Public Agenda 12 DECEMBER 2018

CCDHB Public 12 December 2018 - PROCEDURAL BUSINESS

CAPITAL & COAST DISTRICT HEALTH BOARD Public Agenda 12 DECEMBER 2018

11TH FLOOR BOARD ROOM, GRACE NEILL BLOCK, WELLINGTON REGIONAL HOSPITAL, WELLINGTON, 1pm.

ITEM ACTION PRESENTER MIN TIME PG 1 PROCEDURAL BUSINESS 10 1pm 1.1 Karakia 1.2 Apologies Records A Blair 1.3 Continuous Disclosure - Interest Register Confirms A Blair 3 - Conflicts of Interest Accepts A Blair 6 1.4 Confirmation of Draft Minutes 7 November Approves A Blair 8 2018 1.5 Matters Arising Notes A Blair 1.6 Action List Notes A Blair 16 1.7 CCDHB Work Plan 2018 and 2019 Notes A Blair 18 20 1.8 Chair’s Report Notes A Blair 10 22 1.8.1 Chair’s Correspondence 1.9 Chief Executive’s Report Notes J Patterson 10 51 Appendix 1 — Letter – Well Child Review 59 Appendix 2 — Financial Summary, October 62 2018 Appendix 3 — Disposal of Waitangirua 70 property

1.10 Clinical Council Report Notes J Tait 5 57 2 PRESENTATIONS 2.1 Patient story Notes C Gibson 5 3 FOR DECISION 3.1 2019 Joint Capital & Coast and Hutt Valley Endorses A Blair 10 71 District Health Board Meeting Schedule and Workplan 73 Appendix 1 — Draft 2019 Joint Board Workplan Appendix 2 — 2019 Meeting schedule 75 4 FOR DISCUSSION 4.1 Health and Safety Report Notes T Davis 5 76 4.2 Children’s Hospital Programme Update Notes T Davis 5 85 4.3 Health System Committee Report Notes R Haggerty 10 88 Appendix 1 Minutes of Meeting 28 90 November 2018

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5 FOR INFORMATION 5.1 People and Capability Report Notes A Wilson 10 96 5.2 3DHB ICT Update Notes S Hunter 10 103 5.3 Reusable vs Disposable Linen Notes T Davis 5 116

Appendix 1 — M Overcash: A Comparison of Reusable and Disposable Perioperative 118 Textiles: Sustainability State-Of-The-Art 2012.

Appendix 2 — F Mcgain: Environmental 119 Sustainability in Hospitals; an Exploration within Anaesthetic and Intensive Care Settings.

Appendix 3— N Yoshgikawa: Life Cycle 315 Assessment of Reuse System for Surgical Gowns. 6 OTHER 6.1 General Business Notes A Blair 5

6.2 Resolution to Exclude the Public Approves A Blair 5 327 DATE OF NEXT MEETING 28 FEBRUARY 2019 – BOARD ROOM, PILMUIR HOUSE, HUTT HOSPITAL, LOWER HUTT

Capital & Coast District Health Board June 2018

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CAPITAL & COAST DISTRICT HEALTH BOARD Interest Register

12 DECEMBER 2018

Name Interest Mr Andrew BLAIR ∑ Chair, Hutt Valley District Health Board (from 5 December 2016) Chair ∑ Chair, Queenstown Lakes Community Housing Trust ∑ Member, State Services Commission Advisory Group on Crown Entity Chief Executive Remuneration ∑ Advisor to the Board of Breastscreen Auckland Limited ∑ Advisor to the Board, Forte Health Limited, Christchurch ∑ Advisor to the Board of St Marks Women’s Health (Remuera) Limited ∑ Advisor to Southern Cross Hospitals Limited and Central lakes Trust to establish an independent short stay surgical hospital in the Queenstown Lakes region ∑ Owner and Director of Andrew Blair Consulting Limited, a Company which from time to time provides governance and advisory services to various businesses and organisations, include those in the health sector ∑ Former Member of the Hawkes Bay District Health Board (2013-2016) ∑ Former Chair, Cancer Control (2014-2015) ∑ Former CEO Acurity Health Group Limited Dame Fran WILDE ∑ Ambassador Cancer Society Hope Fellowship Deputy Chair ∑ Chief Crown Negotiator Ngati Mutunga and Moriori Treaty of Waitangi Claims ∑ Chair, Kiwi Can Do Ltd ∑ Chair National Military Heritage Trust ∑ Chair, Remuneration Authority ∑ Chair Wellington Lifelines Group ∑ Deputy Chair, Capital & Coast District Health Board ∑ Deputy Chair NZ Transport Agency ∑ Director Museum of NZ Te Papa Tongarewa ∑ Director Frequency Projects Ltd Dr Kathryn ADAMS ∑ Member, Capital & Coast District Health Board Member ∑ Fellow, College of Nurses Aotearoa (NZ) ∑ Reviewer, Editorial Board, Nursing Praxis in New Zealand ∑ School Nurse Vaccinator (casual) Regional Public Health, HVDHB ∑ Workplace Health Assessments and seasonal influenza vaccinator, Artemis Health ∑ Secretary, National Party Ohariu Electorate ∑ Director, Agree Holdings Ltd, family owned small engineering business, Tokoroa ∑ Member, National Party Health Policy Advisory Group ∑ Assistant Research Fellow at Otago University — Physiotherapy

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Name Interest Dr Roger BLAKELEY ∑ Member of Capital and Coast District Health Board Member ∑ Deputy Chair, Wellington Regional Strategy Committee ∑ Councillor, Greater Wellington Regional Council ∑ Member, Harkness Fellowships Trust Board ∑ Member of the Wesley Community Action Board ∑ Director, Port Investments Ltd ∑ Director, Greater Wellington Rail Ltd ∑ Economic Development and Infrastructure Portfolio Lead, Greater Wellington Regional Council ∑ Independent Consultant ∑ Brother-in-law is a medical doctor (anaesthetist), and niece is a medical doctor, both working in the health sector in Auckland ∑ Son is Deputy Chief Executive (insights and Investment) of Ministry of Social Development, Wellington Ms Eileen BROWN ∑ Member of Capital & Coast District Health Board Member ∑ Board member (until Feb. 2017), Newtown Union Health Service Board ∑ Employee of New Zealand Council of Trade Unions ∑ Senior Policy Analyst at the Council of Trade Unions (CTU). CTU affiliated members include NZNO, PSA, E tū, ASMS, MERAS and First Union ∑ Executive Committee Member of Healthcare Aotearoa. Ms ‘Ana COFFEY ∑ Member of Capital & Coast District Health Board Member ∑ Councillor, Porirua City Council ∑ Director, Dunstan Lake District Limited ∑ Trustee, Whitireia Foundation ∑ Brother is Team Coach for Pathways and Real Youth Counties Manukau District Health Board ∑ Father is Acting Director in the Office for Disability Issues, Ministry of Social Development Ms Sue DRIVER ∑ Community representative, Australian and NZ College of Anaesthetists Member ∑ Board Member of Kaibosh ∑ Former Chair, Robinson Seismic (Base isolators, Wgtn Hospital) ∑ Advisor to various NGOs ∑ Daughter, Policy Advisor, College of Physicians Ms Sue KEDGLEY ∑ Member, Capital & Coast District Health Board Member ∑ Member, CCDHB CPHAC/DSAC committee ∑ Member, Greater Wellington Regional Council ∑ Member, Consumer New Zealand Board ∑ Deputy Chair, Consumer New Zealand ∑ Environment spokesperson and Chair of Environment committee, Wellington Regional Council ∑ Step son works in middle management of Fletcher Steel Ms Kim NGARIMU ∑ Member of Capital and Coast District Health Board Member ∑ Deputy Chair, Capital & Coast District Health Board, FRAC Committee ∑ Member, Medical Council of New Zealand (MCNZ) ∑ Member, Specialist Education Accreditation Committee (Australian Medical Council)

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Name Interest ∑ Member, Māori Heritage Council ∑ Member, Waitangi Tribunal ∑ Board Member, Te Māngai Pāhō (Māori Broadcasting Agency) ∑ Board Member Eastern Institute of Technology ∑ Board Member Heritage New Zealand ∑ Alternate Crown Trustee, Crown Forestry Rental Trust ∑ Director, Taaua Ltd (Public policy and management consulting company) ∑ Trustee, Judith and Taina Ngarimu Whānau Trust (has shareholdings in various health related companies – share acquisition and sale is independently managed) Mr Darrin SYKES ∑ Board Member, Capital & Coast District Health Board Member ∑ Chair, Capital & Coast District Health Board, FRAC committee (effective 21 February 2018) ∑ Member, Capital & Coast District Health Board, Remuneration Committee (effective 21 February 2018) ∑ Trustee, Wellington Regional; Sports Education Trust (trading as Sports Wellington) ∑ Board Member, Sport and Recreation New Zealand (trading as Sport NZ) ∑ Chief Executive, Crown Forestry Rental Trust

Capital & Coast District Health Board

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CAPITAL & COAST DISTRICT HEALTH BOARD Interest Register

EXECUTIVE LEADERSHIP TEAM 7 NOVEMBER 2018

Julie Patterson ∑ Chair, Adverse Event Expert Advisory Group to Health Quality and Interim Chief Executive Officer Safety Commission ∑ Member of recent Independent Panel Advising on NZNO/DHB Multi-Employer Collective Agreement ∑ Director of New Era Business Services Ltd ∑ Director of Tinui Enterprises Ltd ∑ Trustee of Wellington Hospital Foundation ∑ Chair SIPCAG HQSC ∑ CEO representative on ACC’s NE Taskforce Working Group

Mr John Tait ∑ Vice President RANZCOG Chief Medical Officer ∑ Chair, National Maternity Monitoring Group ∑ Member, ACC taskforce neonatal encephalopathy ∑ Board member, Wellington Hospitals Foundation ∑ Board member Asia Oceanic Federation of Obstetrician and Gynaecology ∑ Chair, PMMRC Rachel Haggerty ∑ Director, Haggerty & Associates General Manager, Strategy Innovation & ∑ Chair, National GM Planner & Funder Performance Nigel Fairley ∑ President, Australian and NZ Association of Psychiatry, Psychology General Manager of 3DHB Mental Health, and Law Addictions and Intellectual Disability ∑ Trustee, Porirua Hospital Museum Services ∑ Fellow, NZ College of Clinical Psychologists ∑ Director and shareholder, Gerney Limited Carey Virtue ∑ None Executive Director Operations Medicine Cancer and Community Delwyn Hunter ∑ Partner is employed by CCDHB (MHAIDS) Executive Director Operations Surgery Women and Children Thomas Davis ∑ None General Manager, Corporate Services Andrea McCance ∑ Deputy Chair, Board of Trustees, Mary Potter Hospice Executive Director of Nursing & Midwifery

7 NOVEMBER 2018

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Andrew Wilson ∑ Director and shareholder of ForeConsulting Business Services Ltd General Manager, People and Capability — contracts to health services ∑ Family member is a midwife employed by CCDHB ∑ Family member is employed by TAS Michael McCarthy ∑ Director/Trustee Prime Site Properties Ltd Chief Financial Officer ∑ Consultant to Ahuriri Health Trust ∑ Business relationship with Teresa Wall/Lady Rei (Chair of CCDHB MPB) in primary care consulting ∑ Daughter works in cervical screening programme Arawhetu Gray ∑ Co-chair, Health Quality Safety Commission – Maternal Morbidity Director Māori Health Services Working Group ∑ Director, Gray Partners ∑ Member, Te Hauora Rūnanga o Wairarapa Board Taima Fagaloa ∑ Sister is a Registered Nurse for 3DHB MHAIDS Director of Pacific Peoples’ Health/Manager Planning & Funding, Child & Population Roger Palairet ∑ Chair and Trustee of Carers NZ (non-profit organisation promoting Chief Legal Counsel the interests of family carers; funders include MoH, MSD and Waitemata DHB) ∑ Chair and Trustee of the Wellington Community Trust ∑ Sister-in-law is a paediatric nurse at CCDHB Shayne Hunter ∑ Owner/Director Genesis Consulting Group – a boutique consulting Chief Information Officer Technology, 3 practice DHB ∑ Director Patients First – a not-for-profit charitable company, jointly owned by GPNZ and RNZCGP, with the purpose to provide and facilitate information solutions in primary care Anna Chalmers ∑ Vice President of the National Council of the Motor Neurone Communications Manager Disease Association of New Zealand

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CAPITAL AND COAST DISTRICT HEALTH BOARD DRAFT Minutes of the Board Held on Wednesday 7 November 2018 at 1.12pm 11th Floor Boardroom, Grace Neill Block, Wellington Regional Hospital, Wellington

PUBLIC SECTION

PRESENT: Mr A Blair (Chair) BOARD Dame F Wilde, DNZM, QSO Ms E Brown Dr R Blakeley Ms S Kedgley Ms A Coffey (left 3.35pm) Mr D Sykes Dr K Adams

STAFF: Mrs J Patterson (Interim Chief Executive Capital & Coast DHB)) Mr J Tait (Chief Medical Officer) Mrs R Fitzgerald (Board Secretary) Ms A McCance (Executive Director, Nursing and Midwifery) Mr T Davis (General Manager, Corporate Services) Ms A Stewart (Acting Executive Director, QUIPS) Mr N Fairley (General Manager 3DHB MHAIDS) Mr M McCarthy (Chief Financial Officer) Mr A Wilson (Acting General Manager, People and Capability) Ms C Virtue (Executive Director, Operations)

GENERAL PUBLIC: There was one member of the general public who left at 2.03pm.

______RESOLUTION —ACCEPTANCE OF LATE PAPER CAPITAL & COAST DISTRICT HEALTH BOARD AND HUTT VALLEY DISTRICT HEALTH BOARD — SINGLE CE APPOINTMENT AND OPTIONS FOR GREATER BOARD COLLABORATION The Board: (a) Accepted the tabling of the late paper, however, this was to be discussed in ‘Board only’ discussions.

Moved Fran Wilde Seconded ‘Ana Coffey CARRIED

1 PROCEDURAL BUSINESS

1.1 PROCEDURAL The Capital & Coast District Health Board Chair, Andrew Blair, welcomed guests, members of the general public, Board members, guests from the Māori Partnership Board and Wellington Hospital Foundation, and the Executive Leadership Team. Karakia was led by Darrin Sykes.

1.2 APOLOGIES Kim Ngarimu and Sue Driver.

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1.3 INTERESTS 1.3.1 REGISTER OF INTERESTS ‘Ana Coffey identified a possible conflict of interest and will register with the Board Secretary. There were no items on the agenda that would cause any conflict.

CONFLICTS RELATED TO ITEMS ON THE AGENDA No other conflicts were foreshadowed in respect of items on the current agenda but there would be an additional opportunity at the beginning of each item for members to declare conflicts of interest.

1.4 MINUTES OF PREVIOUS MEETING 10 OCTOBER 2018 RESOLVED THAT: The minutes of the CCDHB Board meeting held on 10 October 2018, taken with the public present, were confirmed as a true and correct record. Moved: Roger Blakeley Seconded: Kathryn Adams CARRIED

1.5 MATTERS ARISING UPDATE The 2018 Board Evaluation survey will be released in December.

1.6 ACTION LIST The reporting timeframes on the other open action items were noted.

1.7 CCDHB WORK PLAN 2018 Changes noted.

CCDHB WORK PLAN 2019 Tabled and noted.

