Reducing personal protective equipment waste in the emergency department of a large regional hospital: codesign informed by system science

Health sector footprint

Climate change is the biggest global public health threat of the 21st century.1 Paradoxically, while seeking to improve human health, the health sector contributes to climate change and environmental degradation through high energy and resource use. Healthcare is responsible for 4.4% of global net emissions, which is equivalent to the annual greenhouse gas emissions of 514 coal-fired plants.2 The Australian healthcare sector generates approximately 7% of Australia’s total greenhouse gas emissions3 and high volumes of pollution and waste.4

In 2017–2018, Victorian public health services generated approximately 35 000 tonnes of waste and of this approximately 8000 tonnes were recycled, 5000 tonnes were clinical waste and 22 000 tonnes was ‘general waste’.5 Global health emergencies, like the COVID-19 pandemic, exacerbate this waste crisis. During the pandemic, the surge in use of personal protective equipment (PPE) globally resulted in approximately 3.4 billion single-use masks, gowns and gloves6 being discarded daily. This drew health workers’ attention to the scale of, and issues associated with the environmental and health impacts of medical waste in healthcare.7 As these discarded materials find their way into landfills, incinerators, or even natural environments, they undergo a process of fragmentation and degradation, breaking down into microplastics that can be carried far and wide by wind and water.8 The pandemic also highlighted inadequacies in clinical waste disposal measures and the excessive classification of much clinical waste as ‘infectious’, which results in unnecessary and environmentally and economically costly disposal processes.9 However, there remains a gap in targets and comprehensive strategies to reduce waste and emissions from clinical care products, services and delivery.

Meanwhile, debate about the benefits of single use versus reusable prevail. Disposables are perceived as cost-effective due to lower procurement costs10; however, this does not take into account the waste costs incurred by the hospital/health department. Disposables are also considered more convenient11 and believed to pose no infection risk due to less viral load.12 Whereas reusables often have higher upfront expenses require additional services and/or infrastructure for cleaning and sterilisation and seemingly more stringent guidelines for infection control.11 13 14 Limited evidence demonstrating the life-cycle advantages of disposables versus single use continue to drive business as usual, that is, the use of single-use PPE. However, international recognition of the harm of overconsumption and linear economic models is shifting perceptions and providing a supportive environment for the uptake of circular economy approaches using life-cycle thinking and product stewardship.

Life-cycle analysis (LCA) involves assessment of a product’s or service’s environmental impact throughout its entire lifecycle—from raw material extraction, processing and manufacturing to distribution, usage and disposal.15 Product stewardship is central to ‘life-cycle’ thinking, signifying the responsibility for managing the health, safety and environmental aspects of raw materials, intermediates and consumer products throughout their lifecycle.16 Incorporating product stewardship into procurement policies has the potential to empower healthcare stakeholders and decision-makers in making informed choices.17 By adopting such practices, healthcare organisations can significantly enhance resource use efficiency, implement proper hazardous waste management and conduct supply chain analyses,18 thereby facilitating environmentally friendly material substitutions in the production process of products.

The waste reduction hierarchy is a practical model that helps healthcare organisations apply a circular economy approach.19 The hierarchy emphasises on prevention or reduction of waste generation, maximising efficiency and minimising resource use.20 If reduction is not feasible, reusing solutions and waste repurposing are employed, such as procuring reusable or recyclable materials.20 Recycling follows, reprocessing materials into new products instead of sending them to landfills. Recovery, including incineration and anaerobic digestion, is considered only when recycling is not practical. Lastly, disposal is reserved for materials that cannot be reused, recycled or recovered, leading to significant environmental and health impacts.

System-focussed, contextual responses are required

To create health system, change responses adapted to local context are crucial.21 The Global Roadmap for Healthcare Decarbonisation recommends Implementing circular economy principles to procure supplies, deploy clean technologies, reduce the volume and toxicity of healthcare waste, and manage waste sustainably.22 A minimum step towards this goal requires the health sector and its supply chain to consider the use of every medical product, whether it is necessary (reduction) and plans for end-of-use recycling or safe disposal. Framing this as part of a Circular Economy means gradually decoupling economic activity from the consumption of finite resources and designing waste out of the system. Transitions in such systems of such complex nature remain problematic and resistant to change.23 This is not least because approaches to change typically do not adequately understand the systems within which they are trying to foster change, and even less the perspectives, views and capacities of the people within those systems who would be required to implement these changes.24

