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Classification and regulation of medical waste disposal and management is determined by the U.S. Environment Protection Agency (EPA), Drug Enforcement Agency (DEA), as well as state and municipal departments of public health. Since the Medical Waste Tracking Act (MWTA) of 1988 expired in 1991, waste is primarily regulated at the state level environmental and health departments, and not the EPA.103
Regulated medical waste (RMW) is potentially infectious or biohazardous and contains either blood or other potentially infectious material, including bodily fluids (e.g., cerebrospinal fluid, pleural or pericardial fluid, or saliva) or human tissue. Importantly, relatively small amounts of blood or other infectious material may contaminate waste without being classified as RMW. RMW is usually collected in red bags or bins and is transported to a handful of highly regulated facilities that then treat the waste by high-temperature incineration, autoclave, or chemical treatment.
The World Health Organization notes that up to 15% of hospital waste may be considered RMW104, however, under 8% is more typical in the United States. Many health care staff do not separate RMW properly, either due to lack of knowledge or convenience, and may exceed the 15% WHO recommendation.104-107 This leads to increased costs and environmental emissions stemming from the special treatment that RMW requires.
Sharps waste includes needles, syringes (even without needles), blades, and broken glass. These inherently risk infectious cross-contamination, making their disposal management more dangerous. They may be disposed of in dedicated red sharps containers or specialized bins dedicated to sharps with pharmaceuticals.
Pharmaceutical waste is classified under the Resources Conservation and Recovery Act (RCRA)108 and classes relevant to operating rooms include those that are acutely hazardous (P-listed), non-acutely hazardous (U-listed), or unlisted. P-listed pharmaceuticals (e.g., nitroglycerin, physostigmine, nicotine) require special treatment, and disposal bins are typically black. U-listed or unlisted drugs may have a separate bin (e.g., purple, purple and white, or blue).
Controlled substance waste disposal requires special treatment to render it unrecoverable and to prevent diversion and abuse. Historically, facilities managed controlled substance disposal by witnessed dumping down sinks into sewage systems. However, sewage plants do not treat pharmaceutical waste, and such disposal methods result in environmental contamination and exposures. This is particularly concerning for those facilities that consider propofol as if it were a DEA controlled substance, as propofol is toxic to ecosystems. Sewage dumping is no longer permissible, and special bins containing solidifiers are now required that render controlled substances unrecoverable.109
The vast majority of solid waste generated in the operating room may be considered municipal solid waste (MSW) and is not contaminated or hazardous. This includes paper, plastic, cardboard, and intact glass. Packaging material used to protect and maintain the sterility of supplies and equipment accounts for a large part of this solid waste. This waste is typically disposed of into white, clear, or black bags and sent to local landfills or incineration plants. In addition, some MSW is potentially recyclable, provided local vendors are willing and able to receive clinical materials.
An estimated one million tons of clean, non-infectious plastics alone are generated at health care facilities nationwide each year.99 In addition to plastic, other commonly recyclable materials include metal, paper, and cardboard. The anesthesiology waste stream represents approximately 25% of total operating room waste, and 60% of that may be potentially recyclable.100 Much of the recyclable waste is generated when materials are opened and prepared, before the patient even enters the operating room, and is therefore clean.
In 2017, China stopped accepting plastics and paper waste products due to environmental and health concerns posed by poorly segregated recyclables. This led to closure of many recycling programs within the U.S. dependent on Chinese markets. As a result, total national plastics recycling has dropped from 9% overall to 5-6%.110 Partnerships with local plastics manufacturers and recycling vendors can provide greater programmatic resilience and safeguard against international disruptions in recycling supply chains.
A variety of batteries are frequently used in medical equipment (and sometimes only once), many of which contain hazardous metals such as lead, cadmium, and mercury that require special disposal. The Mercury-Containing and Rechargeable Battery Management Act (The Battery Act) of 1996 required that all states establish programs for the collection, transport, and disposal of batteries. Some states have adopted laws requiring disposable battery recycling.111
Human civilization is largely based on a “take-make-waste” linear economy, whereby materials are taken from the Earth to make products that are often only briefly used, and then eventually thrown away. By contrast, in nature, byproducts from one system become feedstock for another, and waste does not exist. Modeling design and management principles on this nature-inspired circular economy is a fundamental approach to more sustainable systems. Circular principles begin with avoiding unnecessary use of materials. Products and processes should be redesigned with fewer embodied materials and energy. Product lifespans should be extended through use of more durable materials, and modular design to ease dis/reassembly for safe cleaning and repair for reuse, repurposing and eventual recycling of materials only when product reuse is no longer possible (See figure 2 below). Policies that drive the health care industry away from manufactured obsolescence and towards a more circular economy are required.14,54
Figure 2. From MacNeill AJ, Hopf H, Khanuja A, et al. Transforming the Medical Device Industry: Road Map to A Circular Economy. Health Aff (Millwood). 2020;39(12):2088-2097.54
Curated by: the ASA Committee on Environmental Health
Date of last update: January 29, 2024
