is incredibly lacking. In fact, almost all of the research that I found on hospitals themselves were from research groups outside of the United States. While the Regional Academic Health Center includes some great advances with regards to sustainability and reduced emissions, there is still a lot of room for growth. The RAHC is also not a big hospital by any means. The environmental impact of the RAHC seems minuscule when compared to that of some of the larger hospitals in the United States who house around 2,000 beds. There is a huge lack of focus on the healthcare system from environmentalist groups as well as governments who could implement policies and regulations on hospital waste disposal methods. One could even reduce emissions by thousands of tonnes by focusing on a single, large healthcare facility. It seems that there is a huge potential for growth in this topic as with more funding for research in order to analyze more hospitals and gather more accurate data, we can begin to formulate reasonable and realistic alternatives to modern day hospital waste disposal and energy usage mechanisms.
Future Research:
As far as looking at subsequent research, one could begin by actually trying to calculate the sustainability of a hospital by quantifying it in exactly how many tonnes of carbon dioxide it emits every year, how many kilowatts of energy does it use per day, how much waste does it take to a landfill every year, etc. It would also be interesting to look into the air quality of hospitals. Hospitals are very unique in that they are major producers of bio-hazardous waste and they also house large amounts of waste at any given time. Perhaps storing large amounts of potentially toxic waste could reduce the overall air quality of a hospital. Perhaps a hospitals overall massive energy consumption and thus emissions could decrease the overall air quality. This research would be particularly relevant for hospitals that incinerate their waste on site as incineration carries the risk of releasing toxic pollutants into the air and thus decreasing the air quality (Jones, 1999). Finally, more research is needed with regards to how green space in hospital settings in particular may affect patients and their care. It is documented that access to green space or windows that overlook green space can have positive effects on both patients and staff, but can it actually reduce the length of stay for patients? Again, hospital sustainability has a huge potential for growth as we know so little about such a big, and overlooked problem. With the population projected to continue to grow worldwide, this problem needs to be solved now more than ever, and how can we solve a problem if we don’t know how big it is first?
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