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2024 Digital Exclusive No. 1
What Are the Top Sustainability Practices That You Would Recommend Any Cath Lab to Undertake Within the Next Year?
Experts offer their solutions and goals for a greener future in the CCL.
With Bina Ahmed, MD, FACC, FSCAI; Richard Bogle, PhD, FRCP; and David L. Fischman, MD
Despite some of the rhetoric over acknowledging the presence and impact of climate change, there is little doubt that human practices are directly linked to greenhouse gas (GHG) emissions and its related consequences. There is also little doubt that health care delivery and its emissions makes a significant contribution to global GHG output. When drilling down to better understand health care-related carbon footprint, we must look at cardiac catheterization lab (CCL)-related output. CCLs are busy throughput areas that are intensive resource utilizers. Each year, more than 1 million catheterizations are performed in the United States alone. Despite the burgeoning impact of health care–related GHG emissions, there are currently no expectations or recommendations to define a pathway to a more ecologically sustainable CCL practice. Establishing ways to reduce, reuse, and recycle in the CCL can result in a substantial reduction in landfill waste, allow for products to extend their lifecycle, and can result in cost-savings over the long-term.
All aspects of patient- and nonpatient-related activities in the CCL could be made more ecologically sound, but there is often pressure to meet patient safety standards, infection control mandates, and overcome provider-related resistance to change. However, there are several “easier” goals that every CCL could achieve.
1. Establish a CCL sustainability team. This is a way to bring together a group of people who may have a natural interest in reducing a CCL’s carbon footprint. Inviting team members such as nurses, techs, medical trainees, associate providers, and physicians allows for a diverse group to share ideas from their unique perspectives. Regular meetings to discuss progress, hurdles, and future steps will keep up the needed momentum for long-term benefit and lasting change.
2. Minimize per case use of materials. This could easily result in a 25% to 50% reduction in landfill waste. “Lean cath packs” can be created to include the minimal materials (eg, syringes, bowls, needles, towels) needed to complete an average case. Expected challenges include vendor resistance and provider preferences—both of which can be overcome by education around need and eventual cost savings. Structural cases, in particular, are associated with increased utilization mainly because cath packs are not tailored to the specific needs of the structural case. Identifying lean packs for structural procedures, such as transcatheter aortic valve replacement or products such as MitraClip (Abbott), should be considered.
3. Setting a goal to capture 100% of recyclables. This would require that paper and plastic packaging materials remain uncontaminated and clean when they are handed off for proper disposal. Discussion and staff education about what can be recycled will increase compliance. Challenges include dependence on hospital recycling policies and ease of disposal into landfills. Many hospitals do not recycle and there may need to be a larger discussion about the benefits from an ecological standpoint and the potential for selling forward recyclable plastic materials.
CCL practices are overdue for a sustainability check. There is a need to uncouple the idea that a more ecologically sustainable CCL practice comes with constraints, increased costs, compromised patient care, and futile effort. Instead, we must realize that a collective movement to decarbonize CCL practice is imperative for the protection of our patients, health care systems, and our planet.
None of us can fail to have noticed the huge volume of equipment required to deliver a small metal coil into a stenosed coronary artery. At the end of any case usually one or two plastic rubbish bags are filled with the remains of the equipment and packaging that have been used. From boxes, foil wrappers, plastics in the form of wrappers and hoops through to endless booklets describing the correct use of the products in dozens of languages. Multiply that up by all the cases done worldwide in cath labs and the volume of waste produced is staggering. Yet how can an individual cath lab do things differently and become a green cath lab?
Every cath lab needs a waste management program. This might not sound terribly exciting, but it will underpin everything we do for sustainability. Establishing a robust recycling program for noncontaminated waste like paper and plastics and thinking about the possibility of reprocessing single-use devices where this can be done safely, effectively, and legally. Underpinning the green cath lab is staff training and awareness. Educating the team about the importance of sustainability and how they can contribute to it in their daily work activities. Everyone I have come across wants to do their bit to “save the planet” but too often it is seen as either someone else’s problem or sometimes such a “wicked problem” that there is learned helplessness with individuals feeling they are powerless to have any impact on the issue. Training the team on waste segregation, energy conservation practices, and the proper use of reusable equipment and showing them the impact of what they are doing is vital.
When purchasing supplies, we should insist that sustainability is a factor imprinted into the evaluation matrix. Those suppliers and manufacturers who provide sustainably sourced products with minimal packaging and produced with eco-friendly methods should be preferred. This could include biodegradable drapes or gowns and sustainably manufactured catheters and sheaths. Once the product has arrived in the cath lab, an effective stock management system to stop waste of expired products is also important in controlling costs and promoting sustainability.
