I figured that, at some point, I’d blog on red bag waste, or, as it’s commonly known, Regulated Medical Waste (RMW), but I thought I’d first spend time on issues that are more obviously associated with sustainability. However, I’ve started a benchmarking project in which I compare UCDHS’ sustainability performance with that of winners of the various Practice Greenhealth (PGH) awards. Among other things, PGH looks at waste diversion practices, and includes RMW among these. So I did a few calculations and extracted some data from our 2013 award application, and compared it to the RMW information in the PGH 2012 Benchmarking Report.

Conclusion: We’re horrible.

Really, our numbers are so bad that we all should be embarrassed. Yes, we can talk our way out of it a bit, as we could take out the RWM generated in research functions, but it’s not that much. The reality is that we tend to use the red bag as a general garbage can, and some people tend to discard items as RMW when they could go to regular trash. In general, many of us are WAY too conservative when determining whether an item should be managed as RMW. Take a look at the numbers that follow, and you, too, will be embarrassed.

Practice Greenhealth has three different award levels. In 2012, we, along with 79 other hospitals, won the Partner for Change (PfC) award. Next level up is PfC with Distinction, which was awarded to 41 applicants, including UCSF. At the very top is the coveted Environmental Leadership Circle (ELC) award, won by 28 hospitals. For evaluating waste generation, Practice Greenhealth uses weight per adjusted patient day. For 2012, the average RMW generation for PfC winners was 3.3 pounds/APD; for PfC w/Distinction, 2.2 pounds/APD; and for ELC, a stingy 1.5 pounds/APD. The weight shown on our 2013 award application is 9.0 pounds/APD. Nine pounds of RMW per Adjusted Patient Day!

We’re horrible. But with “horribility” comes opportunity, as I will illustrate later.

We should be happy that they even let us submit an award application with RMW numbers like that. Don’t think that the folks at PGH don’t notice. This past Saturday I received an e-mail from awards coordinator Lin Hill:

Hi John,
Loved your application. A couple questions.
Your refuse/APD is half what UCSF is and close to some of our other award winning universities, (impressive), but your RMW% of wastestream is almost 3x theirs.
Why do you think it’s so high?
It seems like an opportunity for great cost savings.

Lin, PGH’s Janet Brown, and I discussed RMW last month on a conference call, and they were astounded (“surprised” isn’t strong enough) to learn that we have red bag bins in every patient room. I used to think that this practice was normal, but, when my wife was inpatient at Napa’s Queen of the Valley a few years ago, I learned otherwise. I quickly noticed that there was no red bag bin in her room. Instead there was a roll of small red bags in a drawer, and when a nurse had to dispose of some RMW, she put it in one of the bags, tied it off, and walked it to the soiled utility room. What a concept! It turns out that this same practice is used by UCSF Medical Center and UCLA’s medical centers, where it contributes to their low RMW numbers.

There also seems to be an overabundance of caution when deciding whether or not an item needs to be managed as RMW, which has been noted by many of us in EH&S. We’ve often fielded questions about RMW, particularly from nurses who suggest that colleagues are placing innocuous items in the red bag. This tells me that 1) it’s too easy to “over-redbag” items, and 2) guidance on what constitutes RMW needs to be more accessible.

The general policy on RMW is found in Hospital P&P 2005, with Attachment 1 addressing “Medical Waste Classification”. To me, this information is a bit too dense, making it hard to tell whether or not something should be handled as RMW. Nicole Mahr, RN, an Infection Preventionist with whom I’m working on this issue, says there is a reluctance to get too detailed in a policy, which, in my view, reflects the long turnaround for policy updates which makes timely changes a challenge. We were specifically discussing disposable isolation gowns, which apparently are often red bagged as a matter of practice. Nicole will be preparing a blog for First Tuesday that will address proper handling of used isolation gowns; we’ll see that, in most cases, they should go to trash, not red bag.

This issue of the overuse of red bags needs to be addressed, and Nicole and I will be leading an ad hoc work group to put together, once and for all, accessible red bag waste criteria that we’ll make readily available to all. We’ll address what qualifies an item for the red bag, and will look at common items, like isolation gowns, that all too frequently are handled as RMW.

One last thing that I’d like to mention is cost. Until September 2011, we treated most of our red bag waste in microwave units at the Back Dock. The costs of this process were not documented, and it seemed to create an environment that suggested that there was no cost to treating our red bag waste. However, with our current waste management processes, it costs $0.19 per pound to treat red bag waste. On the other hand, general trash is about $0.04 per pound, making it five times more expensive to throw something in the red bag that doesn’t really belong there.  Some food for thought: we paid over $400,000 in 2012 for management/disposal of RMW.  We should be able to make a significant dent in that if we get our act together.

As you can see, there are a lot of opportunities to improve our RMW management practices that will help us reduce our red bag waste, save money, and move in step with other medical centers in the UC system and elsewhere. Let me know if you’d like to participate in our work group. I’ll bet we can get below 5 pounds RMW/APD in a year. Can you help us achieve this worthy goal?

Do something Green today!