What's the prognosis? Clinical waste management in the NHS
The NHS’s sprawling network creates a diverse and complex set of waste streams. Edward Perchard checks in to see how hospitals manage their waste and what developments are helping fight the constant budgetary battle
The NHS in England spent £87 million on waste in 2014/15. Though a vital part of the healthcare system is dealing with this material safely, the sustained stress on healthcare and welfare budgets caused by austerity mean that every penny counts. The domestic waste – trays of uneaten food, discarded cards and flowers, newspapers, bottles and boxes – are easy enough to deal with. The most expensive and most complicated part of waste from hospitals is the clinical waste.
Clinical waste is defined in the Controlled Waste Regulations 2012 as waste from a healthcare activity that: ‘contains viable microorganisms or their toxins that are known or believed to cause disease’; ‘contains medicine that contains a biologically active pharmaceutical agent’; or ‘is a sharp or body fluid or other biological material contaminated with a dangerous substance’.
Given the hazards related to the mishandling of these materials, there is more to think about than how they can be most cost-effectively treated. The ‘Bible’ of NHS waste managers is Health Technical Memorandum (HTM) 07-01, ‘Safe Management of Healthcare Waste’, which provides in great depth the legislation, definitions, classifications and best practices for the treatment of all manners of waste arising in a clinical setting.
As HTM 07-01 starkly highlights: ‘The management of healthcare waste is an essential part of ensuring that healthcare activities do not pose a risk or potential risk of infection and are securely managed.’ This responsibility is borne out in the breadth of regulations that healthcare providers must follow when managing waste including Controlled Waste Regulations, the Hazardous Waste Directive, and Carriage of Dangerous Goods Regulations.
The Guy’s and St Thomas’ (GST) NHS Foundation Trust is one of the largest employers in South East London, with some 13,500 members of staff helping to provide care to around 2.4 million patients a year. Spread across two main sites – Guy’s Hospital in the substantial shadow of the Shard and St Thomas’ Hospital a stroll along Westminster Bridge from the Houses of Parliament – and a number of community health facilities across the area, GST has to manage its waste on a large scale, no easy feat given the breadth of collections required by regulations.
As recommended by HTM 07-01, clinical waste at GST is segregated using a range of containers with a set colour code. The contents of four of the six bins – cytostatic (drugs like chemotherapy treatments that have a toxic effect on cells) waste and sharps; anatomical waste (amputated limbs and other body parts); pharmaceutical waste; and mixed medicinal and non-cytostatic waste – can only be disposed of through high temperature incineration (HTI). And despite their common destination, all four need to be separately collected and stored.
Waste for HTI collected at the Guy’s site is burnt at Augean’s plant in Kent, the only facility in the UK capable of recovering energy from the process. Waste is burnt at 1,100 degrees centigrade to guarantee the destruction of any hazardous properties. St Thomas’s HTI waste is taken to Tradebe’s incinerator in Surrey, which doesn’t recover energy. Though it comprises of four different waste streams, only a small amount of the hospital’s waste actually goes to HTI – around five or six per cent – according to Trust Waste Manager Alan Armstrong.
The other two bins consist of orange bags for materials disposed of through ‘alternative treatment’ and black and yellow ‘tiger stripe’ bags for ‘offensive waste’. Although it is still infectious, orange bag waste does not have to be incinerated, and can instead be recycled through the aforementioned alternative treatment, which most usually, as at GST, takes the form of autoclaving, a process that sterilises the waste by steaming it at around 850 degrees in what Armstrong calls “a big pressure cooker”, before it is shredded and recycled into materials like playground matting. Things like personal protective equipment (gloves, masks, aprons); wipes and dressings; incontinence waste and IV bags and tubing can be included in this stream.
Offensive waste, meanwhile, is made up of non-hazardous materials that have been produced from the treatment of noninfectious patients but that are contaminated with body fluids (things like used nappies, non-infected gloves and aprons, and colostomy bags). This waste can be landfilled, treated, recycled, or sent for energy-from-waste recovery.