A move to digital documentation is a quick win for any manufacturer. Removing the lengthy booklet from the packaging reduces weight and waste. A simple QR code on the box can take the user to the current version of the product information simply and effectively.
Finally, monitoring and reporting recycling volumes is important so that cath lab teams can see what they are achieving and to ensure that the green cath lab project itself is sustainable. Implementing these practices can not only contribute to environmental sustainability but also potentially reduce operational costs and improve the health and safety standards in the cath lab. It’s a win-win situation.
Recognizing that 2023 was the hottest year ever due to global warming, world leaders attending the recent 2023 United Nations Climate conference agreed to transition away from fossil fuels to reduce global emissions by 43% by 2030, with an aim to net zero by 2050.1 The United States is the fifth largest contributor to GHGs with the United States health care sector, contributing nearly 5% of carbon emissions.2 This is on target to increase three-fold by 2050 and poses significant challenges to environmental sustainability. The CCL is not immune from this problem as it is one of the most intense users of energy in the health care sector. A large contributor to the carbon footprint is the unnecessary waste and failure to recycle.
Approximately 5.9 million tons of waste are generated yearly in United States health care facilities, with a small fraction recycled.3 A recent study demonstrated the potential for recycling a significant amount of noncontaminated waste from catheterization laboratories. When extrapolated for the 965,000 percutaneous coronary intervention procedures performed annually in the United States, this could generate a minimum of 1.36 million kg of recyclable wastes.4 Although recycling nonmedical wastes, such as plastic and cardboard, in hospitals has been encouraged this has not been the case in the majority of CCLs due to poor compliance and concerns that the process is complicated and inefficient.
1. Improve awareness of the issue. Most individuals live in communities where recycling of household wastes, specifically plastic, cardboard, and paper is encouraged if not mandatory. In fact, they are supplied with containers to dispose of these materials on a routine basis. Often, they are informed of the cost savings to their community. The CCL is a community and should be no different. The CCL study cited previously should be a starting point to educate the CCL staff on the significant waste generated in the CCL and the potential impact that recycling will have on environmental sustainability. The conversation should begin in the CCL but will require a collaboration with clinicians and hospital administration as policies and practices are developed and put into place.
2. Review CCL procedures and utilization of resources. Although recycling all materials in the CCL (including biohazards) would be ideal, a starting point should be noncontaminated plastic, paper, and cardboard. CCL staff should review the procedures performed, the materials used, and which of these materials can be recycled. A case in point is the box that coronary stents are packaged in as well as the voluminous package inserts that don’t get dropped on the sterile field. Often, they get thrown out with the trash that ends up in landfills. Furthermore, materials used during a particular procedure come in disposable packs. It is imperative for the staff and proceduralists to periodically review the packs so as to remove extraneous items. Are there more hard plastic syringes packaged then are necessary?
3. Development and implementation of recycling procedures. A systematic approach to the development and performance of waste collection is required. A list of items that can be safely recycled should be posted for easy review. This should include hard plastics, cardboard packaging, and paper. Most importantly, clearly marked containers should be provided for this material. Although more challenging, quantification of this material by weight would be ideal to help demonstrate the success of a recycling program and provide feedback to the staff on this success, just as local communities do.
It is only when we begin to appreciate the importance of recycling at work as we do at home and accept the responsibility toward implementing ways to recycle will we begin to reduce our carbon footprint and promote environmental sustainability in health care. The processes highlighted in this article should serve as a starting point to the development of a more comprehensive program that should include recyclable biohazard materials as well.
1. European Commission. UN Climate Change Conference: World agrees to transition away from fossil fuels and reduce global emissions by 43% by 2030. Published December 13, 2023. Accessed December 21, 2023. https://commission.europa.eu/news/un-climate-change-conference-world-agrees-transition-away-fossil-fuels-and-reduce-global-emissions-2023-12-13_en
2. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PloS One. 2016;11:e0157014. doi: 10.1371/journal.pone.0157014
3. Joseph B, James J, Katarikkal N, Thomas S. Recycling of medical plastics. Adv Ind Eng Polym Res. 2021;4:199-208. doi: 10.1016/j.aiepr.2021.06.003
4. Doshi H, Savage MP, Ruggiero N, et al. Recyclable waste in the cardiac catheterization laboratory: the potential to curb the carbon footprint. JACC Cardiovasc Interv. 2023;16:737-741. doi: 10.1016/j.jcin.2023.01.367
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