|Year : 2019 | Volume
| Issue : 1 | Page : 62-66
The RECOVER initiative: Supply recovery and donation beyond the operating room
Peter F Johnston, Pamela Jumbo-Cueva, Varsha Kurup, Aparna Govindan, Somnath Rao, Ziad C Sifri
Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
|Date of Submission||04-Jun-2018|
|Date of Acceptance||20-Jul-2018|
|Date of Web Publication||23-Apr-2019|
Dr. Peter F Johnston
Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB G506, Newark, New Jersey
Source of Support: None, Conflict of Interest: None
Background: Similar to previous models for recovery and donation of clean and unused operating room (OR) supplies, that would otherwise be discarded, a new program was started at our institution in 2016. Subsequently, the initiative was expanded to units outside the OR. This study aims to explore the output of these other units on top of our current program. We hypothesize that expansion is feasible and productive, with minimal added effort.
Materials and Methods: Clean and unused supplies, in original packaging or open box, which would otherwise be discarded were collected in marked bins from the OR, Surgical Intensive Care Unit (SICU), and the trauma bay (TB) of our urban, academic center. Supplies were sorted, weighed, and inventoried weekly by qualified volunteers. Totals were calculated through proprietary inventory software.
Results: The program salvaged 9024 individual items of 129 unique types grouped into 7 categories. In total, 1065 kg of supplies worth an estimated $20,550 USD were collected from the three patient care areas over 7 months. Adding the SICU and TB resulted in a 33% increase in recovered weight and 13% increase in value. Twenty-nine new items were added to our inventory. If this program was expanded to recover supplies from the other ICUs in our hospital, we estimate an additional 951 kg worth $9443 USD could be collected.
Conclusions: Thousands of clean, unused supplies, weighing over a metric ton, are discarded in our hospital annually. The OR is the largest source of such material; however, expanding beyond the OR generates significant additional yield. Expansion is feasible with minimally added volunteer hours. Supply recovery initiatives undertaken nationwide and may help mitigate the economic and environmental costs associated with excess medical waste generation and produce staggering quantities of supplies for donation.
The following core competencies are addressed in this article: Systems-based practice.
Keywords: Environmental impact, hospital waste management, humanitarianism, supply recovery
|How to cite this article:|
Johnston PF, Jumbo-Cueva P, Kurup V, Govindan A, Rao S, Sifri ZC. The RECOVER initiative: Supply recovery and donation beyond the operating room. Int J Acad Med 2019;5:62-6
|How to cite this URL:|
Johnston PF, Jumbo-Cueva P, Kurup V, Govindan A, Rao S, Sifri ZC. The RECOVER initiative: Supply recovery and donation beyond the operating room. Int J Acad Med [serial online] 2019 [cited 2019 Jul 16];5:62-6. Available from: http://www.ijam-web.org/text.asp?2019/5/1/62/256797
| Introduction|| |
In the United States (US), disposable, sterile, single-use supplies are the norm in the operating room (OR), emergency department (ED), and Intensive Care Unit (ICU). It is estimated that nearly 2 million kilograms of recoverable materials valued at roughly $200 million USD are disposed of annually, from ORs in academic centers within the US.,, Similarly, in the ED or ICU, any supplies brought to bedside but not used become medical waste requiring regulated disposal, despite often remaining in the original sterile packaging.,,,, This results from a strict regulatory climate for the US hospitals and supply manufacturers preventing reuse or redistribution of such material. Exaggerated liability concerns associated with the use of such goods exist, despite the lack of evidence for actual risk of harm., In the end, these supplies are tagged for disposal in incinerators or landfills at a significant cost to the hospital as well as the environment.,,
At the same time, hospitals and practitioners in low- and middle-income countries (LMICs) are desperate for these same materials due to numerous, complex barriers.,, This situation has led to the creation of supply recovery programs to recoup and donate unused supplies. Similar to the previous REMEDY model, we endeavored to start a similar program, the RECOVER initiative, at our institution. Although there are hundreds of large academic centers around the country, so far the published literature regarding supply recovery programs has been limited to a few examples, even fewer recent ones, and only in regard to the OR.,,,,, While previous publications have demonstrated the value of such programs in regard to the OR, none yet have reported the contribution of other patient care areas, both in terms of excess medical waste and what can be recovered.