Adaptive methods for stakeholders to cocreate waste reduction solutions

Australian hospitals and health services are taking increasing responsibility for their carbon and environmental footprint25 including a willingness to explore participatory processes and understand health systems from the perspectives of those who lead them, and design responses to the issue of clinical waste. Existing studies acknowledge that system science approaches can bring about meaningful systemic change within healthcare organisations26–30 though the use of systems science methods within healthcare settings is a relatively new area of research and practice. A promising method is called group model building (GMB), a participatory systems approach which has been used effectively to drive changes in community health, child health and general practitioner prescribing behaviour.31–33 While effective in other fields, GMB is yet to be conducted to understand and contextualise the interconnections between the drivers of waste in health services and cocreate solutions to reduce them. This study aims to explore the relationships between factors contributing to a hospital emergency department’s current levels of single-use PPE waste and strategies to mitigate the impacts of this waste.

Study design

Qualitative, community-based participatory research was used to understand the complexities of the issues, promote colearning and help build momentum for action.34 The study used GMB to understand dynamic behaviour by identifying causal relationships, feedback loops and leverage points.35

Setting

Setting includes a large regional university hospital in Victoria, Australia providing primary through to emergency care services. It employs >7000 staff and houses a teaching hospital with formal research partnerships with several universities. At the request of hospital staff, the organisation prioritised environmental sustainability in its 2020–2025 strategic plan, has a newly formed Environmental Sustainability Executive Subcommittee and has initiatives in place including purchasing all its electricity from a wind farm in a carbon credit trading arrangement. The ED was chosen as a department where a high amount of PPE is used.

Participant recruitment

Phase 1 (GMB steps 1 and 2): purposive stratified and snowball sampling was used to identify and recruit participants working in the ED including doctors, nurses and allied health staff (n=10); sustainability manager (n=1), procurement lead (n=1) and waste management coordinator (n=1) were identified by senior leaders. Consumer representatives (n=2) were recruited via the health service consumer engagement team. A total of 15 stakeholders contributed to the interviews and focus groups sessions.

Phase 2 (GMB step 3): purposive sampling was used to identify and recruit policy-makers, scientists, sustainability experts and suppliers with an understanding of single-use PPE waste. Participants included representatives from existing participants from phase 1 and key stakeholders from state government (n=1), infection prevention experts (n=2) industry sustainability experts (n=2), materials science (n=1), implementation science (n=1), LCA (n=1) and health economists (n=1), clinicians (n=1) from other health services with expertise in LCA. A total of 25 stakeholders were involved (15 existing participants from phase 1 and 10 new participants).

All participants were 18 years or older and living in Victoria.

Patient and public involvement statement

No patients and public were involved in this study.

Data collection and analysis

Phase 1: data from the first set of qualitative interviews (n=2), online focus groups (n=2) and in-person focus groups (n=1) were used to generate a preliminary CLD and five key themes. The second round of online interviews (n=2) and focus groups (n=2) confirmed and refined the CLD and themes and generated ideas for action for reducing single-use PPE waste in the ED.

The CLD was developed by researchers during and between sessions by entering the data (participant stories of drivers of single-use PPE overtime) into the Systems Thinking in Community Knowledge Exchange software.37 The links between variables identifying cause and effect were created and then coded to reflect whether a change in the causal variable led to a similar change in the resultant variable; for example, increasing COVID-19 infections led to increased single-use PPE use. These codes were developed into five driver themes.

Phase 2: the CLD and four action areas identified in phase 1 were presented to the broader stakeholder group. Participants confirmed that the CLD reflected phase 1 discussions. The initial step involved participants identifying priorities and action plans for the four action areas. Participants elected to contribute to developing action plans for two action areas in which they had the most expertise.

GMB Scripts adopted from Hovmand and Rouwette34 were used to guide both phases and a series of interactive and reflective activities helped participants integrate their perspectives and create a model of problem drivers and priority actions.

The interviews and focus groups were conducted as a combination of online Zoom sessions (n=4) and in-person (n=1) meetings at the ED. The combination of session types accommodated participation of staff working in a busy ED, a geographically dispersed research team and broader group of participants in phase 2 who lived or worked outside the region. Phase 1 occurred between July and August in 2022 and phase 2 in October 2022. Interviews and focus group workshops varied in length between 1 and 2.5 hours each.