1.8 CHAIR’S REPORT The Chair’s correspondence report was taken as read. The Board: (a) Noted and thanked the Wellington Hospital Foundation for their funding gift of $1,045,000.00 during 2018 to the Wellington Regional Hospital; (b) Noted and thanked CCDHB staff from the Māori Health team, Communications, Children’s Hospital Project team and other CCDHB staff involved in the planning and coordination of the Blessing of the Mauri stones event; (c) Noted and thanked the Kapiti City Council for the use of their chambers for the Health System Committee and Finance Risk Advisory Committee meetings in October. The verbal report was received.

1.9 CEO’S REPORT The paper was taken as read. The Board: (a) Noted the Clinical council recommendations from their review of the 2018 Capital & Coast District Health Board Workplan; (b) Noted the positive results from the effectiveness and impact of TAVI and the continuation by the Clinical Council to ensure a post-implementation review occurs to understand the impact of other significant pieces of change in clinical practice;

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(c) Noted the progress to date of the sale of the Taupo Holiday Homes; (d) Noted that the 2019-2025 Mental Health and Addictions strategy will be presented to the Disability Services Advisory Committee and the 3DHB Boards in December; (e) Noted the financial results for September are unfavourable due to increased costs of treatment disposables, unachieved efficiency targets for the month and bulk payment of prior year HVDHB disputed invoices (f) Noted the meeting and presentation from the Kapiti Health Advocacy Group (KHAG).

2 PRESENTATION

2.1 WELLINGTON HOSPITAL FOUNDATION Chair of the Wellington Hospital Foundation, Bill Day provided an update and summary of the activities undertaken by the Wellington Hospital Foundation during 2018. Accompanying Mr Day were his staff: ∑ Samantha Munro, Donor Relations Manager ∑ Trish Lee, Volunteer Manager ∑ Shona Brunton, Grants and Charity Partnerships Manager ∑ Clare Ennis, Communications and Events.

The Board: (a) Noted and thanked the Wellington Hospital Foundation and their many volunteers for the tremendous work they do and the incredible amount of funding that they have raised during the year.

2.2 MĀORI HEALTH PARTNERSHIP BOARD Chair of the Māori Partnership Board (MPB), Teresa Wall, accompanied by Peter Love, spoke of the revised Maori Partnership Board Memorandum of Understanding and highlighted the Board’s lack of progress against the targets as shown in the Trendly reporting.

Identified three main areas that the MPB would like to discuss with the Board: ∑ Equity ∑ Workforce ∑ Commissioning for equity. It was suggested that meetings with MPB on these issues could be organised outside of the Board either at Board workshops; with the Health System Committee; attendance of Board members at MPB meetings, or alternatively with separately organised meetings with Board members as time at Board meetings was limited. Further discussion will be held between the chairs.

3 FOR DECISION 3.1 HEALTH SYSTEM COMMITTEE REPORT The paper was taken as read.

The Board: (a) Agreed to the formation of eight Community Health Networks, noting that some flexibility will be required during the next phase of implementation planning;

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(b) Endorsed the focus on initiatives to improve service delivery models in Kāpiti with the intention of improving health outcomes and reducing the burden of travel for avoidable hospital care for the people of Kāpiti; (c) Endorsed the work of the Kāpiti Health Advisory Group and the need for collaboration between CCDHB and KHAG on developing Community Health networks and locality planning for Kāpiti; (d) Endorsed CCDHB, KHAG and community stakeholders collaborating on service development and Locality planning for the Kāpiti locality having regard for the five priority areas identified by KHAG above; (e) Endorsed the localities focus on South Porirua and the development of services to support the formation of the CHN within this locality. Noted the importance of community responsiveness and the Committee’s request that staff bring back to the Board a graphic showing how CHNs and localities relate to each other; (f) Writes to Government Ministers responsible for Housing asking they consider legislative amendments to regulate for safer home heating for all citizens; (g) Writes to the Minister of Health in support of investment opportunities for healthy housing assessment and advice services to whānau with children experiencing asthma and acute upper respiratory tract infection; (h) Discussed the issue of access to information on hours and qualifications level of the aged residential care and support workforce to the National DHB Chairs and Chief Executives meeting for discussion. Moved Fran Wilde Seconded Sue Kedgley CARRIED

Actions: 1. Management to draft a letter for the Chair’s signature to Government Ministers responsible for Housing asking that they consider legislative amendments to regulate for safer home heating for all citizens; 2. Management to draft a letter for the Chair’s signature to the Minister of Health in support of investment opportunities for healthy housing assessment and advice services to whanau with children experiencing asthma and acute upper respiratory tract infection.

Board meeting was adjourned at 2.40pm for a Board only meeting.

Board meeting was recommenced at 3.29pm.

The late paper was discussed:

3.2 CAPITAL & COAST DISTRICT HEALTH BOARD AND HUTT VALLEY DISTRICT HEALTH BOARD — SINGLE CE APPOINTMENT AND OPTIONS FOR GREATER BOARD COLLABORATION The paper was taken as read.

The Board: (a) Noted the material provided by EY following the combined Boards workshop held at HVDHB on 25 October comprising options on the Single CE Appointment process and options on Options for greater Board collaboration;

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(b) Approved a combined “Appointments Committee” comprising the members of the existing CCDHB and HVDHB Appointments and Remuneration Committees, being Andrew Blair (Chair CCDHB and HVDHB), Fran Wilde (CCDHB), Darrin Sykes (CCDHB, Wayne Guppy (HVDHB) and Yvette Grace (HVDHB), plus the lead representative of the appointed recruitment agency; (c) Noted the Chair has commenced the process to procure proposals from the 3 recruitment organisations recommended by EY, for consideration and approval by the Appointments Committee; (d) Approved the attached draft Position Description for the single CE, as amended following the combined Boards workshop on 25 October, and following subsequent input from Board members; (e) Noted the discussion held at the combined Boards workshop favouring the establishment of a Stakeholder Assessment panel to support the appointment process, and that recommendations will be made by the Appointments Committee to the CCDHB and HVDHB Boards for approval in relation to the selection and appointment process; (f) Requested that a joint boards workshop be held at CCDHB on 28 November to consider options for board and committee meetings in 2019 that may be adopted by each board, and requests a paper with options be prepared in advance; (g) Agreed to invite members of the HVDHB Board and management to attend as observers any meeting of CCDHB (in the expectation of a reciprocal invitations to CCDHB Board members and management to attend as observers HVDHB Board meetings) and agrees subject to addressing any matters of confidentiality that CCDHB Board papers are shared with HVDHB Board members, and HVDHB Board papers be available to CCDHB Board members; (h) Noted that the 2 acting CEs support the process to combine board papers and hold joint board meetings; (i) Agreed that the Chairs of the CCDHB and HVDHB Statutory Committees discuss how these Committees may align in 2019 in support of the proposed increase in collaboration between the two boards, and bring a combined recommendation back to each board for their December board meetings.

Moved Roger Blakeley Seconded Fran Wilde CARRIED

4 FOR DISCUSSION 4.1 HEALTH AND SAFETY REPORT The paper was taken as read.

The Board: (a) Noted the number of reported Health & Safety incidents has decreased slightly this month; (b) Noted that there were no reported Notifiable Events this month, continuing a 23 month trend; (c) Noted the number of incidents resulting in lost time injuries at the time of the report production was three; (d) Noted the current Health and Safety Risks in the Risk report.

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5 FOR INFORMATION 5.1 QUALITY AND SAFETY REPORT The paper was taken as read.

The Board: (a) Noted the progress with the implementation of the Clinical Governance Review; (b) Noted the quarterly results of the National Patient Experience Survey; (c) Noted the success of the Poster winner at the HQSC Scientific Symposium; (d) Noted the quarterly results of the HQSC quality and safety markers; (e) Noted the CCDHB quarterly results in the updated HQSC quality measures dashboard.

Action 3. Management to provide a paper and trend analysis on Hospital Acquired infections, use of antibiotics and infection control to the Health System Committee.

5.2 NEW CHILDREN’S HOSPITAL PROGRAMME STATUS REPORT The paper was taken as read.

The Board: Health & Safety Report (a) Noted that there has been no incidents since the last report. New Children’s Hospital Programme of Works (a) Noted that Ministers of Health and Finance have approved the business case for the design and build of the new Children’s Hospital. (b) Noted that the Concept design works for reconfiguration of the Oncology Department is continuing whilst the Oncology Department undertake a review of the Oncology Services. (c) Noted that the CCDHB teams completed reviews of the 50% Detailed Design documents that were issued to the CCDHB on the 17 September 2018 and discussed our comments with the architect but did not submit formal comments due to the incomplete status of the 50% design drop. (d) Noted that the Māori Partnership Board identified a location for laying of the Mauri stones. The ceremony took place prior to the Board meeting. (e) Noted the event to mark the commencement of the new Children’s Hospital works on the site, involved a wide range of stakeholders such as; CCDHB staff, the Crown, CCDHB Board, the Benefactor and his team, Consumer Groups, CCDHB Partnerships, and others.

5.3 SUSTAINABILITY ACTIVITIES AT CCDHB The paper was taken as read.

The Board: (a) Noted the results from sustainability activities and the progress with projects underway; (b) Noted and commended the results.

5.4 BOARD GOVERNANCE MANUAL — REVIEW

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The paper was taken as read.

The Board: (a) Noted that the 2017 version of the Board Governance Manual is largely up to date; (b) Noted that the references to the previous Hospital Advisory Committee (HAC) and Community and Public Health Advisory Committee (CPHAC) and the Terms of Reference of those committees are out of date given the establishment of the Health System Committee; (c) Noted that the Terms of Reference of the Finance Audit and Risk Committee (FRAC) and the Memorandum of Understanding with the Maori Partnership Board are being reviewed and may change; (d) Agreed that the Board Governance Manual should be amended (and resubmitted to the Board for approval) to take into account the Health System Committee arrangements; (e) Noted that the Governance Manual be reviewed once the Memorandum of Understanding with the Māori Partnership Board has been agreed to and the FRAC terms of reference reviewed. Moved: Eileen Brown Seconded: Roger Blakeley CARRIED

5.5 CLINICAL GOVERNANCE REVIEW UPDATE The paper was taken as read.

The Board: (a) Noted the progress on the implementation of the Clinical Governance recommendations; (b) Noted the development of a Clinical Governance Framework for the CCDHB Provider Directorates.

6 OTHER 6.1 GENERAL BUSINESS Discussion on joint workshop dates and workplan for 2019. Action: 4. Management to provide the Board with recommendations on joint workshop dates and workplan for 2019 and to include ‘equity’ action.

6.2 RESOLUTION TO EXCLUDE THE PUBLIC The Board NOTED and RESOLVED to: (a) Agreed that as provided by Clause 32(a), of Schedule 3 of the New Zealand Public Health and Disability Act 2000, the public are excluded from the meeting for the following reasons:

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CEO’s report prejudice or disadvantage commercial activities and/or FRAC Recommendations disadvantage negotiations Risk Report New Children’s Hospital Programme of Works Status Report Allied Laundry Workforce and Employment Relations Update Investment Plan Update

Moved: Andrew Blair Seconded: Roger Blakeley CARRIED

The meeting closed at 4.16pm.

7 DATE OF NEXT MEETING

Wednesday 12 December 2018, 1pm, Level 11 Board Room, Grace Neill Block, Wellington Regional Hospital.

CONFIRMED that these minutes constitute a true and correct record of the proceedings of the meeting

DATED this ...... day of...... 2018

Andrew Blair CCDHB BOARD CHAIR

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Meeting Type: BOARD PUBLIC

SCHEDULE OF ACTION POINTS – DECEMBER 2018 PUBLIC MEETING

Action Date of Agenda Topic Action Designated to How dealt Delivery date No meeting item with number P0075 6.1 General Business Management to provide the Board with recommendations ELT Paper December on joint workshop dates and workplan for 2019 and to include ‘equity’ action. P0074 5.1 Quality & Safety Management to provide a paper and trend analysis on Acting Exec Dir Paper December Report Hospital Acquired infections, use of antibiotics and QIPS February 2019 infection control to the Health System Committee. P0073 3.1 Health System Management to draft a letter for the Chair’s signature to Dir SIP Letter December Committee Report the Minister of Health in support of investment opportunities for healthy housing assessment and advice services to whanau with children experiencing asthma and acute upper respiratory tract infection. P0072 7 November 3.1 Health System Management to draft a letter for the Chair’s signature to Dir SIP Letter December 2018 Committee Report Government Ministers responsible for Housing asking that they consider legislative amendments to regulate for safer home heating for all citizens P0071 3.3 Health System HSC Committee to draft formal letter, to be signed by HSC Letter November Committee Chair, to the Mayor and Chief Executives of Housing New Committee Zealand and Ministry of Social Development to emphasise support for the Rolleston development model. P0068 12 5.1 3DHB ICT Report Management to organise a Board workshop before CEO Coordinate November September Christmas and to include strategic ICT technology and with ELT January 2019 2018 capital funding.

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Actions closed since 12 December 2018

Action Date of Agenda Topic Action Designated to How dealt Delivery date No meeting item with number P0070 1.7 Add quarterly reports on Sustainability progress into 2019 Board Add to 2019 November Board workplan Secretary Board workplan P0069 10 October 1.7 CCDHB Workplan Add 2019 Workplan with Board papers until end of this Board Add to Board November 2018 2018 calendar year Secretary papers

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Capital & Coast Health District Health Board Workplan 2018

Regular monthly items: (Public) Chair’s Report; CEO’s Report; Citizens Health Council Report; Clinical Council Report; CPHAC-HAC Report (from 16 May onwards); Children’s Hospital Report; Resolution to Exclude (Public Excluded): Chair’s Report; CEO’s Report; FRAC recommendations; Children’s Hospital Update; FRAC minutes.