To expand upon the current model, we have included recoverable supplies from two new patient care areas: the trauma bay (TB) and Surgical Intensive Care Unit (SICU). The goals of this study are to quantify the amount and value salvaged from the RECOVER initiative and describe the added benefit when expanding such a program beyond the OR. We hypothesize that expansion to patient care areas outside of the OR is feasible and productive with minimal added effort or cost.
| Materials and Methods|| |
After review of the WHO guidelines regarding medical supply donation to developing countries and discussion with appropriate personnel, volunteers planned the salvage and donation of clean, unused supplies that were previously discarded as medical waste in the OR, TB, and SICU of a large, urban academic medical center. Data were gathered over a 7-month period regarding materials collected in the OR, TB, and SICU. Goals were widespread implementation and ease of collection as to not place additional burden on the support staff. Signage and collection bins were posted at central locations in the OR, TB, and SICU. Information sessions were held to further educate the support staff on the details and rationale of the initiative and to encourage participation. Nurses, surgical residents, and other ancillary staff were urged to place any supplies that would be otherwise discarded but meeting a standard of cleanliness into the RECOVER bins. The main criteria were no exposure to body fluids, no patient contact, and no visible damage. Following initial collections, further meetings with collecting staff were held to discourage collection of certain inappropriate supplies, such as expired medications and supplies deemed unusable by the RECOVER staff and the donation recipients.
Usable supplies constituted any item in its original packaging or open-box items without contamination that would not require significant reprocessing and met the WHO standards for ethical donation. Unusable supplies were those with obvious or suspected contamination, expired supplies, and open-box supplies that require sterility for use and cannot safely be repurposed such as open suture or hypodermic needles.
Bins were emptied weekly by medical student volunteers trained in universal precautions under faculty supervision. Collected supplies were then sorted, weighed, inventoried, and stored in a secure location within the hospital. Those supplies deemed usable were then packaged for utilization in resource-poor areas, both locally and internationally. When possible, donations were based on preference lists sent by potential recipients. Shipments to recipient locations were facilitated by partnering nongovernmental organizations (NGOs). The cost of shipment was covered by fundraising efforts of global health medical student interest groups as well as partnered NGOs specializing in the collection and distribution of medical supply overseas and those working in disaster settings. We do not routinely sterilize collected materials.
Inventory was kept through the proprietary Goods Order Inventory program. The program was used to create reports regarding the recovery and distribution of supplies which aided in calculations of total amounts and values recovered. Values were calculated based on an algorithm provided by a partner NGO specializing in distribution of medical supplies. Currently, no established standard for calculating values of donated supplies has been published. An estimated average value for each item was calculated based on an average of prices per unit from three common US medical suppliers. This value was then discounted 50% if still in original packaging or 75% if open box. Total values were calculated by applying this estimated average value to the recovery inventory. This study was approved as exempt by the institutional review board.
| Results|| |
Nine thousand and twenty-four individual items were collected over a period of 7 months from 2016 to 2017 from a 14-room operating suite, a 5-bed TB, and the 14-bed SICU. A wide variety of usable supplies totaling over a metric ton worth approximately $20,000 USD were recovered from the three patient care areas [Table 1]. [Table 2] lists common supplies collected from each area. Supplies were separated into one of seven categories: surgical, drapes/gowns, dressing/gauze, respiratory, administration/collection, orthopedics, and general/miscellaneous [Table 3]. While the OR produced by far the highest quantity and value of usable supplies, the TB and SICU nonetheless accounted for a 33% increase in recovered weight of usable supplies and 13% increase in recovered value. Including these two, other area in RECOVER along with the OR allowed for collection of 29 new unique items, a 43% increase in the scope of our inventory for donation. Only a small amount (10%) of the total recovered material, primarily from the OR, was deemed unusable and discarded appropriately.
