Let’s start by throwing the right waste into the right bin

The healthcare industry generates a staggering 5.9 million tons of waste per year in the United States, including 1.7 million tons of plastic waste. ^{Reference Jain and LaBeaud14,Reference Kenny and Priyadarshini15} Healthcare waste is sorted into multiple disposal streams, including incineration, landfill, recycling, and compost, each of which confers a different environmental impact. Biohazardous waste generates higher GHG emissions compared to non-biohazardous waste because high-energy processes such as autoclaving or incineration are frequently required for disposal. Unfortunately, waste audits have repeatedly demonstrated that non-biohazardous waste is frequently segregated improperly into biohazardous waste bins, resulting in unnecessary environmental harm as well as increased healthcare costs. ^{Reference Stall, Kagoma, Bondy and Naudie16,Reference Hsu, Theil, Mello and Slutzman17} Biohazardous waste has therefore become a highly targeted area in healthcare sustainability due to its environmental and financial benefits. IPC likewise is a key stakeholder in waste management, particularly in ensuring that potentially infectious waste is appropriately managed.

Effective waste segregation aligns with the priorities of both IPC and healthcare sustainability and is an outstanding opportunity for collaboration between these fields. Methods to improve waste sorting include education, strategically placing biohazardous waste bins so they are not overused, reducing the size of biohazardous waste bins, and ensuring that signage is current and prominently placed near waste bins. Promoting strategies that are user-centered and minimize the additional burden to busy providers is crucial to attain lasting changes to healthcare waste streams (Figure 1).

Figure 1. Example red bag waste initiative poster, reprinted with permission from authors.

Moretti K, Karb R, Durand R, Kobayashi L, Hayward AS. Wasting No Time: Implementation and the Climate Impact of a Solid Waste Stream Process Intervention in a Large Academic Emergency Department. R I Med J (2013). 2021;104(9):34–37.

OPIM: Other Potentially Infectious Material

Follow “smart” transmission-based isolation (and de-isolation) precautions

Personal protective equipment, or PPE, is a major component of healthcare waste—close to 70% of plastic municipal solid waste collected during a waste audit of an inpatient medical unit was PPE. ^{Reference Mewaldt, Armand, Slutzman and Eisen18} Healthcare IPC programs should take time to review all isolation policies, with the specific goal of reducing unnecessary use of PPE during patient care. This includes prompt de-isolation of hospitalized patients when they are no longer deemed contagious and following standard precautions for endemic multidrug-resistant organisms when program surveillance supports this practice change. ^{Reference Martin, Russell and Rubin19,Reference Bearman, Abbas and Masroor20} Healthcare IPC programs should continue to reevaluate the utility of contact precautions for those with a history of antimicrobial-resistant infections. ^{Reference Most, Phillips and Sebert21}

Equally (or even more) important is to practice judicious or “smart” use of PPE, meaning employing PPE only when truly necessary for patient safety. IPC programs can regularly review internal policies regarding PPE to ensure they are up to date. Furthermore, IPC programs can consider healthcare waste as a factor when implementing or updating policies that require PPE use. Finally, IPC programs should routinely educate their healthcare workforce about their individual roles in preventing unnecessary PPE use for both patient safety and sustainability reasons. Such education can be included in new employee orientation, during hospital IPC rounds, and in annual IPC competency education. There is an opportunity for IPC programs to incorporate education about judicious use of PPE while meeting the Centers for Diseases Control and Prevention (CDC) core practices ²² which are utilized by healthcare regulatory bodies in the United States, including the Joint Commission. ²³ For a patient on standard precautions, in general, this could also include performing hand hygiene alone rather than gloves for examination of patients when there is no contact with body fluids anticipated.

Stop wasting so many medical supplies

Many facilities have IPC policies that require the discard of all “potentially contaminated” single-patient room supplies after discharging a patient who was hospitalized under contact isolation precautions. This practice leads to substantial unnecessary waste plus thousands of dollars of healthcare loss. ^{Reference Otter, Nowakowski and Salkeld24} To minimize this waste, IPC programs can collaborate with inpatient unit leadership to decrease the number of disposable supplies stocked in patient rooms. In addition, techniques such as disinfecting packaged items rather than disposing of them may also be effective in decreasing waste and preventing infections. ^{Reference Otter, Nowakowski and Salkeld24} Further studies examining how such processes may be implemented widely in healthcare systems, as well as of the IPC and environmental sustainability impacts of these techniques, are necessary.