The introduction of these two waste streams has enabled hospitals like GST to divert more of their clinical waste away from non-energy-producing incinerationand save on waste disposal costs. “If we go back to five years ago, the vast majority of our clinical waste was incinerated,” says Armstrong. “Since we introduced the alternative treatment process, just the odd percentage is going off to the incinerator.” Indeed, progress is constant: offensive waste is also a “relatively new waste stream”, having been introduced just a few years ago, and is broadening the options of healthcare providers.
ince 2014, the waste at GST has been managed by East London-based Bywaters, which is responsible for removal of all waste and for managing the two specialist clinical waste subcontractors. The Trust’s 36-strong team of porters and two on-site managers are all contracted to Bywaters, which collects around 108 full wheelie bins every day of the week bar Sundays.
While the cost of incineration has reportedly gone up in recent years, the cost to GST has fallen due to the makeup of the new contract. “We were paying, four or five years ago, before the new contract, just under £900 per tonne for clinical waste incineration,” explains Armstrong. “We now pay £535 per tonne. And that was part of the reason that we changed contract. The previous contractor was a clinical waste contractor, and so it wasn’t in their interest for us to segregate waste from clinical waste.” Now, with Bywaters taking both clinical and domestic waste, that is no longer the case. Improvements in cost efficiency are vital as GST increases its clinical activity. In 2013/14, the Trust spent £1.13 million on waste management, a figure that, despite big savings on treatment, has risen, due to more clinical areas being opened.
As the variety of waste streams has increased, so has the need for staff to be clued up on the differences. Clinical staff are relied upon to segregate the waste accurately and, such are the pressures on NHS staff, quickly. Being one of London’s biggest employers, there is a “constant churn” of staff, requiring the message to be constantly reinforced.
“The clinical and the housekeeping staff are responsible for moving waste from bins to the disposal hold, and then at the disposal hold the large clinical waste wheelie bins will have a label attached to determine the colour of waste that’s gone into the bin. Everybody goes through an induction program when they join the Trust. We also do training sessions, mainly with housekeeping staff, food services assistants, and Infection Control Link Nurses – the link between the Infection Control department and the ward staff, who are then responsible for passing all that information and that message back to the staff at ward level.”
Departments are also monitored on their waste generation using an audit system and mini weighbridges situated at both hospitals. Every wheelie bin is weighed, with a label explaining where the bin has come from. Armstrong and the waste team can then determine which departments are producing the most expensive waste streams. “There could be a department that’s producing a lot of incinerated waste. Why? They’re not a theatre, they’re dealing with patients where that wouldn’t necessarily be needed. So we will go along there, we’ll audit and we’ll introduce a change if it’s appropriate.”
This could be a case of clinical waste being mis- assessed or simply bins being too conveniently placed: “If you’re unwrapping some clinical equipment before an operation, you make sure that you put all the packaging into the recycling bin rather than straight into the clinical waste bin. We’ve done a lot of work in areas by taking away bins where they’re not needed, replacing bins with recycling bins, so you’ve got recycling bins next to the clinical waste bins. The clear message is that you need to think about the bin you are putting your rubbish in, because the cost difference is phenomenal, from recycling to clinical waste generation.”
Of course, given the literally vital importance of keeping hospitals clean and safe, scrutiny of waste management is even tighter than in most other businesses. Public health considerations add an extra layer of decision-making when new processes and solutions are being developed. Armstrong gives the example of reusable containers for sharps, equipment like needles and scalpels that could cause cuts or puncture wounds. At the moment this waste is taken in single use plastic boxes that are disposed of alongside the clinical waste. Reusable containers get taken off-site with the waste, but are emptied, deodorised and cleaned, ready for reuse – providing a cost- saving as well as saving on plastics. Armstrong says work to make these containers safe and practical has “come on leaps and bounds” in recent years, but the Trust’s Infection Control team has yet to be convinced, concerned about potential needle-stick issues.