Month January February March 16 May 13 June 11 July 8 August 12 September 10 October 7 November 12 December Location CCDHB CCDHB CCDHB CCDHB CCDHB CCDHB CCDHB CCDHB Ratonga Rua o Porirua CCDHB CCDHB Strategic Sub Sub Regional Maori Partnership Sub Regional Sub Regional Sub Regional Strategic Wellington Committees Disability Group Board Strategic Pacific Disability Group Pacific Health Advisory Hospital Health Advisory Group Foundation S WORKSHOP

N Sub Regional Wellington Hospital Group update O

I Strategic Pacific Foundation update T

A Health Advisory CCDM Māori T IOD presentation Group Partnership N

E Board S

Patient Stories E General Medicine To be arranged and Vision Impaired To be arranged Bob’s story Angela’s story Peter’s story To be arranged To be arranged R

P Department confirmed and confirmed and confirmed and confirmed Strategy and Prioritisation of Updated Board Even Better Health Annual Plan, Intellectual 2019 Board Draft Financials Annual Board Planning Annual Planning Initial Cases Schedule, Workplan Care Plan 17/20 Overview of Capital Disability Individual Schedule and Report Governance 2018/19 and Committee Pyxis Business Case Budgeting and Expenditure and Service Units (ISU) workplan Manual Memberships 2018 Funding Budget Plans Draft Annual Report Low Paid Workforce 2018/19 Taupo Holiday 2017/18 N

O Homes I

S Priorities and

I Central Regional Draft Annual Plan

C Investment

E Services Plan Security 2018/19

D Opportunities 2018/19 Management System Prioritisation and Replacement Investment Upgrade and Integration Annual Planning Draft Annual Plan NZHPL SOE Update for NOS Business Investment Investment Plan Overview 2018-2019 implementing the Case Plan Update Update Commented [RF[1]: Not available for November meeting. Even Better Health System Health Care Plan Final 2018/19 Plan Update Statement of Performance Expectations Feasibility Study – Health & Safety Risk Report Health & Safety Health & Safety Health & Safety Health & Safety Health & Safety Health & Safety development of a Report Report Report Report Report Report Report primary birthing N

O unit Quality Report Review of Clinical Quality Report Risk Report Risk Report Quality Report Risk Report I S

Regular Reporting S Governance

U Risk Report Risk Report Quarter 4 Risk Report Māori Health C S

I Quarter 3 Performance Report Strategy Update Commented [RF[2]: Transfer to March 2019 D Performance Report Bi-monthly Bi-monthly 3DHB Health System Health System Health System Bi-monthly People Health System Bi-monthly People & Health System Bi-monthly Hospital and MHAIDS update Committee Report Committee Committee & Capability Committee Capability Committee People & Health Services including quality Report Report Report Report Capability report 3DHB DSAC Report 3DHB DSAC Report Bi-monthly SIP Bi-monthly 3DHB DSAC NOS Business Health System update Mental Health and People & Report Case Health System Committee Bi-monthly People Addiction Inquiry Capability Committee Report Report & Capability Information Litigation and legal Capital Process TAS National Litigation and Financial Update 3DHB ICT Update Litigation and legal Environmental 3DHB ICT Update risk update Work legal risk update risk update Sustainability Facilities and Programme Insurance Renewal Birthing Update Update 3DHB ICT Update Maintenance 3DHB ICT Update 2018/19 Facilities and Update Environmental Infrastructure Update Sustainability Facilities and Update Infrastructure Economics of Electric Update Vehicles

Regional Alcohol, Addictions and Drugs,

V10

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BOARD SITE VISITS Regional Children’s To be arranged and Mental Health To be arranged To be arranged and 2/2A Coromandel To be arranged and To be arranged To be arranged 11.45am-12.30pm Dental Services confirmed and Addictions and confirmed confirmed Street, Newtown confirmed and confirmed and confirmed Service Centre

V10

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Capital & Coast Health District Health Board Workplan 2019

Regular CCDHB items: (Public) Chair’s Report; CEO’s Report; Clinical Council Report; HSC Recommendations; HSC Minutes; Children’s Hospital Report; Resolution to Exclude (Public Excluded): Chair’s Report; CEO’s Report; FRAC recommendations; FRAC minutes; Children’s Hospital Programme Status Update.

Month 31 January 28 February 27 March 1 May 30 May 26 June 31 July 29 August 25 September 30 October 28 November 18 December Joint Location TAS HVDHB CCDHB CCDHB CCDHB CCDHB CCDHB HVDHB CCDHB CCDHB CCDHB CCDHB Strategic Sub Sub Regional Māori Wellington Hospital Sub Regional Māori Sub Regional Wellington Sub Regional Committees Disability Group Partnership Foundation update Strategic Pacific Partnership Disability Group Hospital Strategic Pacific

S Joint Board Health Advisory Board Foundation Health Advisory N Group Group O I Māori Partnership T

A WORKSHOP Board T N E S Patient Stories E To be arranged and To be arranged To be arranged and To be arranged and To be arranged To be arranged To be arranged and To be arranged To be arranged To be arranged and To be arranged and R

P ICT confirmed and confirmed confirmed confirmed and confirmed and confirmed confirmed and confirmed and confirmed confirmed confirmed Strategy and Technology Insurance Even Better Health Draft Regional Insurance 2020 Joint Board Draft Financials Final Annual Allied Laundry AGM Planning Care Plan 17/20 Services Plan renewals Schedule and Annual Report Report 2018/19 and Report workplan Māori Health NZHPL Draft Annual Plan Board Governance N Long Term

O Strategy Accountability Final Draft Regional 2019/20 Manual I S

I Service Services Plan C

E Final Draft Annual 2019/20 TAS Annual Report

D Investment Plan 2019/20 and AGM Planning Final Annual Plan ∑ Facilities and Capital Budget 2019/20 ∑ Services Annual Planning 2019/20 Draft Prioritisation Investment Plan Progress update – ∑ Other Annual Plan and Investment Update Regional Services associated Even Better Overview Update for 18/19 issues Health Care Plan implementing Update Progress update – the Health Regional Services System Plan 18/19 Hospital Network Health & Safety Health & Safety Hospital Network Health & Safety Health & Safety Hospital Network Health & Safety Health & Safety Hospital Network Health & Safety Mental Planning Report Report Planning Report Report Planning Report Report Planning Report Health Quality & Safety Risk Report Risk Report Quality & Safety Risk Report Risk Report Quality & Safety Risk Report Risk Report Quality & Safety Risk Report Regular Reporting Services Report Report Report Report

N Quarter 2 O I Performance Quarter 3 Quarter 4 S S Report Performance Performance Report

U Capital

C Report S I Funding D 3DHB MHAIDS 3DHB MHAIDS 3DHB MHAIDS Strategic 3DHB MHAIDS update update update Workforce issues update

3DHB ICT Update 3DHB ICT Update 3DHB ICT Update 3DHB ICT Update

3DHB DSAC Report 3DHB DSAC Report 3DHB DSAC Report 3DHB DSAC Report

People & Capability People & Capability People & Capability People & Capability Report Report Report Report

Disability Report Disability Report Disability Report Disability Report

Information Population Health Litigation and Litigation and Population Health Litigation and Population Health Environmental (Regional Public legal risk update legal risk update (Regional Public legal risk update (Regional Public Sustainability Health Report) Health Report) Health Report) Update Environmental Environmental Environmental Facilities and Sustainability Sustainability Facilities and Sustainability Facilities and Infrastructure Update Update Infrastructure Update Infrastructure Update Update Update V4

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8 November 2018

Mark Mabbett Chief Executive Officer Allied Laundry Services Limited Hospital Gate 12, Ruahine Street PALMERSTON NORTH 4410 Email: [email protected]

Dear Mark

CONFIRMATION OF SHAREHOLDER REPRESENTATIVE FROM CAPITAL & COAST DISTRICT HEALTH BOARD TO THE ANNUAL GENERAL MEETING 27 NOVEMBER 2018

At the recent Capital & Coast District Health Board (CCDHB) meeting held on Wednesday 7 November 2018 it was agreed to nominate Ms Gina Lomax, Executive Director Operations of Clinical & Support Services, to attend your next Annual General Meeting as CCDHB’s shareholder representative on Tuesday 27 November 2018 at Allied Laundry Services Ltd, Palmerston North.

Yours sincerely

Andrew Blair Chair Capital & Coast District Health Board

Cc Ms Gina Lomax Executive Director Operations

Capital & Coast DHB | Private Bag 7902, Wellington South Wellington Hospital, Riddiford Street, Newtown, Wellington 6021 Phone: 04 385 5999 | Fax: 04 385 5856

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Our Year in Annual Review Review Year to June 2018

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Our vision That people in our communities who need palliative care have access to compassionate and quality care, when and where they need it.

Our approach Taking a whole person approach, we will provide and promote high quality specialist palliative care, grief support, education and care planning services. Working alongside our health partners, we aim to make a difference in the communities we serve.

Our values Respect Compassion Dignity Hospitality Stewardship

Front Cover: Serving strawberries and icecream at the annual Strawberry Festival are (left to right) Brian Dawson, Wellington City Councillor; Rt Honourable Jacinda Ardern, Prime Minister; Jennie Vowles, volunteer, and Naomi Haye, volunteer

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Mary Potter Hospice Board 1 July 2017 – 30 June 2018

Contents

Our vision Chair’s message 2 From the Chief Executive 3 Our Strategy 2017-2022 4 Our service: Patients are the stars at the centre of our care 5 Community Services are stronger 6 Porirua team stepped up to maintain services 6 Enhanced Hospice@Home service 6 Patients positive about extended service 6 Our Inpatient Services 7 From left seated: Sister Margaret Lancaster; Mark Cassidy, Chair; Andrea McCance, Deputy Chair Standing: Dr David Werry; Malcolm Bruce; Dr Grant Pidgeon; Stephanie Dyhrberg; Martin Lenart Psycho-social support increased 7 Bereavement Programmes 7 Day Units 8 Mary Potter Hospice Executive Team Pasifika Liaison 8 1 July 2017 – 30 June 2018 Māori Liaison 9 Patron: Apartments project 9 Education and research 10 Our people 11 Bev’s Matariki Star recalled a special holiday 12 Farewell to a star 13 Quality – it always matters to us 14 Our communities – our five-star supporters 15 Kerry Prendergast Kids Room is a hit among some star performers 18 Volunteers – our shining stars 19 Financial reporting 20 Hospice supporters 22 From left: Devon Diggle, Strategy Manager: Dr Astrid Adams, Director Contacts 23 of Palliative Care (starting in January 2019); Frances Robinson, Co-Director Support Services; Philippa Sellens, Director of Fundraising, Marketing and Communications; Brent Alderton, Chief Executive (from April 2018); Diana Pryde, Director Support Services; Donna Gray, Director of Clinical Services (from May 2018)

Absent: Teresa O'Toole, Acting Executive Lead Education, Quality & Research

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Chair’s message From the Chief Executive

In April this year hospices so that we can continue to support the Since the mihi whakatau on my first day as Chief we were pleased to wellbeing of people in our communities at their Executive in April, I have felt very welcome at welcome our new most vulnerable. Mary Potter Hospice. I have been very grateful Chief Executive for all the support I have received from people Without the support of our corporate and Brent Alderton. The within and outside the Hospice. And I have been community donors, individual supporters and Board has charged immensely impressed with the quality of all of volunteers the Hospice would not be able to Brent and his those who work at the Hospice – both paid and reach the patients and their families and whānau executive team with voluntary. My first few months in the role have it already does. The Board would like to implementing its been rewarding and extremely satisfying. acknowledge the invaluable contribution you strategy, Me aho make and confirm that we are looking at ways to A highlight has been going on visits with the mai ngā whetū, Our enhance and grow those relationships. community team. I am convinced that our Place in Palliative Care. The strategy addresses strategy for the future, which includes an I have been privileged to connect with many of our the pressing need to change the way we do It was with sadness that in May this year we Enhanced Hospice@Home service, is right for patients. Here I am with Jim from the Wellington day unit things if we are to survive to meet the future farewelled Brian Ensor, our Director of Palliative our patients and their whānau. During the visits I needs of our diverse communities. My thanks go Care, who served the Hospice so well over 14 have witnessed our incredible staff working with to Te Pou Tautoko for their guidance and in years. We wish him well in his new position at running. The key is to increase our revenue and families at a very stressful time in their lives. Each particular I acknowledge their naming of our Hospice Waikato. Our dedicated and committed we are planning ways to do this, including staff member plays such a valuable role in strategy, which means “Let the glowing stars staff are our most valuable asset and the Board is engaging with government very strongly, along supporting patients. light our way”. mindful of the change and disruption that they with Hospice NZ and other Hospices, to provide have had to deal with over the year. We would A key challenge for me is ensuring the financial better funding and support for palliative care We face a steep increase in the need for our like to thank you all for the professionalism and resources for the Hospice. As our costs rise, with across New Zealand. services, and the purpose of the strategy is to support that you have shown. increasing salaries, petrol costs and other things, position the Hospice so that it can continue to The 2017/18 year has been a challenging one for our proportion of government funding provide quality palliative care to everyone who I would like to thank my fellow Board members our retail team. The forced closure of the Porirua continues to drop. In the year covered by this needs it in Wellington, Porirua and Kapiti. This year for their enormous voluntary contribution over shop and warehouse affected our income for the report, government funding increased by only we had an 8% increase in patient numbers and we the year. Running a complex organisation like year. We opened a new shop in Porirua in August one percent and covered only 45% of our costs. know that the number of people needing our Mary Potter Hospice is not easy, and without the 2018 and our retail income is now heading back This is very concerning to the Board and unique service will continue to grow significantly. commitment and expertise of the Board it would on track. We also opened a new shop in Karori, Executive team. simply not be possible. There have been times much better located to the main retail area, and Last year we received an increase of about one when I have had to ask for urgent and important We realise that we cannot keep putting out our this has proved to be a good decision. I would percent in government funding while the costs of decisions to be made quickly and the Board has hand to the community for ever-increasing like to thank the retail staff and many volunteers providing our services increased by more than 7%. never complained nor shied away from its amounts to help us, despite their incredible for their efforts to ensure that our shops provide For the coming year, to maintain services, the important role. generosity and support. That is why we are a great service and great products to our Board has approved a deficit budget, meaning we building the apartment complex adjacent to the customers, and for their patience during a will be spending more money than we are earning. My thanks also to our Patron Kerry Prendergast Hospice building in Mein Street. The rental difficult year. This is an uncomfortable position for any Board, who has provided support and endorsement of income from the 39 apartments will help fund especially one that is passionate about providing a our work throughout the year. I look forward to I would like to thank the Board for their support our operations into the future. I would like to quality and much-needed service, free of charge. working with her again over the coming year. for me and the Executive team during the year. thank the amazing donors who have committed The construction of the apartment complex next They have been most supportive and allowed me substantial funds to make the apartments to the Hospice will help, but the income we will Throughout the year the Board has been very to get well settled. My thanks also to the possible, as their contribution will ensure that a see from it is still several years away. The Board is focused on the values of the Hospice in our Executive team for keeping the Hospice in good financial return to the Hospice is made therefore working closely with Brent and his team decision making and our contacts with the heart as they continued to manage during the more quickly. on implementing strategies to meet our short, Hospice team and stakeholders. These values of period before my arrival. Respect, Compassion, Dignity, Hospitality and medium and long term financial needs. Our daily shortfall is about $17,000 after our Stewardship provide our platform for decision Brent Alderton income from the government and we rely on Also, together with our colleagues at Hospice making and our vision for the future. Chief Executive shop income, bequests and generous donations New Zealand, we will be making our case for to see us through. We are looking at ways to turn urgent additional government funding for Mark Cassidy Chair around the current deficit budget that we are

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Our Strategy 2017-2022: Our service: Patients are the Me aho mai ngā whetū stars at the centre of our care – Let the glowing stars light our way At Mary Potter Hospice our focus is Volumes of services delivered always on the person, not their illness, Our patients are the glowing stars, and The strategy reflects moves that are already and our goal is to provide quality 1000 being made towards a comprehensive Patients in service 902 the purpose of the strategy is to ensure 900 services for the patients and families 837 community service, with after-hours visits, 816 that we can meet the needs of people more care available at home in the last days of who trust us with their care. 800

who need us in Wellington, Porirua and life, and day services providing support to 700 We care for people when their illness is Kapiti. This year we had an 8% increase patients and carers, and volunteers. incurable, and they need help to manage their 600 in patient numbers on last year. The strategy was named Me aho mai ngā whetū symptoms. We care for the whole person; their 500 – Let the glowing stars light our way – with physical as well as their emotional, spiritual and Launching the strategy in March, Board Chair advice from Te Pou Tautoko (Mary Potter social needs. We also support their family/ 400 Mark Cassidy said the Hospice was deeply Hospice’s Māori Advisory Group). whānau, carers and friends to make the most of 300 committed to meeting that need. “Many people their time together. would like more support at home from our very 200

capable teams of counsellors, social workers, Our staff work to affirm life, to help people 100 medical professionals and therapists,” he said. accept death and provide support for people in 0 “Our volunteers are dedicated and committed, their homes and in aged residential care and some would like to take on roles that facilities. Most of our patients stay in their own directly support patients in the patient’s homes. Sometimes, however, patients may own home.” benefit from a stay at our specialist Inpatient 2015/2016 2016/2017 2017/2018 Unit in Newtown. We work with patients, The overall goal of the strategy is that everyone families and other healthcare providers to Activity 2017/18 2016/17 2015/16 has access to compassionate, quality palliative develop an individual care plan to meet each care when and where they need it. This is care 1 patient’s needs. A partnership approach helps us Patients in service 902 837 816 that meets their needs; is integrated in to use the resources we have most efficiently. partnership with other health providers and Inpatient Unit admissions2 448 454 472 the community; is high quality and effective; The Hospice supports people from many adapts to changing needs and evidence; and cultures and we are always conscious in our Bereavement is affordable. planning and practice to be aware of the beliefs counselling contacts 1,849 1,665 1,599 and customs that are important to the person New referrals and their extended family. We practice aroha ki to service 849 842 816 te tangata – respect, empathy and regard for others. ¹ Source data – Monthly average patient report from We are committed to ensuring that the Hospice our patient database Palcare. The figures are can continue to meet the needs of the different from those reported in previous years Wellington, Porirua and Kapiti communities free which were from the Referrals report. of charge and for decades to come. ² The number of Inpatient Unit admissions is affected This year we saw an increase in patient numbers by the length of stay in the Hospice. to 902 – up from 837 in 2016/17.

