Improving waste separation in hospitals - insights for intervention design

Hospital operating suites create large amounts of waste in their daily operations. Part of this waste is clinical waste (for example blood-stained items) which is costly to dispose of because it requires special treatment such as incineration or chemical processing, prior to disposal to landfill.

Non-clinical waste originating in operating suites can be placed in the general waste stream or can be recycled, either though commingled recycling or specialised recycling streams. In addition to undertaking a wide range of important tasks in a hospital, nurses play a key role when it comes to sorting waste appropriately during daily hospital operations. Unfortunately, for a variety of reasons, waste in high intensity environments, such as operating theatres, does not always end up in the most appropriate stream. This means that recyclable waste (for example paper, cardboard or recyclable plastics) can be found in the general waste stream, leading to avoidable landfill, or general waste and recyclable waste being disposed of in the clinical waste stream, which increases disposal costs and its environmental impact.

Between 2018 and 2020, Sustainability Victoria in collaboration with the Department of Health engaged BehaviourWorks Australia to improve waste separation in operating suites. The project aims were to:

a) increase recycling in the operating suites and

b) reduce the amount of general waste and recyclable items that were placed in the clinical waste stream. Doing so would reduce the weight of the clinical waste stream and therefore its disposal cost.

We tackled these issues in partnership with three Victorian public hospitals.

The challenge:
Improving waste separation in hospital operating suites to increase recycling and decrease waste management costs
Sustainability Victoria, Department of Health, three Victorian public hospitals

What did we do

  • In collaboration with the Waste Education Officer at the Department of Health, we conducted interviews with nurses in two of the partner hospitals to understand the influences on nurses’ waste sorting behaviour.
  • Together with key hospital stakeholders, we mapped out the bin infrastructure and waste flow in each of the three partner hospitals to further refine our understanding of influences on waste sorting behaviour.
  • We held a co-design workshop with key stakeholders from all three hospitals and the Department of Health to design interventions that address the identified facilitators and barriers and improve waste separation in the operating suites.

What did we find

From the interviews and waste maps we learned that nurses’ waste sorting behaviour was influenced by a number of factors:

  • One key influence was their access to the appropriate bins. Sometimes bins were placed far away in a corner, blocked by equipment or another (less appropriate) bin would be closer. With regards to recycling, we also learned that available recycling streams in the operating suites not only differed between hospitals but also between rooms within a hospital operating suite. This was sometimes due to a lack of space, where another bin simply wouldn’t fit into an already crowded room.
  • We also found out that often by default large rather than small clinical waste bags were used in the operating rooms (even though exceptions exist).
  • Time could work as a barrier or facilitator depending on whether nurses felt they had sufficient time to sort waste or had more pressing tasks to attend.
  • Nurses’ self-assessed knowledge on correct waste sorting behaviour was fairly high, however, there was still room for improvement.
  • Waste support staff also played a role in nurses’ waste separation behaviour. Nurses relied on support staff to line bins appropriately, empty them when full and transport waste out of the operating suite. Unsurprisingly, nurses also identified their colleagues as another key social influence.
  • While nurses recognised the positive outcomes of reducing landfill and materials being reused if recycled, they expressed some lack of trust in the overall recycling process, wondering if the items they placed in the recycling bin would actually get recycled once they left the operating suite or the hospital.

The interviews and waste maps identified some key common influences on nurses’ waste sorting behaviour across hospitals, but they also clearly highlighted that there exist many differences between hospitals. This included their existing waste and bin infrastructure, task allocations and contractor agreements around the collection and disposal of waste. This meant that for each hospital, the hospital-specific facilitators and barriers needed to be taken into account when designing interventions to improve waste sorting behaviour.

The intervention

The co-design workshop was held in October 2019. During the workshop, we designed three intervention packages, one for each hospital. Co-designing interventions together with key hospital staff was an important part of this project to ensure that staff had ownership over the interventions and considered them acceptable and feasible in their daily hospital operations.

Unfortunately, the implementation of the interventions coincided with the rapid spread of COVID-19 in the beginning of 2020. Therefore, we were only able to fully roll out the intervention package of one hospital, which is described in detail below:

  • Changes to the recycling waste streams: To address the access issues and to make waste separation as easy and quick as possible, we decided to introduce new recycling bins on wheels. This meant that staff could easily pull recycling bins closer for better access while being able to move them out of the way when the situation in the operating suite required it. Additionally, recycling bins for sterilisation wrap (which is a wrapping material to keep instruments sterile) and soft plastic were introduced, as these streams previously did not exist in the operating suite. All bins were clearly labelled using adapted versions of new bin signage the Department of Health had previously designed.
  • Changes to the clinical waste stream: Given that large clinical waste bags were often used as a default option, we provided staff with the opportunity to use more appropriately sized bags for clinical waste. To do this, the hospital introduced smaller clinical waste buckets for cases where little clinical waste occurs. The idea was for the small bin size to ‘nudge’ staff to only place clinical waste items into the smaller bins. However, we also kept the larger bin bags present to ensure they could be used without losing any time if needed.
  • To address knowledge gaps, an in-service education session for nurses, doctors, technicians and waste support staff on the appropriate waste streams for different kinds of hospital items was run. Additionally the hospital displayed educational posters about waste sorting on a whiteboard in the operating suite.

The implementation of this intervention package was led by the hospital’s own staff, specifically their Waste Officer and their operating suite green team. Having the support of these implementation champions was crucial for the project and the roll-out of the intervention package would not have been possible without them.

What happened?

While our immediate plans to evaluate the intervention had to be cancelled due to COVID-19, the following year the hospital contacted us to report a success: With a lot of hard work and input from the hospital’s own enthusiastic theatre green team, the project had helped to divert an estimated five tonnes of sterilisation wrap from landfill over one year.

This feedback demonstrates that even during uncertain times, behaviour change is possible – particularly when working in collaboration with engaged and dedicated project partners.

About the project

This project was part of the larger “Waste Education in Healthcare Project” which was delivered by the Victorian Health Building Authority, with support from Sustainability Victoria through the Victorian Waste Education Strategy.

Research Lead

Lena Jungbluth

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