If collections remain steady, an estimated 1827 kg of usable supplies worth $35,229 USD would be collected annually by RECOVER, 1459 kg from the OR, 50 kg from the TB, and 317 kg from the SICU. Assuming that other ICUs in our hospital would generate similar waste per bed, an additional estimated 951 kg of usable supplies worth an additional $9,443 USD would be collected annually if the program captured all ICUs. Furthermore, if our numbers for the OR, TB, and SICU were expanded to the other 232 large US academic medical centers, we would predict that a total 247,000 kg of usable supplies worth $4.7 million USD could be collected yearly.
| Discussion|| |
An enormous amount of medical waste is generated in US hospitals with a significant financial and environmental cost.,,,,, A substantial portion of this material is comprised of clean, unused supplies, which are discarded due to a perceived legal risk, lacking true evidence base, despite being safe to resterilize or repurpose. Meanwhile, in many LMICs, these supplies are in desperate need across a wide spectrum of situations., The primary contributor to wastage of such reusable supplies in the health-care system is the OR; however, there are many other areas of the hospital with similarly wasteful policies regarding unused supplies. Based on similar models focusing on the OR, we initiated a supply recovery program at our own large, urban academic center. Unlike previous models, however, we expanded to other patient care areas based on our observations that excess waste was a problem everywhere in the hospital. We aimed to measure the scope of our program and to document the potential additional contribution of areas outside of the OR such as the SICU and TB which has not been previously described.
Not surprisingly, the OR was the biggest source of recovered supplies, as previous data have shown that within hospitals, ORs generate 20%–33% of total medical waste. In the initial months of expansion, the SICU and TB produced smaller, yet still significant, quantities of supplies with slightly less value per weight recovered. However, expanding to these two areas still produced considerable increases in total weight and value of recovered materials over the OR alone. In addition, they added more unique items, extending the scope of the inventory and frequently yielded supplies still in their original, sterile packaging. While maybe not as robust in quantity or value as the OR, other areas of the hospital should be explored to maximize recovery.
The OR, while providing the greatest amount of supplies, also had the highest percentage of material deemed unusable (10%). Most often, supplies from the OR were opened and thus nonsterile and therefore needed repurposing or resterilization. Frequently and especially with specialized surgical devices, this was not possible, making them unusable for our purposes. The TB and SICU were slightly more efficient in terms of collection, making them even more attractive for expansion. Furthermore, adding these two areas to the collection network required only 2–3 more person-hours per week from our medical student volunteers.
Despite many items being open-box, using such goods “as is,” repurposing for non-sterile use, or re-sterilizing materials generates significant utility for such wares. Frequently in LMICs, despite “free” medical care, hospitals are not able to keep stocks of the necessary equipment. Patients and their families are often required to buy any needed supplies, compounding the financial burden associated with obtaining care which can be catastrophic. Although discussion of the substantial and ongoing need for medical supplies among hospitals in LMICs is beyond the scope of our data, it has been well described by others.,,
The limitations of this study reflect the difficulty studying a fledgling program. The data are limited to our own urban, academic centers and other institutions would likely have slightly different experiences based on numerous factors. However, while results may vary, the potential for supply recovery and donation exists across all institutions. Estimated value is a difficult metric as no established standard exists to measure the depreciation of medical supplies that have been donated, especially if products are outside of the original packaging. Our values were estimated using US prices for individual purchase and thus do not take into account bulk purchasing, local supply chain, and logistical issues, such as customs. Full cost benefit may be difficult to complete, however is warranted.