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Community Services are stronger Porirua team stepped up in partnership with education providers. Medical students, student nurses and massage students Our community services have been to maintain services are offered placements in the IPU and strengthened as we move to providing more The Porirua and North Wellington Community community teams. care directly to patients where they are. Most Team had to move into temporary premises patients are cared for at home and in aged when an April storm caused major flooding and Psycho-social support increased residential care facilities. On any day we could exposed asbestos at the Prosser Street Hospice A pilot project carried out by Hospice Social be supporting, on average, 270 patients. Shop and warehouse, directly next door to the Worker Mary Hulme-Moir in 2017 demonstrated community base. The team made sure services Each of our three bases – in Wellington, Porirua that increased psycho-social support made it to patients and families were not disrupted while Louise Katene (right) with fellow and Kapiti – has a team of nurses, doctors, easier for patients and families to access early new office space was found. The Hospice has Enhanced Hospice@Home nurse Diane Evans occupational therapists, counsellors, social Advance Care Planning. This allows them to think meanwhile purchased a building in Porirua East workers, Māori and Pasifika Liaison staff, about and discuss personal preferences and future for its new community base. This will be She says she enjoys offering care to patients in administrators and volunteers. As well, a Day treatment choices. It also supports the refurbished this coming year to provide the team their homes, where most people prefer to be. Services team provides bereavement programmes, bereavement process following a death. Following with fit-for-purpose facilities, including a “Definitely there was a demand, which fell on legacy work and companion volunteers. the success of the pilot, the Hospice increased counselling room, outpatient clinic, education the already stretched District Nurses. But the District Nurses only went out to our patients social work capacity across the community and Alongside the community teams, the Aged facility and Day Unit as well as office space for who urgently needed someone,” Louise says. Inpatient Unit, recruiting a further three social Residential Care (ARC) partnership nurses and the multi-disciplinary team. “Now we can visit our patients until 10pm. We workers to support patients and families to deal social workers support patients who move to Arrangements were made to move the can settle patients leaving the Inpatient Unit or with the issues they face at the end of life. aged-care facilities. This team also provides community base into part of the new building hospital into home and make sure they have palliative care education with the Hospice’s Bereavement Programmes ahead of the sale being finalised. everything they need – and support the family. ARC partners. This provides a unique opportunity to shift some This year our bereavement work was reviewed by The community teams work closely with other Demand builds for Enhanced of our service into the community and increase our psycho-social team. We offer bereavement health professionals in a shared-care model. Our Hospice@Home service the great service already provided by the counselling to help people who are struggling to partners include general practice teams, district This year we increased our out-of-hours community team and our partners.” come to terms with a loss of someone they love. nurses, Wellington Free Ambulance, oncology support with nurses from the Inpatient Unit Collaboration across the Hospice’s three bases Louise packs a bag of food to take with her and, nurses, specialist nurses, local iwi health service now working in the community every day until ensured a more consistent process and at the start, had to set a timer to remember to Ora Toa and home support and social care 10pm. This model of care, called Enhanced bereavement support group meetings took place eat. She says sometimes she can spend long agencies. These partnerships are highly valued Hospice@Home (H@H), started in Wellington in across our region. A collaboration with the hours with a patient who needs her. She says the as they encourage an integrated response to the May as a pilot programme to offer specialist Cancer Society in Newtown led to the setting up H@H service provides continuity of care for the rising demands for palliative care in our region. palliative care to those patients at home who of a group to meet the unique needs of those patients and there has been positive feedback need more help to manage symptoms or have under 50 with children, who have lost a partner. from families. The working relationship with the other end-of-life needs. This is in addition to our Those attending a bereavement group in Kapiti District Nurses has been strengthened. 24-hour telephone advisory and support service. became movie-going friends with the Porirua group joining them. This is the perfect outcome Enhanced Hospice@Home was extended to Our Inpatient Services cover Porirua and North Wellington in June. where the Hospice has enabled members of the The Inpatient Unit (IPU) in the Hospice’s community to support each other. The Enhanced Hospice@Home team provided Newtown base supports community care with an additional 115 visits or phone calls to 41 short-term admissions for symptom The review also highlighted the opportunity to patients in the first six weeks of the pilot, to June management, end-of-life care and respite. The create different activities in the community. As a 30. We are surveying family members to identify IPU multi-disciplinary team includes nurses, result we are launching a series of workshops to the impact of H@H on them. health care assistants, doctors, social workers, provide practical help for carers and others who physiotherapists, occupational therapists, are grieving: Patients positive about spiritual carers, massage therapist, music • Home alone – managing money, cooking for extended service therapist, counsellors, administrator, hospitality one, calming the mind and socialising staff and volunteers. The team also works Louise Katene came to Mary Potter Hospice as a • Lining up your ducks – funeral and advance closely with our health partners, including new graduate three years ago and is one of six care planning registered nurses rostered to deliver the H@H Wellington Regional Hospital and the hospital’s extended service. Palliative Care Team as well as Hospice • Time out – fun and time off for carers Community Services. We support the Breathlessness is helped with a small handheld fan • Holiday season resilience – remembrance development of the palliative care workforce and creative activity for kids.

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Day Units This year, the Hospice had contact with 155 Māori Liaison to mark the closing of our building in Prosser Pasifika patients. Pasifika Liaison Tiumalu Street. Elizabeth recognised the team’s need During the past year patients received over 700 Tena ra koutou katoa. Ka mihi, ka mihi, ka mihi. Sialava’a has also been involved in Advance Care for a process to enable people to leave episodes of care in our Day Units in Newtown, Planning discussions with more than 80 people. Māori Liaison Elizabeth Munday has this year behind the spirit of challenge and loss and Porirua and Kapiti. The idea is that patients can focused on promoting liaison services among look forward with fresh energy and fresh join in meaningful and creative activities and Tiumalu works closely with the Hospice’s the Hospice community teams, which has eyes. Ngāti Toa Chair Taku Parai, Kaumatua share time with friends, while carers take a break. multi-disciplinary teams to support Pasifika significantly increased the number of referrals Kahuwaeroa Katene and Tau Huirama The Porirua Day Unit had a new Legacy Group, in patients, particularly where there might be from Māori. participated in proceedings. which patients were encouraged to create special reticence by patients and family to accept the items and gifts while reflecting on their lives. The services on offer because of family expectations The Māori Liaison had 267 patient contacts Elizabeth and Pasifika Liaison Tiumalu Sialava’a items created can be powerful coping tools. Our of care or a language barrier. during the year. have worked together to build relationships with Day Unit coordinators shared skills and insight several aged residential care facilities, including with colleagues from Taranaki Hospice and The Pasifikia Liaison has an important role in Elizabeth’s pakihiwi ki pakihiwi (shoulder-to- Kemp Home and Pōneke House in Mt Victoria, Arohanui Hospice in Palmerston North. This educating Hospice staff and volunteers, to raise shoulder) approach with colleagues to support and engaged with District Nursing on culturally regional catch-up occurred twice during the year. awareness about Pasifika people’s needs and whānau has provided the opportunity for informal safe practice. expectations for their care and their family. She cultural insight for our staff. She has continued to Pasifika Liaison also works with other health and social service meet with volunteers and new staff. Apartments project Talofa lava, Taloha ni, Kia Orana, Malo e lelei, Ni sa providers, Pasifika networks and churches to Elizabeth arranged several important events in The apartments to be built on the vacant piece of bula, Fakaalofa lahi atu, Halo Olaketa, la orana, share information about the palliative care association with the Hospice’s Māori Advisory Hospice land at our Newtown site will help bridge Kam na mauri, Kia Ora and warm Pacific greetings. services the Hospice provides to meet the Group, Te Pou Tautoko, and Ngāti Toa: some of the funding gap between our income end-of-life needs of Pasifika people. and our costs. While the apartments will make a More Pasifika people are seeking services at • The farewell to former Chief Executive Ria A Pasifika Advisory Group oversees the liaison positive cash contribution to the Hospice from Mary Potter Hospice since we introduced the Earp in October 2017 marked her 11 years service and connects the Hospice to external day 1, this contribution will grow as the debt is Pasifika Liaison role to strengthen links with the of service. Pasifika community. advisors working in Pasifika health. paid down and interest payments reduce. • A mihi whakatau for incoming new Chief Executive Brent Alderton in April 2018. During the year covered by this report, a large amount of preparatory work was undertaken to • Porirua Mayor Mike Tana joined the Day get the project well-established. The first phase Pasifika Liaison: A patient’s experience Unit patients in Porirua for afternoon tea In of the project will begin in late 2018, with the March 2018. renovation of existing Hospice-owned Tiumalu shares an experience help fill out the appropriate On reflection this was great • A Karakia whakamutunga (a time for kai, residential properties adjacent to the vacant where time was short for a Hospice paperwork. team work, working with kōrero and reflection) was held with the land, followed by the construction of the larger Samoan patient: another health profession and After we had been there for a Porirua community team, store and apartment complex. our Palliative Care This man had no medication few hours, the father took a warehouse staff and volunteers in May 2018 Coordinator, to help a sick in the house. He had stopped bad turn and our Palliative Care man and his family. eating and was in huge pain. Coordinator recognised that The hospital’s Pacific Health he was now in the dying Unit social worker and I were process. Together we able to talk to the family explained this to the family. about what was happening. The family told us we had We were able to speak to the helped them and had calmed patient in Samoan too, giving things for them too, and they him words of comfort. had been able to accept that At the mihi whakatau for the their father was dying. incoming Chief Executive are (left The Hospice Palliative Care to right seated) Elizabeth Munday, Coordinator looked after the We left the house feeling Māori Liaison; Sister Margaret patient and helped him with his relieved and thankful that we Lancaster, Board Member; Aunty Kahuwaero Katene, Te Pou pain, and she discussed his were able to help this man Tautoko; Denis Grennell, Te Pou medication with the family and and his family. He died that Tautoko. Standing are Tiumalu explained what was happening night, peacefully and Sialava'a, Pasifika Liaison; Vanessa Tiumalu Sialava’a has worked with to their father. I was also able to surrounded by his family. Eldridge, Day Service Manager; many Pasifika patients this year Brent Alderton, Chief Executive and Tau Huirama, Te Pou Tautoko

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Feedback from Hospice NZ Fundamentals Education and research During 2018, external auditors carried out an independent audit of the Hospice services. The • The discussion around symptom assessment and Mary Potter Hospice offers an extensive findings regarding education were: management was fascinating – learnt a lot. palliative care education programme to health professionals and the community, as well as "The focus on ongoing education and national • Palliative session has been very helpful as it has updated my ongoing education for staff and volunteers. The networking works well to support the knowledge and provided new approaches to family and goal is to develop a specialist workforce, organisation in delivering care based on the best residents who are in the process of bereavement. enhance the ability of our partners to provide available evidence. Mary Potter Hospice is well • Attending these sessions were very helpful for me. Before, I quality care and support the community in its served by experienced medical and nursing was afraid of facing situations like these but with the help of efforts to look after its own friends and family. palliative care specialists. Mary Potter Hospice is these sessions, I am more confident in handling palliative at the forefront of palliative initiatives in The Hospice was an active member of the care residents. supporting patients in aged care facilities and regional Living Well, Dying Well strategic group. advance care planning" – excerpt from 2018 • Given me lots to think about with giving support/care and Ongoing education in palliative care will be audit. dignity to the patients that come into my care. Thank you for required for all health professionals closely a great day. involved in the care of patients with end-of-life Education in aged residential care needs. One of our key areas of focus is education for Sheryn and Striker have become Our Professional Development Palliative Care staff in aged residential care facilities. Our regular visitors to the Inpatient Unit to share some TLC Education Programme provides specialist programme includes the Hospice NZ workshops, seminars and symposia to a growing Fundamentals of Palliative Care and syringe group of health professionals interested in driver training. During 2017/18, we have seen work at Mary Potter Hospice motivating, 83% end-of-life care. Most recently, education has more people attending as the result of increased Our people said their relationship with their manager was expanded into designing regional and national engagement with the sector. During the year we farewelled former Chief good to excellent, and 75% said they would partnerships to develop master classes and Executive Ria Earp after 11 years and welcomed Education activity: Hospice NZ workshops consider returning to the Hospice. seminars on specialist topics. new Chief Executive Brent Alderton in April. (number of attendees) New staff Hospice staff are encouraged to engage in 400 A new Chief Executive, new Executive Team Our orientation programme enables new postgraduate study and to present their research 300 members and some new senior roles are now in and case studies at conferences and seminars. place. We are delighted that Donna Gray is our employees to understand all aspects of Mary 200 This is supported by the organisation and with new Director of Clinical Services, having started Potter Hospice. All new staff meet Chief funding from workforce development funds and 100 at the Hospice as Inpatient Nurse Manager 10 Executive Brent Alderton and other key people corporate or philanthropic sources. 0 years ago. Our Director of Palliative Care, Dr in the organisation. We also hold a quarterly Hospice NZ Syringe driver Syringe driver Hospice NZ Care Brian Ensor left us in May. Dr Astrid Adams will Pathway to Belonging orientation day, where Fundamentals competency update Assistants training start as Director of Palliative Care in January new staff can get to know each other in an 2015 2016 2017 2019. New ways of working brought to the informal environment. Hospice by senior employees have added Wellness diversity and energy, and skills developed by The Wellness Action Group was convened in late staff acting in more senior roles have been 2017 to support a positive culture of workplace transferred to substantive roles. wellness. The group meets quarterly and has Mary Potter Hospice employed 156 people on taken on wellness promotional activities such as 30 June 2018 (92 full-time equivalent positions) Mindfulness May, supported by weekly compared with 130, or 97 full-time equivalent meditation sessions conducted by a staff positions in the previous year. Three new roles member, a walk to pat the animals at the SPCA were created during the year, a Scheduling and other activities including the Round the Bays Coordinator and two positions with run/walk and Go by Bike Day. responsibility for volunteers – a Community Workshops were held to give information on Volunteer Lead and Volunteer Coordinator. financial wellness, with topics such as what to Twenty-seven employees left the Hospice look for in a Kiwisaver programme and how to during the year – 15 participated in an exit prepare for retirement. interview. Of those, 83% said they found their

