OOn a Thursday in August 2021, deep into the pandemic, two Massachusetts General Hospital doctors stood dressed, gloves, boots and ready in a retrofitted lounge on the 21st floor of Phillip’s House, an inpatient space with 20 single rooms and sweeping views of Boston, the Charles River, and neighboring Cambridge.
Just after 3 p.m., the cleaning staff, who usually wheeled the rubbish off the floor to a collection area, had instead been taken to the lounge, where the floors, walls and heavy antique furniture had been cleaned, covered and taped – a process that in itself took three people about two hours.
The garbage items on the 21st floor — every mask, dress, box, glove, and empty bottle — were weighedsorted and catalogued as part of a 24 hour waste audit aimed at reducing the use of plastic and the hospital’s contribution to climate change.
“As they kept coming in, we thought, ‘Oh my God, another, you know, dumpster,'” says Jonathan Eisen, who suggested and conducted the waste audit with another hospital physician, Christian Mewaldt.
In all, the day produced 168 kilograms (more than 370 pounds) of waste — a majority of plastic — an amount equivalent to more than 8 kilograms (nearly 18 pounds) per patient, in one day.
The healthcare system in the United States is responsible for approx 8.5% of the country’s greenhouse gas emissions, from sources such as energy used to manufacture and distribute personal protective equipment (PPE) such as disposable gowns, gloves and masks. Every day, some 14,000 tons of waste is produced in hospitals and other healthcare facilities across the country, about a quarter of which is plastic. Yet 91% of plastic is not recycled, and ends up buried in landfills and elsewhere.
Some hospital systems, including Mass General Brigham, move to address the problemthrough direct actions such as reduce fossil fuel use, compost food waste, change anesthesiological practices and recycling the blue packaging used in the sterilization of operating room instruments. In April, MGH celebrated the second anniversary of the founding of the Center for Environment and Healthwhich are the spearheads of the hospital’s efforts.
When the sorting of the rubbish collected in Phillips House hospital rooms was finally completed at about 1 a.m. Saturday morning, Eisen snapped a photo of the piles of rubbish. One, consisting of 559 polypropylene disposable hospital gowns, stood taller than Mewaldt’s 5-foot frame. About 90% of what was collected was ordinary waste that did not require specialized disposal regulated medical waste.
“As we were doing it and felt like we were making some progress, more and more trucks full of trash were coming in,” said Mewaldt. “It definitely felt like it just crashed on our heads.”
What started as a pre-pandemic idea for the two doctors to swap tiny shampoo bottles with in-room dispensers at Phillips House turned into something more ambitious. Eisen said his interest in climate change and healthcare was sparked when he joined the staff at MGH in 2018 as an attending hospital physician. He had heard through the grapevine that Mewaldt had helped remove styrofoam containers from the cafeteria, which is now a composting program. The two had a phone call about the shampoo bottles. Then the pandemic hit and they put the idea aside.
“Where it started for us was a shared desire to try to improve climate impact through the delivery of health care, and the recognition that we were creating a lot of waste in our health care,” said Mewaldt. “And that some of it was probably preventable. It drove us both a bit crazy.”
Attempts to get rid of the cafeteria Styrofoam had turned out to be much more complicated than Mewaldt had originally thought, he said, and the process took months. He and Eisen started talking again about doing a project at Phillips House in April 2021, during a plateau in the pandemic. Eisen brought up an audit.
“Jon had an important insight – that we would probably get much further in our arguments if we could show how much waste we were actually producing and how much of it was possibly unnecessary,” says Mewaldt, now a cardiovascular guy at nearby Beth Israel Deaconess Medical Center.
The 21st floor of Phillips House seemed like an ideal environment, Eisen said, because there are single patient rooms, about three-quarters of which typically have contact with infectious disease precautions, including antibiotic resistant infections and covid-19. Those precautions include the use of PPE.
At the beginning of April, Eisen emailed Jonathan Slutzman, who headed the then newly formed Environmental and Health Center. Slutzman had conducted an audit of the hospital’s emergency room in 2018 and published the results in a paper titled “Dumpster Diving in the Emergency Department,” in The Western Journal of Emergency Medicine.
Healthcare audits are an increasingly popular way to measure exactly what kind of waste hospitals produce, according to a study of audits from 2022 under the direction of Slutzmann. That study calls for reporting standards so that waste in different environments can be compared to save money and reduce deluge worldwide. Slutzman said when Eisen came to him, he encouraged him — and was in a position to help coordinate the project.
Eisen and Mewaldt began collaborating with Latoya Brewsterdirector of environmental services, Jennifer Sargenthead of nursing and Denis Bogere, the hospital’s operational manager at the time, to set up the logistics and ensure that the floor’s daily rhythm would not be disrupted.
They were done in August.
“It was so eye-opening — just a huge amount of garbage being generated,” Sargent said on one Webinar 2022 posted on the hospital’s website.
The audit also found a “surprising” amount of unused supplies in the waste collected, such as gloves, Mewaldt notes.
Brewster, who coordinated with other departments involved and cleaning staff to make sure everything went smoothly, the audit said helped her understand how much normal waste was created.
“I knew there was some contamination, that is, just garbage, going in there,” she said. “But I didn’t understand — or visualize — how much.”
The emissions of greenhouse gases, or GHG, emitted to create and dispose of the waste cataloged in the audit were the equivalent of driving 350 miles, charging 65,000 smartphones or burning 269 pounds of coal, Eisen and Mewaldt found, using Models from the Environmental Protection Agency.
Today, the hospital is exploring how and when to switch back to the reusable gowns that were once standard, the researchers said.
They pointed to the success of other hospital systems with reusable gowns, including the UCLA Medical Center, which began using them in 2012. Over three years, that system saved $1.1 million on purchase and avoided an estimated 297 tons of waste being sent to landfills. a case led by researchers at Stanford.
The swap at Mass General would likely begin as a pilot program to work out kinks, such as placing ties on the gowns, as well as a careful evaluation of contact precautions. Slutzman said a decision on the trade could come next year.
“There are some challenges. We need to make sure we find a device that meets everyone’s needs, in the sense that it has to be portable, comfortable, easy to put on and take off and cover people adequately,” said Slutzman. “So we have to satisfy a number of stakeholders.”
Disposable gowns are usually made of synthetic fibers, including polypropylene, polyester and polyethylene, while reusable jackets are often woven polyester. And the National Academy of Medicine recommends the switch.
In addition, reusable coats can typically be washed 75 to 100 times, according to the study led by the Stanford researchers. The University of California, Los Angeles successfully used reusable gowns during the pandemic, Eisen and Mewaldt noted. They said the audit armed them with information to push for the switch.
Slutzman, who describes waste audits as “the gateway drug to sustainability science,” said while setting it up may mean careful coordination between many hospital groups, it is not difficult to do one. And that gives hospitals tools to implement changes.
“The way to reduce what goes out is to control what comes in — and change your purchasing and acquisition process,” Slutzman said. “Once the horse is out of the stable, it is difficult to get it back in. Once the plastic is in the hospital, it goes out again. It has to go somewhere.”
Better practice, he said, is “to work with our vendors, our manufacturers, our regulators to make sure that the easy practice is the right practice.”