IPC programs should also collaborate with their facility’s logistics and procurement leadership to find opportunities for minimizing disposable items and replacing them with reusable supplies whenever possible. Examples may include surgical instruments, endoscopes and their accessories, and commonly used items such as “single-patient stethoscopes.” One children’s hospital recently discontinued the purchase of single-patient stethoscopes for patients in isolation precautions. The disposable stethoscopes were considered poor quality by clinicians and needlessly contributed to hospital waste. The solution was to routinely stock 1 high-quality stethoscope at the bedside in every inpatient room (Figure 2). The stethoscopes are routinely cleaned and disinfected as “high-touch surfaces.” As a result, clinicians no longer carry personal stethoscopes, further decreasing the risk of indirect pathogen transmission. A renewed focus on high staff competency for medical supply cleaning and disinfection, rather than relying on disposable items alone, can reduce contributions to the medical waste stream. Discussions about minimizing healthcare waste should be happening from healthcare administration (facility level) to the bedside staff (patient level) and everyone in between.

Figure 2. Example of placement of a high-quality stethoscope that was routinely cleaned and disinfected as “high-touch surfaces.”

Attend a medical meeting or plan an interview…virtually

The American Society of Tropical Medicine and Hygiene analyzed that in 2019, approximately 4,000 attendees collectively traveled approximately 27.7 million miles to reach the conference venue, equating to roughly 58 return trips to the moon for their annual conference alone. ^{Reference Bousema, Selvaraj and Djimde25} High-priority solutions to reduce the massive GHG emission footprint from transportation to meetings include decentralized conference “hubs,” a rotational model alternating between in-person and virtual formats, as well as hybrid conferences that combine both modalities. One way to increase accessibility to trainees for a professional meeting is to reserve a conference room and invite others who may not typically join to watch lectures with a faculty member or attend. This is a great way to create social connection and expose trainees or other clinicians to ID topics and greatly reduces the environmental impact.

Virtual interviews should be considered as the new standard for screening interviews. The environmental impact of interviewing for residencies by 1 graduating medical student class in the prepandemic era (when this process was conducted in person) was estimated to be approximately 1 million pounds of GHG emissions, which is roughly equivalent to the carbon sequestration capability of a 700-acre forest. ^{Reference Bernstein and Beshar26,Reference Kaelin, Durfey, Dorfman and Moretti27} The virtual option for ID fellowship was assessed by both fellowship program directors and virtual interviewees in ID and both groups prefer to have a virtual option for recruitment. ^{Reference Rockney, Benson and Blackburn28}

Reduce transportation emissions from patient care, infection prevention, and stewardship work

Telemedicine decreases healthcare GHG emissions and costs and may also decrease motor vehicle-associated injuries and fatalities. ^{Reference Sharma, Yellowlees, Gotthardt, Luce, Avdalovic and Marcin29,Reference Patel, Gonzalez and Turner30} The Pediatric Infectious Diseases Telehealth Working Group found that in the pre-COVID era, only 13%–20% of ID providers used telehealth modalities. ^{Reference Hakim, Gaviria-Agudelo, Edwards and Olson31} However, the same group published data showing that post-COVID, telemedicine utilization increased 4-fold, and satisfaction with telemedicine modalities grew to over 90%. ^{Reference Kalyoussef, Hakim and Kumar32} Further research is needed regarding which patients are best suited for telemedicine, though many report that established patient visits are often easiest as rapport and initial evaluations have already been established.

Infection prevention and antimicrobial stewardship are also able to be practiced remotely and may mitigate limited staffing across the United States. ^{Reference Pryor, Vokes, Anderson and Bearman33} Early in the coronavirus disease 2019 pandemic, the CDC successfully conducted telephone and video-based infection control assessment and response (TeleICAR) consultations to over 600 nursing homes. ^{Reference Walters, Prestel and Fike34} The CDC has created a library of standardized IPC checklists that can be used for both in-person and virtual IPC consultations. ³⁵ A statewide antibiotic stewardship program in Utah was implemented in 2016 and has successfully provided both clinical and stewardship consultation to 16 small community hospitals. ^{Reference Vento, Veillette and Gelman36} Similar telehealth stewardship programs have reported successful results, including reduced broad-spectrum antibiotic use and reduced cost. ^{Reference Shively, Moffa and Paul37,Reference Klatt, Schulz and Fleischman38}

Telehealth has been endorsed by the Infectious Disease Society of America (IDSA) “to provide up-to-date, timely, cost-effective subspecialty care to resource-limited populations.” ^{Reference Young, Abdel-Massih, Herchline, McCurdy, Moyer, Scott, Wood and Siddiqui39} Beyond these cited benefits by IDSA, telehealth also decreases negative climate impacts.