Staff from Mary Potter Hospice and other organisations at a Tikanga training day

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Bev’s Matariki Star recalled Matariki is a time to reflect, to learn from the Farewell to a Star He says more people are dying in aged past and to look ahead to new beginnings. It is a residential care and there has been an increasing a special holiday Dr Brian Ensor resigned in May after time of unity, coming together and paying flow of patients from hospice care to these This year, in the spirit of Matariki, everyone at 14 years as Director of Palliative Care at Mary tribute to our ancestors. The Matariki stars homes. “The elderly are more likely to die in Mary Potter Hospice was invited to create a Potter Hospice. Over that time, he was a key project reflected on the meaning of aged residential care than anywhere else.” And Matariki star as a commemorative activity. player in our team of health professionals Matariki. People could choose to keep or give he says that aged care homes generally do a delivering quality clinical care while meeting an their stars to someone special or hang them on good job. But it is a difficult area to negotiate for Patients, families and staff members were increased demand for services. encouraged to think about the places that our Whetū i te rangi (Stars in the Sky) hospices. “The difficulty is in prognosis; you connected them to the special people and collaborative art installation as part of our Brian says one of the unique strengths of Mary don’t want to transfer someone who only has a memories in their lives and to create a star with Matariki celebrations. Potter Hospice is its teamwork and the depth of week or two. It does matter that we get that maps of those places. Bev Knight’s star recalled its multidisciplinary team. “It’s been prepared to right as often as we can.” a European holiday she had enjoyed with put its money into other disciplines and has had Brian says Mary Potter Hospice has successfully her husband. to find the money to do that. Most hospices developed partnerships with primary care don’t have occupational therapy and providers to care for people in the community Bev, who was staying in the Inpatient Unit, physiotherapy.” featured the United Kingdom and Ireland on her and delivers education and training to make sure star, and one of the maps she chose was of He says Mary Potter is also fortunate in the people receive good end-of-life care whether Waterford in Ireland. Bev enjoyed talking about calibre of counsellors and social workers it has. they are at home or in an aged care facility. It her visit there and how she purchased a vase Social worker support is becoming one of the has built strong links with education providers made from the world-famous Waterford glass, greatest needs and for reasons that are complex. and recently established a Pasifika Liaison role to and had it shipped back to New Zealand. “It’s to do with poverty and social supports and improve access and understanding of Hospice the dispersement of families and the complexity care for Pasifika people. On her return home Bev was thrilled to see that of funding,” he says. her vase had arrived. However, she was Brian trained in general practice and moved into disappointed to see a ‘Made in Poland’ label on “The whole health area is increasingly complex hospice work in 1990 at Te Omanga Hospice in the base of the vase. Bev recalled that she was and changing. Hospices have to contend with Lower Hutt. He has also held the role of medical so upset by this that she and her husband this, and with the different businesses within the director at Hospice North Shore and worked as a communicated with Waterford Crystal for many Hospice, such as fundraising and marketing. The senior clinical lecturer at the University of Otago months until another vase was sent – this time challenge really is to keep the business-as-usual in Wellington. Brian is now Medical Director at one made in Waterford. going strongly underneath all of that.” By Hospice Waikato and retains his role as a Clinical business-as-usual he is referring to the delivery Advisor to Hospice New Zealand. of clinical care to patients.

Bev Knight took part in the Matariki commemorative activity at the Hospice Nearly as famous for his MCing as his incredible medical skills, Dr Brian was often in hot demand as a speaker

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Quality – it always matters to us Our communities At Mary Potter Hospice we are always Service improvements included: – our five-star supporters asking ourselves how we can do things • Introduction of mobile devices/iPads for the better to improve our quality of care. It community teams enables immediate access Record result for 2018 is very pleasing to have our efforts to electronic patient record and ‘real time’ Street Appeal patient information. The Hospice team also Our street appeal raised $100,795 this year. This recognised not just by patients and their have access to CCDHB/hospital records to was $16,500 up on last year and the most we families/whānau, but by external enable sound coordination of care have ever raised. We had tremendous support auditors too. • Introduction of Zoom video-conferencing from volunteers, the community and businesses. between clinical staff and patients in the We had 1,051 volunteer collectors out on the In the past year, independent auditors reviewed community street – 157 more than in 2017. the Hospice at a time of significant changes in our leadership team. They found the standards • Review of emergency and disaster plan and This is one of our largest fundraising campaigns were excellent. testing of telephone/communication tree of the year and we invested $25,742 in marketing across teams and promoting the appeal. However, we The auditors said that the Hospice has a culture of received nearly triple that with more than best practice and continuous quality improvement • Introduction of electronic patient assessment $74,000 worth of ‘in-kind’ services. With the with consumers at the centre of care. tools: ESAS and Karnofsky assessment tools support of our media suppliers we were able to • Introduction of Scheduler, a tool that We use consumer feedback to monitor quality, publicise the campaign on buses, billboards, in categorises patient needs/symptoms, has including interviews with patients and families libraries, on the radio, in the newspaper, on enabled improved coordination of the about their experiences, patient and family social media and on geo-targeted websites. community services team satisfaction surveys, comment cards, complaints Our corporate suppliers were also out on the and feedback and public engagement events. • Integration of Te Ara Whakapiri in the Inpatient streets with us. Tommy Baird from the Business Among the patient and family feedback were the Unit, a national end-of-life care framework Networking International (BNI) Kapiti Coast Great Tractor Trek drops in following comments: published in 2017 chapter brought his two children to collect with Phil Aish arrived in Wellington in February with • Ambulance management plans updated – to “Given me stability at a time when there was too him. Suzy O’Connell, from Capiche, was there. his Great Tractor Trek team on a mission to raise ensure all our health partners are up to date much change for me to cope with.” Capiche developed the creative for the funds for hospices in memory of his wife, Janice. with a patient's plan of care in the home “You made X feel at home. Nothing was too campaign for free. Sofia Paterson came from He travelled the length of New Zealand with a much trouble. You have displayed great patience • New dedicated nursing and social work roles NZME. Her organisation gave us substantial cavalcade of vintage tractors, jeeps and trucks, discounts on media. and raised a total of $33,809. Several donations along with skilfulness and cheerfulness, and I • Implementation of a staff wellness and were earmarked for particular hospices and the have been learning about patience from you too!” maturing workforce programme Every year we get incredible support from remaining funds were split evenly among all 34 “I didn’t feel like eating when I came in and now I individuals and businesses, whose contribution hospices – $917.23 for each. am – the food portions and care taken with food makes ensures we can keep our services free. presentation made me feel like eating again.” Here are some highlights: Runners compete for The auditors said the 2017 Patient Satisfaction Bernie and the Hospice Survey indicated that people wanted more Marie-Jo Portenski, daughter of Wellington information. Since then, patient information champion marathon runner Bernie Portenski, brochures have been reviewed and updated to ran the Rotorua Marathon in May in Bernie’s enhance patient understanding. memory and to raise money for Mary Potter Hospice. It was a plan devised in the Inpatient We published our annual Clinical Governance Unit, where Bernie spent the last weeks of her Report which provides an overview of the quality life. MJ and her family raised $3,895 through activities for 2017 and reviews trends in quality GiveaLittle. In December 2017 the Wellington and safety across the Hospice. It provides Scottish Athletics Club held its Scottish Night of evidence and accountability regarding the Miles at the Basin also in Bernie’s honour and quality of the Hospice’s performance. raised $1,145 for the Hospice.

Runnng in memory of Bernie Portenski

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Hospice Strawberry Festivals The Kapiti Coast Festival in November 2017 got the week-long Hospice Strawberry Festivals off to a great start, with 6,000 visitors and 94 stallholders helping to raise $54,000 for the Hospice. Along with huge amounts of Hospice Strawberry strawberries and ice cream, there was a Festival at Midland Park sausage sizzle, face painting, burgers and hot dogs, a cake stall, a bouncy castle, massage and plant sales. punnets of 3,900 strawberries In Wellington, mid-week, Prime Minister Jacinda Ardern and Finance Minister Grant two-litre tubs Robertson took their turn volunteering at a of ice cream strawberry booth at Midland Park. The third 250 event was held in Porirua the following weekend. The Hospice Strawberry Festivals litres of gelato raised a total of $97,000. 20 Amazing Kapiti volunteers receiving certificates of thanks Waikanae Lions Garden Trail bottles of Shott strawberry sauce The Waikanae Lions Garden Trail in November 60 raised $8,000 for Mary Potter Hospice. Overall, thoughtfulness of the staff and volunteers. “It the event raised $16,000, shared between the Connecting at Creekfest amazing was amazing, and I really appreciate all they did Hospice and the Zeal Youth Development volunteers The Mary Potter Hospice stall was a popular for both Rod and me.” Jennie has continued to Centre. Presentations were made by Steve 150 attraction at Porirua’s Creekfest in March, where volunteer and has decided to leave a bequest Tomlinson, Director of The Law Connection of we gave away free apples, Hospice balloons and to the Forever Foundation. The group of people Waikanae. His company was the main sponsor some colourful leis. Creekfest is an annual who have left a gift to the Hospice in their wills of the event. Each of the garden owners raised festival held in Cannons Creek to raise the $40,816 is called the Camellia Heritage Club. received a certificate of thanks. awareness about the health and wellbeing services available. We were fortunate to have Celebrating Christmas some Hospice advertising on the big screen. Our Wellingtonians again showed their support for wheel of fortune was a magnet and many the Hospice at Christmas. The Farmers Tree of people wanted photos with the Hospice team. Remembrance raised $58,883 for us. The national Others wanted to share their experiences about event is held in the busy weeks leading up to our services and we heard some heartfelt stories Christmas Eve and gives Farmers customers the of how Mary Potter Hospice had helped them opportunity to remember someone special to and their families. them, and to make a donation or buy a limited- Volunteer plans to make edition Christmas decoration in support of a lasting difference the work of their local hospice. The Christmas generosity continued with Kapiti Woodworkers For the past 30 years Jennie Vowles has used Guild again donating wood-turned bowls filled her energy and organisational skills to raise with sweets as Christmas presents for patients. money for Mary Potter Hospice and, in 2014, We also had our team of volunteers wrapping she won an award of appreciation from the Christmas gifts with beautiful paper donated by Hospice. Jennie and husband Rod started Pan Pacific Marketing and Office Max for a gold- raising funds for the Hospice in 1989 by coin donation. They were set up outside Unity organising a huge garage sale in Karori. Books on Willis Street and outside Whitcoulls However, Rod developed cancer in 2001 and on Lambton Quay. Volunteeers also sold needed the support of the Hospice. Jennie says Enjoying strawberry sundaes at the Kapiti Coast Festival, November 2017 our Christmas Raffle tickets and Christmas cards. she was struck by the kindness and

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Kids Room is a hit among Volunteers – Our shining stars some star performers Volunteers contributed more 60,000 them prefer to be at home. This programme will hours to the Hospice during the year. make that an even better experience. “This is about supporting people to live and to make Our eight stores raised nearly $2 million Their vital work continues to expand their lives as good as they can be,” Karen says. this year, a credit to our army of along with demand for more volunteers volunteers, and the donations of goods in the community. Her role is to match the right patient to the right volunteer and she starts with a visit to the patient from our very generous supporters. Companion Volunteer to find out what they want or need. She says patients have a parade of medical, nursing and Following an agreement with SKY TV, our shops Programme in Thorndon and Porirua are now drop-off support staff coming into their home and she is Companion volunteers are our newest arrivals. points for SKY decoders, remotes and cables. clear that a companion is a non-medical role. Nor Their job is to provide companionship to This additional revenue stream is now worth is the volunteer there to do jobs around the house. patients at home and support to their carers. We around $30,000 a year. started recruiting companion volunteers in early Karen says she is excited about establishing a Our logistics operation was restructured towards 2018 and at 30 June had eight volunteers new programme and appreciates the “100% the end of last year, which has boosted our pick- matched with patients. This is a non-medical support” the Hospice has for its volunteers. “In a up and delivery of goods. We now have trucks role that complements the Enhanced Hospice@ short time, I have become very passionate about on the road seven days a week, operating from Home service provided by our multi disciplinary this organisation.” Online trading targets teams. Companions can sit with patients while Newlands and providing work for four drivers. Learning from our volunteers This has initially resulted in a more than 20% lift collectable items carers take a break, keep isolated people Our volunteer survey has shifted in focus. in donations. Our Karori shop was relocated in Shoppers in the market for a grandfather clock company or support people to complete Instead of asking the volunteers for feedback on mid-April to more suitable premises, next to or a samurai-style sword are finding what they activities that are important to them. We expect the organisation, we are seeking their views on Karori Library and closer to the Karori mall, are looking for on the Mary Potter Hospice this programme to expand as more people their day-to-day experiences with their resulting in an increase in revenue for that store. ‘Commemorables’ page on TradeMe. prefer to receive palliative care services at home. supervisors and teams. This will help teams We were forced to stop trading at our Porirua Savvy volunteers at our eight hospice shops Hospice Community Volunteer Lead Karen identify their strengths and opportunities for shop after a flood in mid-April. The flood also keep a lookout for unusual, rare or popular items Roberts sees growing potential for volunteers to improvement. affected our TradeMe operation, but this was that might appeal to online shoppers and pass support patients in the community. quickly up and running from our Newlands site. them on to our online team. This year they have Karen started at Mary Potter in June 2018 and sold everything from a grandfather clock to Kids Room is a hit with families heads up the new Companion Volunteer Volunteer Stats pottery, vintage glass, and a Japanese katana Programme. She says at any given time the In June we opened a specialised Kids Room in sword. The grandfather clock, which dated from Hospice is supporting 270 patients and most of our Newlands shop, focusing on good quality around the mid-1700s, sold for $521. The sword children’s clothes, shoes, games, toys and baby sold for $178. Monique Byres says the online Number676 of accessories. team keeps up with the play to sell these higher volunteers value or collectable items. “There is no exact “It’s really a niche,” says Hospice Sales Manager science to it. It’s really what the market dictates. Monique Byres. "It’s like a shop within a shop. They get to know what the trends are.” There are a lot of mums with prams and young 60,132 ones and it’s quite a family area.” She says Number of New pop-up shops boost revenue volunteer donated cable spools have been painted bright In November our retail operation participated in hours green and bright yellow to liven up the space. the Mary Potter Hospice Strawberry Festival at She says some games and toys are in very good Midland Park for the first time, with a gazebo full condition and others arrive in boxes still with of items for sale. Revenue from this and retail Number154 of volunteers their price tags, which can make good gifts for sales at the Kapiti Coast Festival reached around recruited all the birthday parties. Monique says sales are $2,000. We also ran a Christmas Pop-up Shop in going well, not just in the Kids Room, but are Thorndon, for the first time, producing helping to increase revenue across the store. additional revenue for the Hospice.