Sessions were audio recorded, with notetakers capturing discussions where the recording was unavailable (ie, Zoom breakouts, in-person small group discussion). In-person sessions involved participants marking up paper copies of the CLD and completing tasks, whereas the online sessions used Zoom functions (eg, ‘annotate’) to engage participants. Data were collated and analysed by researchers during and in between sessions in an iterative process of qualitative coding, theme development and member checking by researchers and participants.

Waste management

This theme highlighted multiple factors, including time pressures, bin availability and proximity within the ED. An increase in available space is associated with heightened bin availability and proximity (bottom right), fostering correct bin use by staff. This, in turn, contributes to proper waste handling and disposal by environmental management staff. However, time pressures, particularly evident in a busy ED (mid-right side), can impede correct bin use, creating a challenge for clinical staff. The dynamic relationship between these waste management factors is depicted in a section of the orange section of the systems map presented in figure 2.

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Participant quotes further emphasise the nexus between time pressures, PPE selection and waste management. An ED clinician highlighted the impact of workload and PPE disposal on bin use in the following quote:

I haven’t got time to find the right bin. I’ll just chuck it in this bin as I’ve got to keep moving [ED Clinician 1, GMB 1].

Another clinician expressed that “…if bins were sorted regularly, I think you would have better bin compliance…” [ED Clinician 4 GMB 1].

Staff engagement

Staff engagement emerged as a pivotal factor linked to waste management. Improved staff knowledge of waste-related issues could catalyse motivation, peer influence and trust in waste management processes (top right). Participants reported that as trust in waste management processes grows, there is a corresponding increase in the correct use of bins by staff, fostering a more effective waste management system (figure 3). An ED clinician highlights the significance of staff engagement:

…we had this program in place and we sorted all our own recycling and after two years we found that the waste handlers were putting it all in the landfill and hadn’t told us. I can go to all this effort. But, if it’s not making a difference it feels like you are not changing anything [ED Clinician 2, GMB1].

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COVID-19 pandemic

The COVID-19 pandemic theme highlighted how the fear of infection coupled with lack of staff education intensified with rising COVID-19 rates, prompting an increased utilisation of PPE by staff, patients and visitors. Simultaneously, the escalating COVID-19 infection rates correlate with a higher frequency of PPE guideline changes, particularly for suspected COVID-19 (SCOVID) cases. This dynamic situation contributes to confusion regarding PPE selection, resulting in increased PPE use. Staff, patients and visitors tend to default to cautious PPE usage when faced with uncertainty (figure 4). Two participating ED clinicians said:

Fear is another factor. Lack of education contributes to fear around using more PPE because you are worried about getting something. Fear of infection…The desire to protect oneself and family. [ED Clinician 1—GMB 1]

Screening of patients for respiratory symptoms. We never had to do that before 2019. We didn’t have to wear PPE for that… but now we are screening all patients with respiratory symptoms as a potential Covid patient. So, we are wearing PPE the whole patient visiting time [ED Clinician 3—GMB1]

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Clinical drivers

The pandemic also influenced clinical drivers (blue theme). The surge in patients presenting with SCOVID respiratory diseases had a direct impact on the ED ability to segregate these patients into designated COVID-19 and non-COVID-19 areas. This reduction in the ED’s capacity to group respiratory patients separately necessitated increased PPE use among staff. Donning and doffing PPE were required for every patient interaction, compared with the previous practice of staff in designated areas keeping their PPE on for the entire shift (figure 5).

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A participant quotes the challenges associated with grouping respiratory patients:

We used to have a respiratory hub and all the respiratory patients were in there, so there would be less changing of all the PPE within that section. But now we don’t do that. Respiratory patients are distributed all over the department. So, there’s PPE everywhere. And there’s much more moving between respiratory patients and non-respiratory patients [ED Clinician 2 GMB1].

Procurement

This theme highlights the profound impact of procurement options and decision-making on PPE availability and usage, as depicted in figure 6 (denoted in purple). Centralised procurement diminishes the hospital’s influence over PPE choices, including multiuse/reusable options (mid-bottom). Centralised procurement creates an economy of scale and fosters a surge in supplies of single-use PPE. The perception of abundant supplies subsequently amplifies the frequency of PPE changing and disposal. Conversely, a rise in PPE costs reduces the frequency of changing and disposal, resulting in an overall reduction in the quantity of PPE used. This is reflected in the quotes by the procurement stakeholders.