Decrease pharmaceutical waste

From manufacturing to consumption and eventual waste disposal, the climate impact of inpatient pharmaceutical waste, particularly antimicrobial waste, is substantial. Considerable energy is required for transportation and autoclaving or incinerating of pharmaceutical waste, and landfill waste generates methane, a potent greenhouse gas. Unused drugs that are discarded can occur with any weight-based dosing regimen and is a particular problem with pediatric patients. Pediatric doses are often prepared in advance but subsequently discarded if not administered due to patient discharge or cancellation/modification of treatment. Unfortunately, these unused doses cannot typically be repurposed. At least 3 pediatric healthcare systems have separately estimated their antimicrobial waste to cost more than $100,000 annually. ^{Reference Fan, Lu, Fernandez and Jaggi40,Reference MacBrayne, Williams and Obermeier41} It is important to note that this financial estimate does not encompass the additional costs associated with autoclaving, incinerating, transporting, or managing pharmaceutical waste through waste management companies. Pharmaceutical waste has also been documented in adult centers and should be considered for antibiotics such as daptomycin or aminoglycosides due to weight-based dosing. ^{Reference Hintzen, Knoer, Van Dyke and Milavitz42} Strategies to prevent unnecessary waste could include placement of stop times in the electronic medical records at least 24 hours in advance to notify inpatient pharmacy staff. Of note, most of this drug waste has been documented with antimicrobials but is likely occurring with other pharmaceutical classes.

As practitioners in Antimicrobial Stewardship Programs (ASP) and IPC, collaboration with pharmacy departments is imperative to optimize dosing regimens and minimize waste. The good news is that widely accepted antimicrobial stewardship initiatives, such as eliminating prescribing of unnecessary antimicrobials, using shorter durations of therapy when possible, adding stop dates in advance, and advocating for initial oral (PO) drugs when clinically appropriate, all reduce the climate footprint of healthcare and potentially decrease pharmaceutical waste. One of the only lifecycle assessments of an antimicrobial studied is that of vancomycin which revealed that the production of 1 gram of vancomycin requires 0.6 kilograms of raw materials. This includes water for fermentation and irrigation, extraction of dextrose from corn and soy flour, and the consumption of crude oil and natural gas for processing and transportation. ^{Reference Ponder and Overcash43} This information may be helpful for ASP teams that are targeting vancomycin waste.

Petition your healthcare system for more climate action

There is strong support for healthcare sustainability among healthcare workers. In 2023, a US survey of 1001 healthcare workers demonstrated that over 80% of those surveyed believe that healthcare organizations should address climate change. ⁴⁴ ID physicians have well-established partnerships with the hospital administration, nurses, and other clinicians through IPC and antimicrobial stewardship work. These relationships make us well suited to lead advocacy efforts for more climate action in partnership with our colleagues. There are several objective, actionable steps that healthcare systems can now take. First is the Health and Human Services (HHS) Climate Pledge for specific measurement and mitigation of GHG emissions. Other options are to apply for the Joint Commission Sustainability Certification or join Practice Greenhealth, an organization that helps hospitals reduce environmental impacts. Finally, several centers now have multidisciplinary healthcare sustainability teams that include clinicians. Healthcare workers in Pittsburgh successfully petitioned their administration to sign the HHS Climate Pledge to reduce GHG emissions and formed a sustainability team with clinician-directed projects to reduce emissions. Another powerful request is to ask your center to divest any financial investments from the fossil fuel industry as suggested by this recent New England Journal of Medicine viewpoint. ⁴⁵ If you are interested in some coaching about how to organize with others to affect change, consider applying for the virtual Climate and Health Organizing Fellowship ⁴⁶ through Cambridge Health Alliance. Finally, collective action with colleagues can build camaraderie among the healthcare team and help mitigate climate anxiety. ^{Reference Schwartz, Benoit, Clayton, Parnes, Swenson and Lowe47}