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Financial reporting Where the money comes from… Where the money goes… Other ter Expenses Mary Potter Hospice finished the 2017/18 year Storm damage at the Porirua base nvestent ncoe Returns Volunteer Hours with an operating deficit of $576,000 before In April 2018, the rented Porirua shop, warehouse olunteer services allowing for a loss on revaluation of investments and community base were damaged in a storm of $197,000, giving a total comprehensive deficit and the Hospice had to vacate it. This resulted in Shop for the year of $773,000. This compares with the Expenses Clinical/MDT sta additional costs and loss of stock - a total of overnent previous financial year’s operating deficit of $367,000 shown as Overheads. An insurance $6,000 before allowing for a gain on revaluation op recovery of $36,000 was also recognised as Other ncoe of investments of $56,000. revenue. More is likely to be recovered from our Fundraising Expenses Investment performance insurers but was not included in the financial statements as it was not certain. The loss of the During the year, the Hospice changed its Porirua shop also affected retail revenue. Property & investment manager. The portfolio of equities was unraisin Equipment sold and the funds transferred to unit trusts. At that Apartment development Proects time, a gain was realised and recognised as Other Work continues on the development of the Service Support Revenue From Operations. Overall in 2017/18, the rants residential apartment complex to be built behind Patient Care Education, Hospice recognised a realised and unrealised net the Newtown base. Generous donors are helping euests onations Research and Quality gain of $157,000 from its investment portfolio, with funding to ensure this project can go ahead. compared to $59,000 in 2016/17. The development will be undertaken by a Expenditure Financial performance YE 30/06/18 YE 30/06/17 subsidiary company Mary Potter Hospice Clinical and multi-disciplinary team staff costs ($000) ($000) Apartments Limited set up during the year. increased by 9% from the previous year. This Mary Potter Hospice Operations 12 months 12 months During the year, the Hospice reclaimed from Mary reflects new positions and extended part time For the year ended 30 June 2018 Restated Potter Hospice Apartments Limited all expenditure hours for the expansion of our community-based OPERATIONS it had incurred in relation to the apartments. As services teams for our Hospice@Home Revenue Mary Potter Hospice Apartments Limited then programme. Government 5,943 6,076 reclassified this expense as Work in Progress, the Overall direct patient care/clinical staff expenditure Other 628 314 auditors requested that the 2016/17 financial was 51% of total expenditure which is consistent Total Operational Income 6,571 6,390 statements be restated to show the prior year with last year. This includes the multi-disciplinary Expenditure expenditure of $212,000 on the apartment team, our expanding community services and the Wages and Salaries 7,510 7,105 development as Work in Progress. This improved Inpatient Unit that operates 24 hours a day, 365 the 2016/17 result. Overheads 1,850 1,455 days of the year. Administration 1,076 1,027 Income Audit Opinion Total Operational Expenditure 10,436 9,587 The Hospice received a 1% increase in our DHB Our audited Mary Potter Hospice Financial Operational Deficit to be met by Funds Raised (3,864) (3,197) contract funding for 2018 but has carried some Statements for 2017/18 include the Forever FUNDS RAISED funding forward to 2018/19 which is why the Foundation and Mary Potter Hospice Apartments Revenue financial statements show a drop in this revenue. Limited results as part of the Consolidated Mary Fundraising Income 3,501 3,314 The Hospice continues to use the additional Potter Hospice Group. The Forever Foundation is a Volunteer Services 1,215 866 Innovations funding to assist us with the process of separate capital endowment fund that continues Retail Income 1,968 2,054 extending our community based services, a key to provide an annual grant towards the Hospice Total Funds Raised 6,684 6,235 aspect to our long term financial plan. operating costs. Expenditure The Starlight Circle fundraising initiative begun in The auditors signed off the Financial Statements in Fundraising Expenses 1,010 1,026 2016 is now achieving good returns. October 2018, with an unqualified audit report. Volunteer Services 1,215 866 Fundraising income increased by 5% this year. We Retail Expenses 1,171 1,152 This summary of financial performance has been are extremely grateful for the generosity of Total Funds Raised Expenditure 3,396 3,044 extracted from the audited financial reports of the individuals who left us a bequest. We acknowledge Net Funds Raised Contribution 3,288 3,191 Mary Potter Hospice Foundation. Full reports are the ongoing committed support from donors and available upon request from: sponsors, businesses, groups and individuals, Net Surplus/(Deficit) for the year (576) (6) across all communities of Wellington. Thank you. Mary Potter Hospice PO Box 7442, Wellington 6242 Unrealised Gain/(Loss) on Asset Revaluation Reserve (197) 56 [email protected] Total Comprehensive Income/(Deficit) for the Year (773) (50)

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Hospice supporters Mary Potter Hospice relies heavily on the support of the PLATINUM community, as without it we couldn’t continue to provide Mary Potter Hospice Forever Foundation. our services free of charge. We are grateful to everyone who helps us, in whatever way GOLD they can, to achieve the highest quality service possible for Chapman Tripp, The Farmers’ Trading people in our care throughout the Wellington region. Company Ltd - Farmers Stores Wellington Every donation we receive is precious, and is used wisely Region (Kilbirnie, Lambton Quay, and respectfully to provide the very best patient care. Paraparaumu and Porirua), The Lion Our namesake Thank you to everyone - individuals, families, friends, The Venerable Mary Potter groups, workplaces and so many more – who donated in Foundation. the financial year 1 July 2017 – 30 June 2018. SILVER We are pleased to acknowledge the generous support of Mary Potter Hospice Mary Potter Hospice Retail Support Centre Jack Jeffs Charitable Trust, NZ the following businesses, trusts and organisations. Community Trust, NZ Lottery Grants Inpatient and Community General enquiries and to arrange pick up of donated goods: Board, Pub Charity, Ray Watts Charitable Services – Wellington P: 04 237 2300 Trust, TG Macarthy Trust, Trust House 48–52 Mein Street E: [email protected] PO Box 7442 Foundation (Porirua Community Trust). 9am–4pm Mon–Fri Newtown BRONZE Wellington 6242 Capiche Design, Four Winds Foundation Mary Potter Hospice shops P: 04 801 0006 Ltd, Go Media, Kapiti Coast District Council, Miramar Tawa F: 04 389 5035 NZME, Pelorus Trust, QMS Media NZ, 136 Park Road 197 Main Road E: [email protected] Resene Paints, St Joans Charitable Trust, P: 04 380 7057 P: 04 232 7798 The Church of Jesus Christ of Latter-day Community Hospice – Porirua 10am–4pm Mon-Sat 10am–4pm Mon–Fri Farmers stores from around Wellington region are great Saints - Pacific Area, The Newton Family supporters of Mary Potter Hospice. Each year the Tree of 10 Awatea Street 10am–2pm Sat Kilbirnie Remembrance gives Farmers’ customers an opportunity to Trust, Thomas Cavell Connelly Nichol Ranui Heights donate and to remember loved ones. Charitable Trust, WN Pharazyn Trust. PO Box 50089 Shop 5 Kilbirnie Plaza Porirua Porirua 5240 (behind Baycourt Pharmacy) 21 Kenepuru Drive P: 04 387 1705 P: 04 237 2313 OTHER CONTRIBUTORS: TRUSTS, BUSINESSES AND ORGANISATIONS P: 04 237 7563 APN Outdoor NZ, Bernie’s Pink Gloves, Betty Baynton Stoker Trust, BNI Better Business, BNI Business F: 04 237 0864 10am–4pm Mon–Fri 9am–4pm Mon-Sat Abundance, BNI Capital City, BNI Gold Coast, BNI North City, BNI Positively Wellington, BNI The Brunch E: [email protected] 10am–2pm Sat Bunch, Bowen Trust Board, Brian Whiteacre Trust, Carrello del Gelato, Coffee Supreme, Countdown Waikanae; Paraparaumu Craigs Investment Partners, Crestmont Group, Cyprus Community of Wellington & NZ Inc, Darroch Ltd, Community Hospice – Kapiti Karori Cnr Main Highway and Delaware North - Wellington Airport, Dilmah New Zealand Ltd, Dorothy L Newman Charitable Trust, DW 36 Warrimoo Street 255 Karori Road Kapiti Road (next to Mobil) Dentice Electrical Contractors, ELE Group, Elite Services, Ellen Ngaire Cooper Trust, EM Pharazyn Charitable Trust, Entertainment Publications Ltd, Fabric-a-Brac, FH Muter Charitable Trust, Flight Coffee, Forsyth Barr Ltd, PO Box 460 P: 04 476 0381 P: 04 298 5700 Freedom Link Trust, Goodman Contractors Ltd, Greek Orthodox Community of Wellington, Harcourts Paraparaumu 5254 10am–4pm Mon-Sat 10am–4pm Mon–Fri Foundation, Infinity Foundation Ltd, Irene Baker Foy Charitable Trust, Island Bay Services Club, Joan Moya P: 04 296 1283 10am–2pm Sat Campbell Charitable Trust, Johnsonville Senior Citizens Club, Kapiti Flooring Xtra, Khandallah Medical Centre, Thorndon KPMG, Lions Club of Waikanae, Lions Club of Wellington North, Luvly; Mafutaga Faifeau Samoa Ueligitone F: 04 298 3970 Newlands Tutotonu - Fellowship of Samoan Ministers in Wellington, MediaWorks Radio Wellington, MetService, Mills E: [email protected] 95 Thorndon Quay Albert, Mojo Coffee, Mokoia Masonic Perpetual Trust, Moore Wilson & Co Ltd, participating New World P: 04 472 5819 Newlands Shopping Centre Supermarkets, Ngaio Natural Health Centre, NZ Lawyers Directory/Mediacell Publishers, One Foundation, oOh! Donations Administration (opposite Newlands New World) Media, Pacific Islanders’ Presbyterian Church Newtown, Paddy Brow Charitable Trust, Pak’nSave Kilbirnie, 10am–4pm Mon–Fri P: 04 477 4115 Pak’nSave Porirua, Parkwood Seekers, Parliamentary Counsel Office, Phantom Billstickers, Raumati Beach Freepost 3053 10am–2pm Sat School, Richard & Doreen Evans Charitable Trust, Ricoh NZ Ltd, Robert & Kathleen Lyon Charitable Trust, Ron PO Box 7442 10am–4pm Mon-Sat Long Charitable Trust, Rooster Racing International Inc, Rotary Club of Johnsonville, Siaosi Photography, Newtown Simply Security, Society of Mary (Marist) Trust Board, Splash North Island Spearfishing Championships, Stuff, Wellington 6242 T&R Interior Systems Ltd, The Antique Fair Charitable Trust, The Bill Brown Trust, The Dominion Post, The Mary Stephen Vella Trust, The Nick Lingard Foundation, The Trusts Community Foundation, Trade Me Ltd, Village P: 0800 MARYPOTTER 627 976 Accommodation Group, Walter & Rana Norwood Charitable Trust, Waterfront Raumati Beach, Web2Print; F: 04 389 8706 Wellington Children's Foundation Inc, Wellington City Council, Wellington International Airport Ltd, Wellington Masonic Club Inc, Wellington Scottish Athletics Club Inc, Westpac Stadium. E: [email protected]

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www.marypotter.org.nz

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Notice of TAS Annual General Meeting :00pm, Wednesday 2.30pm, Wednesday 5 December, 2018 Front+Centre, 69 Tory Street, Wellington

2.30:00pm, Wednesday 5 December, 2018

Notice is hereby given that the Annual General Meeting of Shareholders of Central Region's Technical Advisory Services Ltd (TAS) is to be held on 5 December at 2.30pm.

Agenda 1. Apologies 2. Minutes - To review and accept the minutes of the AGM held 6 December 2017 3. Directors’ report on the year ended 30 June 2018 - To receive the report 4. Financial Statements and Report - To receive, consider and adopt the Company’s financial statements for the year ended 30 June 2018, along with the Independent Auditor’s Report 5. Auditors - To record the continuance of KPMG as the Company’s auditors for the 2018/19 financial year 6. General - Any other business

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14 November 2018

Andrew Blair Chair Capital and Coast and Hutt Valley District Health Boards c/o Capital and Coast District Health Board Private Bag 7902 WELLINGTON

Dear Andrew

I am writing to let you know that the time for the TAS AGM being held on 5 December 2018, has changed from 4 pm to 2.30pm. An updated Notice of Meeting is attached.

On behalf of the TAS Board, I would like to take this opportunity to extend an invitation to you (or your representative) to join us, along with Graham Smith, TAS’s Chief Executive, for dinner that evening from 6:30pm onwards. Can your EA please let Jane Doherty at TAS know if you are able to join us. ([email protected])

I look forward to hearing from you.

Kind regards

Murray Bain Chair – TAS

69 Tory Street, Wellington 6011, PO Box 23 075, Wellington 6140, New Zealand Phone: +64 4 801 2430, Fax: +64 4 801 6230 Email: [email protected] Website: www.tas.health.nz

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Michelle Kirkwood [CCDHB]

Subject: FW: OUR ACTIONS TO REDUCE SUGAR

From: Richard Schlasberg Date: 29 November 2018 at 12:55:21 PM NZDT To: "[email protected]" Subject: OUR ACTIONS TO REDUCE SUGAR

As we head into the festive season, I would like to take the opportunity to introduce myself. I have recently taken over as the head of Coca‐Cola Oceania based in Auckland. Originally from Sweden, I have relocated here from the Netherlands and have been working in the Coca‐Cola system for over 15 years.

I would love to hear your views on how you think Coca‐Cola New Zealand is doing as we continue to evolve our business in response to New Zealanders’ health and nutrition needs. We have made some significant changes within our product portfolio, packaging and marketing communication to help Kiwis consume less sugar from our beverages. This animated infographic outlines some of our activities and results to date.

Last year we set ourselves a target to reduce sugar across our entire portfolio by 10% by 2020. We are progressing well towards this goal and are now assessing targets beyond 2020. We are achieving sugar reductions through the reformulation of recipes and producing new low and no sugar drinks, plus harnessing our marketing capabilities to encourage more people to increasingly choose our low and no sugar options and select smaller packs.

Below is an outline of our sugar reduction actions and results. I welcome your views, ideas and suggestions on our progress and work to be done. I warmly welcome an opportunity to work together. If at any time you feel that we are not delivering on our promises, I urge you to contact either me directly at rschlasberg@coca‐cola.com or Karen Thompson at karethompson@coca‐cola.com

Best regards Richard

OUR ACTIONS & RESULTS

Coca‐Cola Following 2017’s launch of Coca‐Cola No Sugar and this year’s world‐first launch of Coca‐Cola Stevia No Sugar, four of our five Coca‐Cola brand variants in New Zealand have no sugar. This year the majority of our marketing investment in our Coca‐Cola brand was on our no sugar Coca‐Cola variants and this will continue. Today almost 50% of our Coca‐Cola brand sales are no sugar variants ‐ and this is growing.

Portfolio We may be The Coca‐Cola Company but we realise everyone doesn’t drink soft drinks. So we’re making many other drinks like organic New Zealand juice, iced tea, coconut water and flavoured milks and waters available to more people in more places. In fact, New Zealand has one of the most diverse portfolios in the Coca‐Cola world ‐ made up of more than 120 products across 21 brands.

Further, all our top selling brands offer a no sugar alternative and almost two thirds of our growth across our entire New Zealand portfolio is in low and no sugar drinks.

Water Water continues to be the most consumed drink in New Zealand. Bottled water is part of this and we are actively working on our bottled water portfolio, ensuring we have the right products in the right places to meet this demand. Our bottled water sales have increased 30% in the past two years as a result.

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Additionally, as an industry, we’ve taken the significant step in the past year to only directly sell bottled water into primary and intermediate schools.

Small pack sizes We’re providing smaller, more convenient packages, making it easier to control sugar consumption from our drinks. Kiwis are loving these smaller pack sizes with our 250mL can sales growing over 40% in the past two years.