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Initially when there was nothing available, they could charge what they wanted. Then you contribute to less single-use because then you used say “let me use the mask for a day”, because you can’t get more of it. Then the supply chain has massively increased globally. Initially, it led to an increase in use. And then led to a decrease in PPE cost and value. [Procurement staff GMB1]

The Department of Health stepped in and created a State supply chain which only stocked single use items, which were made out of plastic, because that was what we could get on a dime. That limited options of reusable vs single use. There were no reusable options. They were mandated to be purchased through the State chain supply. [Procurement staff GMB1]

Main findings

This study systematically examined the drivers of PPE waste in a large regional ED. A CLD categorised key drivers into waste management, staff engagement, COVID-19 pandemic, procurement and clinical drivers. This study captured the complex interactions between the levels of policy, organisation, interpersonal and individual.

The ‘waste reduction hierarchy’19 sets a clear framework across preventing or reducing PPE, reusing, recycling and recovery, and disposal. Our findings, comparison with other literature and recommendations for future policy and practice are considered against this framework.

Preventing or reducing PPE

Reusing

Recycling and recovery

Disposal

Strengths

As the first to apply systems thinking to reduce PPE waste, the study contributes to emerging evidence of the value of this in health services and healthcare sustainability research. Shifting focus from individual-level interventions to a holistic system perspective, the research emphasises the need for interventions at both system and individual levels to address decarbonisation and enhance sustainability in health services.

The engagement of diverse stakeholders in GMB workshops facilitated consensus on PPE waste drivers and solutions, fostering connections across health system ‘silos’ and promoting relationship building among individuals and organisations. Historically, addressing the dual challenge of maintaining high-quality care while significantly reducing PPE carbon footprint, waste generation and environmental pollution has operated in isolated ‘silos’. Acknowledging the importance of stakeholder relationships to drive systems change, this study iterates on the importance of collaboration, knowledge exchange and innovation. By leveraging local changes into impactful shifts, these relationships can drive meaningful system-wide transformations.33

Limitations

This study engaged 25 people to reflect on the experience and views of health and sustainability stakeholders on reducing PPE waste in a hospital ED. While it was able to surface multiple points of view and develop a logic model, these data are limited to the Australian healthcare context and experience of those participating in the research study. Due to the geographically bounded setting of one regional health service, studies such as this cannot claim a generalisable model of the relationships explored. Many insights may be transferable to other wards and departments in this hospital (or other organisations) that share similar procurement, infection prevention guidelines, waste handling procedures and so on. However, specific contextual challenges would need to be addressed, perhaps using a similar study design.

Overall implications for policy and practice

The study’s findings highlight the importance of policy and frameworks for high-impact system interventions. A best-practice policy example is the NHS procurement strategy, providing an explanatory roadmap for procurement leads and suppliers, which has potential utility across all countries. The NHS England61 Net Zero supplier roadmap is a globally leading supply chain stewardship initiative, which will require a Carbon Reduction Plan for all procurements by 2024. A transparent timeline has been made available to suppliers and procurement staff to plan for escalating sustainability requirements.51 From 2030, suppliers will only be able to qualify for NHS contracts if they can demonstrate their progress through published progress reports and continued carbon emissions reporting. Support will be offered to suppliers facing challenges meeting these requirements.

Our findings show that while the above solutions focused on system-wide and policy enablers of a circular economy transition, health workers in each hospital will need to be part of solution generation, ideally supported by academic partnerships. The success of sustainability strategies and decarbonisation efforts in healthcare hinges on comprehensive buy-in throughout the organisation, fostering a culture of embracing new innovations, policies and procedures aimed at waste reduction and improved sustainability practices. The current study stresses the critical importance of securing buy-in from frontline healthcare workers. Practice Greenhealth62 and Yuli63 emphasise employee engagement through employee sustainability orientation programmes, providing refresher training, establishing departmental champions and implementing certification programmes. Waste management was a top sustainability priority in a national survey of USA-based clinicians.64 The survey found that clinicians consider employer policies and actions on climate change when making job-related decisions and feel motivated to undertake sustainability-related work. Our study expands on these perspectives revealing that staff motivation is significantly influenced by peer support and trust in waste management processes, emphasising the need for a multifaceted approach to engaging healthcare workers.

Future research

The study provides insights into future directions for study and hypotheses to be tested about deeper mechanisms driving complex healthcare sustainability challenges. Future interdisciplinary research involving implementation science, LCA and health economic analysis could explore ‘what interventions are most feasible and effective in preventing and reducing PPE waste?’ and ‘what sustainable healthcare interventions maximise economic, health and environmental benefits?’