Promote better food options and decrease food waste in healthcare

Many ID clinicians and antimicrobial stewards already engage in legislative advocacy to modify hospital purchasing programs to procure meat raised without the routine use of antibiotics, and this mitigates both antimicrobial resistance and also GHG emissions. Antibiotics have been shown to alter the structure and activity of mammalian fecal microbiota, which may result in more GHG emissions. ^{Reference Hammer, Fierer and Hardwick48}

Beyond antimicrobial stewardship in agriculture, reducing the amount of meat consumed would significantly decrease GHG emissions. The climate impact of food can be measured by using tools such as the Coolfood calculator. ⁴⁹ By partnering with dietician colleagues in hospitals to promote less meat to be served on hospital menus, ID providers can directly decrease the amount of meat purchased by hospitals. There are also legislative opportunities; New York State passed a bill in late 2019 requiring a vegetarian option on the menu at every hospital. ⁵⁰ At one system in New York City, a gradual shift from 2019 to 2022 resulted in the default meal options at every public hospital to be a meatless one; 50%–60% of their patients just eat the default meal. ^{Reference Grahame51}

Sustainability efforts involving food also include donating excess usable food and composting, which both save methane emissions. The Wellstar Health System in metropolitan Atlanta redistributes excess consumable food to needy individuals. St. Lawrence Health hospitals partner with a local farm on a composting initiative that keeps food waste out of landfills and allows this farm to produce natural fertilizer, thus doubly impacting climate benefits with less landfill emissions and less use of potentially environmentally damaging fertilizer products.

Model and discuss the environmental and other benefits of diagnostic stewardship (not just ID tests!)

Diagnostic stewardship of microbiologic testing has been discussed in recent years and shows promise to both improve clinical care and decrease unnecessary antibiotics. ID professionals can expand this diagnostic stewardship to more routine laboratory testing, such as blood counts and inflammatory markers, such as C reactive protein. In Australia, it was estimated that basic hematology testing requires the energy equivalent of driving 0.4 miles per test. ^{Reference McAlister, McGain and Petersen52} Radiologic testing, especially MRI is associated with high amounts of GHG emissions ^{Reference Chaban, Vosshenrich and McKee53} , so stewardship of this type of testing should also be scrutinized with consideration of lower GHG testing, whenever possible, such as ultrasound. ^{Reference McAlister, McGain and Petersen52} Finally, ID clinicians often generate extensive differential diagnoses, which is encouraged and should be maintained. However, the utility of ordering each diagnostic test should be scrutinized. The pretest probability of a diagnosis, the turnaround time available in relation to other testing that may be higher on the differential diagnosis, and the expected impact on clinical management should all be considered. Just by delaying some tests by 24–48 hours when there are more data available supports diagnostic stewardship and can decrease unnecessary healthcare resource use.

Keep up your good work, and now start measuring the environmental benefits

Infectious diseases provide high-value care and focus on the prevention of illness. Many of our efforts are focused on decreasing hospitalization length of stay and appropriate outpatient parenteral treatment. Decreasing or preventing a hospital stay by just 1 day is estimated to save at least 45 kg of CO₂ (equivalent to 115 miles driven by an average gas-powered vehicle).

If you are involved in quality improvement projects, consider adding environmental savings measurements to your work. This could be transportation-related travel savings (using the EPA calculator ⁵⁴ ), GHG emissions from solid waste in your health center (using a free online calculator), ^{Reference Corbin, Hoff, Smith, Owens, Weisinger and Philipsborn55,56} or GHG savings from reduced hospitalization length of stay in your existing work. The Centre for Sustainable Healthcare in the United Kingdom recognizes that healthcare value is best when patients have good clinical outcomes from a healthcare delivery system that generates the least harmful environmental, social, and financial impacts. There are many inspiring quality improvement projects that have been done by teams to help both patients and the planet. ⁵⁷

We recognize that helping to mitigate climate change can be overwhelming, but incorporating change in daily practices can lead to substantial benefits. If you would like to join other ID professionals to collaborate to decrease GHG emissions, email our group “Sustainabil-ID” at [email protected].