Accessible information Consumers around the world have told us they want straight‐forward accessible information about what they are drinking, without the guesswork. In New Zealand, we voluntarily apply the government’s Health Star Rating system on the front of our packs – with 87% now displaying the integrated energy icon. Plus we’re highlighting serves‐per‐pack on the labels of our multi‐serve bottles, for example our 1.25L displays five serves.

But we’re not being complacent. We’re actively participating in the Food Industry Taskforce and the Health Star Rating five‐year review with a view to making further improvements to front of pack nutritional information.

Responsible marketing In addition to marketing and promoting our low and no sugar options, we are absolutely committed to ensuring our communications are responsible and appropriate for every space and place. We diligently adhere to our long standing global policy not to target our advertising to children and support commercial‐free classrooms.

In New Zealand we continue to voluntarily adopt the Advertising Standards Authority’s Codes, including the new Children’s and Young Persons’ Code, ensuring those under 14 are not directly targeted by our advertising or promotions. We also exercise a duty of care for advertisements directly at young people 15‐17 years. As we work to adhere to these policies, we ask for your help: if you see any examples of advertisements that may be in violation of our policies, please let us know so that we can take action to make it right.

Transparency At Coca‐Cola we want to be as open and transparent as possible in our actions to help reduce the sugar that Kiwis consume from our beverages so others can have input on the steps we take in this journey. For example, earlier this year we reported to the Minister of Health on our progress against the commitments Coca‐Cola Zealand made in 2017 to support the Government’s Healthy Kids Industry Pledge. We will continue to monitor and report on our progress in this and other areas.

Classified ‐ Confidential

CONFIDENTIALITY NOTICE NOTICE: This message is intended for the use of the individual or entity to which it is addressed and may contain information that is confidential, privileged and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, you are hereby notified that any printing, copying, dissemination, distribution, disclosure or forwarding of this communication is strictly prohibited. If you have received this communication in error, please contact the sender immediately and delete it from your system. Thank You.

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BOARD PROCEDURAL

Date: 28 November 2018

Author Julie Patterson, Interim Chief Executive

Subject CHIEF EXECUTIVE’S REPORT DECEMBER 2018

RECOMMENDATIONS It is recommended that the Board: (a) Notes the receipt of the six monthly Health and Disability Complaint Report received from the Health and Disability Commission and the learnings from that report; (b) Notes the current review of the Well Child Tamariki Ora Review and the development of New Zealand’s first Child Wellbeing Strategy; (c) Notes the engagement of the Pacific Directorate with national programmes; (d) Notes the update of the Care Capacity Demand Management programme; (e) Notes the financial reporting improvement this month due to favourable variance in revenue; (f) Notes the response from our backup generators to the latest power disruption to services; (g) Notes the implementation of the lower GP costs to our region; (h) Notes the approval by the Minister to dispose of the Waitangirua property.

APPENDICES 1. Letter from the Ministry of Health — Well Child Tamariki Ora Review; 2. Financial Summary for October 2018; 3. Letter from Minister of Health — Disposal of Waitangirua property.

1 PATIENT QUALITY AND SAFETY

1.1 Health and Disability Complaint Report — January-July 2018 A 6 monthly report spanning from 1 January to 30 June 2018 was received from the Health and Disability Commission (HDC) outlining the number and type of complaints that were received by Capital & Coast District Health Board (CCDHB).

CCDHB received 45 complaints during this period where only 28 required full responses from the service back to the HDC. In this reporting period Mental Health Addictions and Intellectual Disability Services (MHAIDS) received multiple complaints from 2 complainants which were counted individually.

Standard of clinical care was the largest primary complaint issue. Broken further down into care categories of unexpected treatment outcome and missed/incorrect/delayed diagnosis. These results are similar to national trends.

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A key learning taken from this report is about the implementation of electronic systems and the need to involve clinicians in this process, and to continue to maintain vigilance over the efficacy of these systems with ongoing reporting and monitoring.

1.2 Well Child Tamariki Ora Review Making New Zealand the best place in the world to be a child is a top Government priority. New Zealand’s first Child Wellbeing Strategy is being developed with both the Ministry of Health and District Health Boards contributing to the development and delivery of this strategy.

The Ministry of Health intends to co-lead the Well Child Tamariki Ora Review with DHB partners and with Maori to strengthen Tamariki Ora Services (Appendix 1). The Review will include input from Well Child Tamariki Ora providers and other agencies, including the Ministry of Education and Oranga Tamariki.

The following aspects of the Well Child Tamariki Ora programme will be assessed and redesigned: 1. Well Child Tamariki Ora Schedule; 2. Equity; 3. Funding and contracting; 4. Data and insights.

The review is expected to take 12 months. It is anticipated that the new equitable funding and service delivery model of the Well Child Tamariki Ora programme will be in place from 1 July 2020.

2. PACIFIC HEALTH

2.1 Ministry of Health Pacific Focus Groups The CCDHB Pacific Directorate is supporting the Ministry of Health Pacific team to facilitate small focus groups (talanoa sessions) across the country. These talanoa are broader than the Pacific Health and Disability Action Plan, and are intended to inform a series of evidence publications which will support the Ministry, health sector and other government agencies to: ∑ better understand how to achieve equitable health outcomes for Pacific people through their views and perspectives; ∑ look at what services and systems need improvement; ∑ identify what works for Pacific peoples; ∑ better understand how to achieve equitable health outcomes for Pacific people through their views and perspectives; ∑ look at what services and systems need improvement; ∑ identify what works for Pacific peoples.

2.2 National Bowel Screening Programme The Pacific Directorate are fully engaged in the NBSP. There are 1870 Pacific people that are eligible for Bowel Screening. To date the Directorate has been engaged in the National Equity Forum held this year in Wellington. We are working closely with our Cancer NBSP team to ensure our activities are aligned in terms of a strong equity approach. We are engaged in the development of the NBSP steering group. One of the tasks of the steering group will be to develop an equity plan. The National Screening Unit produced an equity checklist for NBSP based on the collaboration between key health professionals in the MOH and Maori and Pacific public health specialists to guide the development of the equity plans.

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3. CARE CAPACITY DEMAND MANAGEMENT

The Care Capacity Demand Management (CCDM) programme continues to progress with great momentum.

CCDHB has received excellent feedback from the CCDM national governance group during a site visit in October. The group was very impressed with our partnership model, our progress and the level of understanding and commitment from the nursing staff and delegates through to our executive leadership team and CCDM Council members.

We have several local data councils implemented across inpatient areas. These councils are part of the governance of the CCDM programme and are essentially ward quality improvement programmes within the ward utilising the core data set.

A full core data set scorecard is being developed and will be available mid-February which will enable transparency and visibility across all areas from the ward to the CCDM Council. The core data set “tells the story” of the wards over periods of time encompassing all of the national core data set measures.

FTE calculations have commenced in the surgical, women’s and children’s directorates and will continue in the medicine, cancer and community and mental health directorates through to June 2019.

A recent appointment of a TrendCare coordinator with a mental health focus will assist in the implementation of the acuity tool into a further eight mental health units in Porirua and Kenepuru throughout 2019. This is being met with positivity from the mental health leaders and staff. Implementation will occur in full partnership with union organisers and delegates.

Three CCDM project support coordinators have been appointed as a result of the additional Ministry of Health funding to support the programme. The roles will focus on three areas of the programme to ensure timely and efficient implementation.

The CCDM programme manager has been invited to the National Maternity Advisory Group for CCDM and TrendCare as a subject matter expert to assist with the implementation of both programmes nationally.

4. COMMUNICATIONS

4.1 Media Enquiries and Releases

There were 46 media enquiries in Four press releases were issued. Coverage November. Key matters for media enquiries includes: were: ∑ CCDHB take up electric vehicle trial ∑ Midwives’ industrial action ∑ Wellington children’s hospital gets $45 ∑ Addictions and synthetic drugs million funding boost from government ∑ Mental health

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4.2 OIA Requests

4.3 Website Traffic in November

CCDHB MHAIDS

4.4 Social Media

Most popular post: Reached: Number who like Congratulations to 430 reactions CCDHB Facebook Paula Dellabarca on 51 comments page: being named neonatal 9,300 20 shares nurse of the year! people 3234

4.5 All Staff Communications (in addition to weekly emails from the Chief Executive) ∑ Children’s Hospital mauri stone laying ceremony ∑ MERAS midwives industrial action ∑ Sudden passing of Dr Peter Hicks ∑ All staff forums across CCDHB and MHAIDS - Ma Tini, Ma Mano, Ka Rapa Te Whai.

5. FINANCIAL UPDATE

5.1 Financial Overview The DHB has a board approved deficit target of ($15.9m) for the 2018/19 financial year.

The result for October was $2.52m favourable to budget, due to $4.9m favourable variance in revenue, slightly offset by increased expenditure (Appendix 2).

The additional revenue was largely due to recognition of $2.78m of 2017/18 wash-up revenue, additional revenue for NZNO MECA $625k & MH pay equity $600k settlements, improvement in

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PUBLIC level of unachieved YTD IDF revenue target and other revenues. All current year additional revenues came with additional costs.

Activity movement compared to last year

Variance Months % YTD YTD Variances YTD % As reported in MoH MIF report Oct-18 Oct-17 s Month change 18/19 17/18 YTD change Discharges 5,450 5,450 - 0.0% 21,855 21,673 (182) -0.8% Caseweights (Excl MH) 5,864 6,065 200 3.3% 23,216 24,051 834 3.5% Bed Days (calculated from Hours) 13,573 13,408 (165) -1.2% 53,013 52,785 (228) -0.4% Length of Stay (excluding day patients) 4.11 3.99 (0.12) -3.0% 3.98 3.88 (0.10) -2.5% ED Presentations 5,227 5,643 416 7.4% 21,514 22,140 626 2.8% ED Admissions 1,955 2,017 62 3.1% 7,901 7,731 (170) -2.2% Theatre Throughput (Hospital) 1,276 1,280 4 0.3% 4,958 5,131 173 3.4%

Financial Results October 2018 Year to Date

Net Result in $000s Actual Budget Variance Actual Budget Variance Surplus/(Deficit) 436 2,959 2,523 7,183 6,558 (625)

6. POWER DISRUPTION

On Thursday 22 November Wellington Electricity network supply was lost at approx. 12:35pm. The cause was external to the CCDHB environment as evidenced by a loss of local power in Newtown.

CCDHB were running Generator # 4 at the time as part of our cyclical testing requirements. All protection devices operated to protect Generator 4 from overload and separate us from any external connections. Two standby generators then started and normal emergency power restoration occurred.

Normal electricity supply returned and we resynchronised at 12:50pm operating off the Wellington Electricity as normal.

We are waiting for a report from Wellington Electricity on the cause.

7. IMPLEMENTATION OF LOWER COST OF GP VISITS

The Government committed to reduce costs for GP services. After negotiation between primary care and the Ministry of Health the change to the costs of services for those who have Community Services Cards was announced. In CCDHB this means that 22,000 people who have Community Services Cards but are not enrolled in a very low cost access practise will have cheaper visits. For some of these people the reduction is from $70 a visit to $18.50. We expect this number to rise as more people are now eligible and these cards will be sent to people automatically. The new criteria include all people in social housing and those receiving accommodation benefits. Only two have not joined this lower fees scheme, out of 59 practises.

In addition, 13 year olds from 1 December 2018, will also have zero fees for enrolled children. This means children aged 13 and under won’t be charged at all of our general practices and after hours services.

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8. CONSENT TO PROPOSED DISPOSAL OF 201 WARSPITE AVE, WAITANGIRUA, PORIRUA

The Minister of Health (Appendix 3) has consented to the proposed disposal of 201 Warspite Avenue, Waitangirua, Porirua subject to specific requirements that include the letter of approval being tabled at the next Board meeting pursuant to clause 43(7) of Schedule 3 of the New Zealand Public Health and Disability Act 2000 (the Act).

Capital & Coast District Health Board November 2018

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BOARD PROCEDURAL

Date: 5 December 2018

Author John Tait, Chief Medical Officer Christine King, Executive Director, Allied Health, Scientific and Technical Andrea McCance, Executive Director, Nursing and Midwifery

Endorsed by Clinical Council

Subject CLINICAL COUNCIL – NOVEMBER UPDATE

RECOMMENDATION It is recommended that the Board: (a) Note that the Clinical Council met on 29 November 2018 and covered four agenda items: i. ABO incompatible Kidney Transplants ii. Capex Plan Update iii. Children’s Hospital Update iv. Draft 12 Month Service & Evaluation Review template.

1. NOVEMBER CLINICAL COUNCIL MEETING The Clinical Council covered the following items at its November meeting:

1.1 ABO Incompatible (AOBi) Kidney Transplants The Wellington Renal Service have been active in renal transplantation since 1969 and have the second largest programme in New Zealand. The vast majority of renal transplants are ABO blood group compatible, including all transplants undertaken in Wellington.

Since 2008 the Auckland Transplant Group have started an ABO incompatible (ABOi) transplant programme, undertaking 2-3 per year over that time. They have achieved excellent results, equivalent to those seen with deceased donor transplants. In the last year the Christchurch Renal Service have started an ABOi programme and expect to do roughly two such transplants per year.

CCDHB sets aside two days per month for the living donor transplants, which allows for roughly 21 live donor slots per annum. Currently this existing capacity is not fully utilised, and the service anticipates utilising the available capacity, with urology and vascular supportive of the move.

Currently we pay for patients to be sent to Auckland or Christchurch, and for the accommodation of patients to stay in Auckland for approximately six weeks (recipient only). In future if procedures are done in Wellington it will save on transport and accommodation, and minimise costs and time away from home for the patient and family. It will also be more efficient time-wise in theatre.

The Council fully endorsed a move to the introduction of ABO incompatible kidney transplants at Wellington Regional Hospital.

1.2 Capex Plan Update The Clinical Council noted the update provided, which outlined the following:

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∑ The updated plan was shared at the last FRAC and Board meetings. ∑ This year’s capex budget is now fully committed. ∑ Our annual depreciation is about $35m. $69m forecast needed to spend next year. ∑ 2013 – 2018 capex spend was lower than our depreciation. ∑ No reason not to progress with current business plans. ∑ Interventional Recovery Ward (IRW) is in the Planning and Design phase and is planned for 2019. ∑ Interventional Radiology Business case is for six machines and six rooms. One of them includes Angiography Lab and Suite replacement (building + Biplane), which is a 12-20 week project. The Point of Entry (POE - pre-business case), has been approved and is also planned for 2019. ∑ However, as Angiography cannot be closed for so long, it is planned to upgrade the Fluoroscopy Suite first, so that it can cater for acute Angio work while the Angiography room is being upgraded. ∑ Development of national asset management plans. Consultants for this have been to DHB’s to assess management maturity - CCDHB is in the top three. Ministry of Health are engaging the consultants for the asset management assessment. ∑ CCDHB will need more capital to spend as is unable to meet within depreciation – this is to be requested from Ministry of Health. ∑ Clinical risks – all urgent items are currently being addressed.

1.3 Children’s Hospital Update An update was provided which noted that the business case has now been approved by the Ministry of Health. The detailed design is being reviewed for any minor changes required, and as the Project Director has resigned a replacement is being considered.

1.4 Draft 12 Month Service and Evaluation Review Template A draft template for papers to be submitted to the Council was discussed. After Council discussion it was felt that the template was more appropriate to be looked after by the CCDHB Clinical Governance Board (CGB)/Clinical Practice Committee (CPC).