Adding new patient areas to supply collection in the OR is challenging and time-consuming. As awareness of the program grows among the staff of the ICU and TB, we expect collection to increase over time. There is further potential for expansion to the various other patient care areas of the hospital which would undoubtedly amplify the yield of RECOVER. Other areas with high turnaround, such as other ICUs, the recovery room, and maternity wards, can be added to maximize impact, though further institutional buy-in and incentives for collectors and volunteers will likely be needed. We hope our program may also raise awareness of waste excess among our staff leading to a culture shift in how supplies are discarded at our institution and a better understanding of system-based practice. Adoption of similar initiatives across the thousands of US hospitals could yield staggering numbering of usable supplies ready for donation to those in need in LMICs.
Because of the many ethical pitfalls associated with medical supply donation to LMICs, bodies such as the WHO and the American College of Academic International Surgery have developed guidelines and statements to direct ethical donation. These important principles such as avoidance of expired supplies, matching specific needs of the donation recipients, and inter-institutional collaboration should be followed as best able when participating in a supply recovery and donation programs., We must be transparent regarding collection methods and condition of the supplies with recipient hospitals and organizations and a disclaimer should be provided detailing the origins and management of recovered supplies. It is key to appropriately match donations with specific needs and capacity., Feedback regarding the use of donated supplies should be collected whenever possible to minimize inappropriate donations and ensure donated goods which are being utilized properly. Continued donations should be prepared based upon such recipient feedback.
| Conclusions|| |
Large amounts of clean and unused supplies are discarded from various patient care areas within hospitals in the US, despite a potential for donation. Supply recovery programs focusing on the OR have been shown feasible in recovering many of these supplies. Expanding to other areas of the hospital such as ICUs and emergency departments can generate a fair amount more quantity and value over the OR alone. Such expansion is a novel and feasible approach which may significantly increase the scope of such programs. By collecting such supplies for donation, we may help providers in dire need of such supplies in LMICs.
The authors would like to thank Andrew Abdelmalek BS, Emilie Soye-Kim, and Asmi Panagrahi for logistical support with the collection of supplies as well as contributions to the RECOVER system which made such research possible.
Financial support and sponsorship
This study was sponsored by the New Jersey Medical School Department of Surgery
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
This study was approved as exempt by the Rutgers Biomedical and Health Sciences Institutional Review Board.
| References|| |
Rosenblatt WH, Ariyan C, Gutter V, Silverman DG. Case-by-case assessment of recoverable materials for overseas donation from 1318 surgical procedures. JAMA 1993;269:2647-9.
Miller S. The REMEDY Program: Recovery and donation of unused surgical supplies to developing countries. Q J Biol Med 2002;19:121-4.
Wan EL, Xie L, Barrett M, Baltodano PA, Rivadeneira AF, Noboa J, et al.
Global public health impact of recovered supplies from operating rooms: A critical analysis with national implications. World J Surg 2015;39:29-35.
Rosenblatt WH, Silverman DG. Recovery, resterilization, and donation of unused surgical supplies. JAMA 1992;268:1441-3.
Rosenblatt WH, Silverman DG. Cost-effective use of operating room supplies based on the REMEDY database of recovered unused materials. J Clin Anesth 1994;6:400-4.
Czajkowski-Beckwith H, Rosenblatt WH. Reprocessing unused surgical supplies for use in developing countries. AORN J 1996;63:236-8.
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.
Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.
Ferraz MC, Cardoso JI, Pontes SL. Concentration of atmospheric pollutants in the gaseous emissions of medical waste incinerators. J Air Waste Manag Assoc 2000;50:131-6.
Garg M, Peck GL, Arquilla B, Miller AC, Soghoian SE, Anderson Iii HL, et al.
AComprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine. Int J Crit Illn Inj Sci 2017;7:188-200.
] [Full text]
Decker R. Hospitals need to limit their liability when selling used and surplus medical equipment. Hosp Mater Manage 1989;14:20-1.
[Table 1], [Table 2], [Table 3]