Despite this, Armstrong says that behaviour, as in so many operations, is what is holding back recycling. The hospital is targeting a 70 per cent recycling rate for the end of this year (2017/18), having hit 66 per cent last year. However, with six clinical waste streams as well as general bins, plenty of material is being missed. “We had a clinical member of staff working in one of the wards at Guy’s, who took the bag of clinical waste out of the bin, laid a sheet on the floor, split it open and 70 per cent of the waste inside was actually recyclable rather than clinical waste. That is a very strong message, it’s the message we’re sending out there. We find contamination in our clinical waste and our domestic waste all of the time, so we know for certain that there are recyclable materials going into our waste streams.”
Outside of clinical waste, GST is taking steps to improve the treatment of everyday waste like food and packaging. The two sites generate around 100 tonnes of domestic waste every month, a figure that Armstrong and the Trust are keen to cut. Again, the weighbridges are used to carry out departmental audits, and general waste bins are being cut out wherever possible. Elsewhere, cooking oil is recycled for use as biofuel by London cabs and a furniture reuse scheme has saved thousands of pounds for the Trust. Departments must check with the waste team if any secondhand furniture is available before accepting requests for new furniture. Armstrong says a partnership with redistribution organisation WARPit that could help extend this programme to medical equipment and office items like toner is in the offing.
Hospitals are not alone in their quest to maximise the efficiency of their waste operations. CIWM provides guidance and there are sector-specific networks like the Healthcare Waste and Resources Research Group, based at the University of Northampton, which since 2007 has aimed to further research into healthcare waste management for the benefit of the public purse, public health and the environment as a whole. Trusts from around the country work together through networks like this to share best practice and provide updates on developments – Armstrong says that there are constant changes in regulation and waste streams.
And across the country, a number of projects are taking place to extend the options for hospitals to recycle and even process themselves materials arising in the healthcare process.
The RecoMed project, a take-back scheme run by the British Plastics Foundation (BPF) and Axion Consulting, is looking at the separate collection of PVC items like IV bags, oxygen tubes and masks in surgery, that would otherwise be included in clinical waste streams. Currently being trialled in ten hospitals, the PVC is put in separate bins in hospital hallways, from where it is collected by Axion and turned into new, low-spec products like horticultural ties.
Hospital staff are given bespoke training to ensure that the right objects are included, with none that contain fluids or are at risk of contamination (in the realest sense) put in the bins. The project estimates that some 2,250 tonnes of PVC could be recycled by collecting these small and light items if the scheme were extended across all UK hospitals, and Jane Gardner, Head of Consulting Services at Axion, says that there are plenty of other bits used during the application of care to a patient that could be recycled.
Meanwhile, at St Woolos Hospital in Newport, the Aneurin Bevan University Health Board is looking at a new way of treating sterilisation wrap, used in operating theatres across the world to package surgical instruments and equipment to protect them from air-borne contaminants and bacteria. At the hospital, a ‘Sterimelt’ machine manufactured by waste company Thermal Compaction Group produces sanitised briquettes from the polypropylene in the wrap. The machine heats the wrap, of which the hospital uses two tonnes a month, to reduce the volume of the sheets, creating a material that can then be manufactured into a variety of domestic or industrial products like blankets, stationary, ropes and chairs.
The year-long trial at St Woolos also took waste from North Gwent Hospital, which saved £1,000 a month through the project. Speaking at the time, Tim Hourahine from the Thermal Compaction Group, said: “There is so much interest because, at the moment, the majority of the waste wrap is either landfilled or incinerated, which is exceptionally expensive. The recycling process removes that cost, plus it produces a workable product which will have a commercial value in the future.”
As austerity continues to pinch, hospitals are increasingly on the hunt for ways to decrease waste management costs and free up funds so that they can continue saving lives.