Following on from the Board’s discussion at the meeting of 7 November 2018, on the role of the Committee, the Committee agreed that providing advice to specific Board requests was a more appropriate use of the Committee’s time. With the intended introduction of the CCDHB Clinical Governance Board, issues bought to the Clinical Council by services will be more appropriately raised through the CGB, or the CCDHB Integrated Care Collaborative (ICC) functions.

The Committee will await further instructions from the Board.

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133 Molesworth Street PO Box 5013 Wellington 6140 New Zealand T+64 4 496 2000

12 November 2018

Tēnā koutou katoa

Well Child Tamariki Ora Review

Making New Zealand the best place in the world to be a child is a top Government priority. To achieve this vision, New Zealand’s first Child Wellbeing Strategy is being developed, with oversight from the Prime Minister in her role as Minister for Child Poverty Reduction. The Ministry of Health and district health boards are contributing to the development and delivery of this strategy.

Our health system will help realise this vision by making sure children have the best chance to develop during their early years. Collectively, we play an important role in empowering children to thrive socially, emotionally and developmentally. The Well Child Tamariki Ora programme is an essential platform for ensuring child wellbeing by delivering essential universal health care to New Zealand children and providing vital health checks to all children under five years of age. This helps to ensure they’re healthy while identifying and addressing issues at an early stage.

To make sure the Well Child Tamariki Ora programme can continue to support this important work effectively, including responding appropriately to whānau with high health and social needs, we intend to review the programme. The Review will look at the extent to which the programme is currently meeting the needs of children and their families, identifying what’s working well and what it is that we need to improve.

The Ministry intends to co-lead the Well Child Tamariki Ora Review with DHB partners and with Māori to strengthen Tamariki Ora services. The Review will include input from Well Child Tamariki Ora providers and other agencies, including the Ministry of Education and Oranga Tamariki.

Rationale for reviewing Well Child Tamariki Ora

The Review is intended to be a key health system deliverable supporting the Government’s child wellbeing priority, resulting in a Well Child Programme that is more flexible, gives whānau more choice and is better integrated with other health and social services. It will assess and redesign Well Child Tamariki Ora’s funding, contracting and service delivery models to ensure the programme is financially sustainable and delivering the best possible health and wellbeing outcomes for babies, children and families. By identifying gaps in the programme, the Review will also help our sector improve health equity.

The Well Child Tamariki Ora Review has four aims: 1. Improving sustainability and performance of the Well Child Tamariki Ora programme 2. Driving equitable health and development outcomes for children 3. Enabling the Well Child Tamariki Ora programme to more effectively contribute to wider child wellbeing 4. Ensuring value for money.

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The Review will be informed by evidence about what works when it comes to improving the wellbeing of children while considering the adequacy and sustainability of current funding for Well Child Tamariki Ora providers. The Review will also look at how the Well Child Tamariki Ora service can better meet the needs of children’s whānau, caregivers and wider communities which we know will better enable children to thrive.

Scope of the Review

The following aspects of the Well Child Tamariki Ora programme will be assessed and redesigned:

1. Well Child Tamariki Ora Schedule – opportunities for improving the timing and content of Well Child Tamariki Ora contacts. This includes the Ministries of Health and Education working to align and integrate services to enhance school readiness. 2. Equity – addressing current access and outcome inequities and looking at opportunities to introduce a more proportionate response to address light to intensive needs while offering more choice when it comes to mode of delivery. 3. Funding and contracting – development of a funding formula to ensure fair allocation of funding across the service, and an outcome-based contracting framework that can adapt to support funding of providers based on consumer demand. 4. Data and insights – the Well Child Tamariki Ora programme has the potential to provide rich information about child wellbeing in the early years. The Review will look at the development of a national database and collection to include in the Integrated Data Infrastructure.

Review timeframe

The Well Child Tamariki Ora Review has a 12 month timeframe to deliver a new equitable funding and service delivery model for the Well Child Tamariki Ora programme. In parallel, the Ministry of Health and DHB leaders are working on the sector’s contribution to the Department of the Prime Minister and Cabinet (DPMC)-led Child and Youth Wellbeing Strategy. The Review and the Maternity Services Improvement Programme will be the health system’s key contributions to this work.

The Review will provide a great foundation for the Child Wellbeing Strategy to respond to the science and evidence, family and whanau voices and emerging Government priorities for investment in child wellbeing. It’s anticipated the new equitable funding and service delivery model for the Well Child Tamariki Ora programme will be in place from 1 July 2020.

Implications for DHBs

As the Ministry anticipates the Review will take 12 months with implementation of any changes to follow, existing Well Child Tamariki Ora contractual arrangements will need to be maintained during the Review period. An interim commissioning plan will be designed to support the programme to provide continuity and sustainability of the service and ensure a smooth transition to the revised service.

The Ministry Review team will work closely with your DHB in addition to Well Child Tamariki Ora providers, Māori, Pasifika peoples, consumers, and other stakeholders to ensure the review enables equitable participation at all levels.

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Keeping you engaged

I appreciate you and your team may have questions about what the Review means for your DHB. The Ministry will keep you and your team updated regularly about the status of the Review and any changes which follow this process. The schedule to engage with stakeholders and the public is yet to be arranged.

You can contact the Review team if you need more information in the meantime by email ([email protected]).

Publicly promoting the changes

A suggested letter outlining the key information to share with your WCTO providers is attached. I would be grateful if you could please send this to your Well Child Tamariki Ora providers as soon as possible.

Information and resources about the Well Child Tamariki Ora Review will be published on the Ministry of Health website to ensure stakeholders are kept up-to-date. The Ministry sees the Review as a positive opportunity to enhance the service we’re providing to New Zealand families, and intends to promote the Review proactively.

Thank you for your support as we undertake the Review with a focus on delivering better outcomes for our tamariki and their whānau.

Ngā mihi nui

Dr Ashley Bloomfield Director-General of Health

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Capital & Coast DHB Board Financial Overview October 2018

Julie Patterson, Interim Chief Executive Officer Michael McCarthy, Chief Financial Officer

CCDHB Financial Overview Page 1 October 2018

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FINANCIAL PERFORMANCE RESULT AND OVERVIEW Summary The DHB has a board approved deficit target of ($15.9m) for the 2018/19 financial year. The result for October was $2.52m favourable to budget, due to $4.9m favourable variance in revenue, slightly offset by increased expenditure. The additional revenue was largely due to recognition of $2.78m of 2017/18 wash-up revenue, additional revenue for NZNO MECA $625k & MH pay equity $600k settlements, improvement in level of unachieved YTD IDF revenue target and other revenues. All current year additional revenues came with additional costs. October 2018 Year to Date 2018/19 Annual Account Type in $000s Actual Budget Variance Actual Budget Variance Budget Revenue 99,964 95,035 4,929 383,129 380,052 3,076 1,139,617 Labour Costs 44,755 43,860 (895) 169,284 169,840 556 509,791 Outsourced Services 1,898 2,137 239 8,200 8,327 128 24,709 Clinical Supplies 11,701 10,450 (1,251) 43,829 42,221 (1,608) 123,648 Infrastructure & Non-Clinical 9,851 9,896 45 41,184 39,618 (1,566) 117,523 Other Providers 32,195 31,651 (544) 127,815 126,604 (1,212) 379,811

Total (436) (2,959) 2,523 (7,183) (6,557) (626) (15,864)

Year to Date Variances against Budget

Revenue is $3.08m favourable YTD, and was due to $2.87m wash-up of 2017-18 IDF revenue, additional revenue for NZNO MECA $625k & MH pay equity $600k settlements. Other revenue was up due to increase in special fund revenue, other Patient related and other DHB provider revenue. This was offset by underachieved IDF revenue (base and stretched target) for 2018/19, related to lower IDF volumes during nurse’s strike and increased influenza cases in previous months.

Labour costs, including Employee and Outsourced personnel are favourable $556k YTD. For Employees this was a favourable $2.17m YTD of which; Nursing costs account for the ($144k) adverse offset by Medical $356k, Management & Admin $1.3m, and Allied $608k of the variance. This was offset by higher outsourced personnel costs ($1.6m) used to fill vacancies and leave.

CCDHB Financial Overview Page 2 October 2018

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Other expenditure is over budget by ($4.26m) YTD. The budget did have YTD stretched efficiency target of $3.3m which are yet to be achieved. There has also been increased costs of pharmaceuticals and treatment disposables in the hospital to date. In addition the DHB has bulk paid prior year HVDHB invoices, and depreciation costs are also higher than initially expected.

External Providers Review

Month - October 2018 Capital & Coast DHB - Funder Year to Date Variance Ext Provider Payments - $000s Variance

Actual vs Actual vs YTD October 2018 Actual vs Actual vs Actual Budget Last year Budget Last year Actual Budget Last year Budget Last year External Provider Payments: 5,812 5,385 5,556 (427) (256) - Pharmaceuticals 23,406 21,541 23,198 (1,865) (208) 5,579 5,644 5,070 64 (509) - Capitation 22,436 22,574 21,195 138 (1,242) 1,737 1,802 1,692 66 (44) - ARC-Rest Home Level 7,117 7,209 6,809 91 (309) 2,627 2,785 3,281 159 655 - ARC-Hospital Level 13,237 14,082 14,507 845 1,270 1,689 1,695 1,735 6 45 - Other HoP 6,900 6,781 6,549 (119) (350) 2,780 2,229 1,926 (551) (852) - Mental Health 9,260 8,916 7,587 (344) (1,673) 3,220 3,247 2,833 27 (386) - Other services (incl demand driven) 12,944 12,987 11,583 43 (1,361) 8,752 8,863 7,995 112 (757) - IDF Outflows 32,515 32,513 31,980 (1) (535) 32,195 31,651 30,088 (544) (2,104) Total Expenditure 127,815 126,603 123,408 (1,212) (4,408)

External Provider expenditure: unfavourable variance year to date ($1.2m) The favourable variances are: ∑ Capitation favourable variation of $138k due to volume changes still to be captured. ∑ Aged Residential Care rest home, hospital and HOP other with $817k favourable due to better NASC management and pay equity costs not as high

The unfavourable variances offsetting these amounts are: ∑ Pharmaceuticals ($1,865k) due to stretch target applied. Some savings to come via additional rebates from Pharmac ∑ Mental Health unfavourable variance ($344k) mainly due to pay equity funding paid to providers. Off set by revenue funding received from MOH

CCDHB Financial Overview Page 3 October 2018

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Employee FTE Financial Reporting to Ministry of Health (MOH Accrued FTE)

For financial accounting purposes MOH require an accrued FTE measure (as shown in the table below). This measure includes all hours on an accrual basis including leave accruals, overtime and casual hours. As an FTE measure this is highly volatile for a 24/7 facility due to the divisor being set based on the number of working days in the month. The Year to Date total is an average for the year. The average $ per FTE is impacted by MECA increases year on year.

CCDHB Financial Overview Page 4 October 2018

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CCDHB STATEMENTS OF FINANCIAL POSITION

CCDHB Financial Overview Page 5 October 2018

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CCDHB Financial Overview Page 6 October 2018

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Notes to the Balance Sheet and Cashflows

A) Notes to Balance Sheet: 1. The DHB’s cash balance at the end of October is lower than budget as the DHB has not drawn on budgeted equity injection. 2. The 2 largest debtors are Ministry of Health $6.8m and Hutt Valley DHB totalling $4.1m. 3. Work in progress is higher than budgeted, with the Children’s Hospital and other project work running earlier than anticipated. 4. Accounts payable, accruals and provisions are in line with budget. 5. The employee salary accruals are higher than budgeted due to timing differences.

B) Notes to Cash flow statement: 6. The cash receipts from operating activities was $3.8m higher than budget mainly due to Electives wash-up being $4m higher than last year. 7. Cash flow on purchase of fixed assets is lower than budgeted this month. Cash flow is coming back into line with the budgeted spend for the year following higher cash outflow earlier in the year. 8. Net cash inflows is $3.9m higher than budgeted due to the Electives wash-up.

C) Ratios 9. Current Ratio – This ratio determines the DHB’s ability to pay back its short term liabilities. DHB’s current ratio is 0.51 (Sep 18: 0.49);

10. Debt to Equity Ratio - This ratio determines how the DHB has financed the asset base. DHB’s total liability to equity ratio is 27:73 (Sep 18 26:74).

CCDHB Financial Overview Page 7 October 2018

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Cash Forecast

This cash projection excludes $15.9m deficit support. The cash forecast shows that we will need to draw down on deficit support to avoid going into overdraft. In January, there is a capital charge payment due of $15m. The working capital facility limit is $55.8m.

Cash Forecast

140 130 120 110 100 90 80 70 60 50 40 $m 30 20 10 0 -10 -20 -30 -40 -50 -60 -70 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 6 6 6 6 5 5 5 5 4 4 4 4 3 3 3 3 3 2 2 2 2 1 1 1 1 2 2 2 2 2 1 1 1 1 0 0 0 0 9 9 9 9 9 8 8 8 8 7 7 7 7 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 3 6 9 2 6 9 2 5 8 1 4 7 1 4 7 0 3 4 7 0 3 7 0 3 6 0 3 6 9 2 5 8 1 4 8 1 4 7 0 3 6 9 2 6 9 2 5 9 2 5 8 1 2 1 0 0 2 1 1 0 2 2 1 0 3 2 1 1 0 2 1 1 0 2 2 1 0 3 2 1 0 0 2 1 1 0 2 2 1 0 3 2 1 0 0 2 1 1 0 2 2 1 0 0 Week

Borrowing Limit Danger Zone Weekly Actual Cash Balance Weekly Forecasted Cash Balance

CCDHB Financial Overview Page 8 October 2018

69 CCDHB Public 12 December 2018 - PROCEDURAL BUSINESS

70 CCDHB Public 12 December 2018 - 3 FOR DECISION

PUBLIC

BOARD DECISION

Date: 4 December 2018

Author Julie Patterson, Interim Chief Executive Officer

Endorsed by Andrew Blair, Chair, Capital and Coast and Hutt Valley District Health Board

2019 JOINT CAPITAL & COAST AND HUTT VALLEY BOARD MEETINGS AND Subject WORKPLAN

RECOMMENDATIONS It is recommended that the Board: (a) Agrees that Option 1 is the outline schedule of meetings. This means that quarterly Board and FRAC meetings in February, May, August and November, but including provision of sufficient time prior to and following the meetings (i.e. the joint meetings around the middle of the day) for separate meetings of each board, noting that this time might initially be longer than the joint part of the day, decreasing over time; (b) Notes that CEs and senior management work on an implementation plan; (c) Notes that subject to addressing matters of confidentiality, all board papers of each board are made available to members of the other board and that board and senior management of each Board have a standing invitation to attend the board meeting of the other DHB as observers; (d) Notes that these arrangements be reviewed in May.

APPENDICES 1. Option 1 2019 Joint Board Meeting Schedule; 2. Draft 2019 Joint Board Workplan.

1. PURPOSE To report on progress towards joint Board meetings in 2019.

2. DISCUSSION The Board members of Capital & Coast and Hutt Valley District Health Boards met on 28 November 2018 to discuss meeting schedule options (Appendix 1) and the way forward for Joint Board and FRAC meetings in 2019. Management of both organisations have initiated discussions about how this could be progressed and what a joint work plan might look like, what agenda items should be on agendas for joint and separate meetings (Appendix 2). Comparing the current work plans and papers for the two Boards it is apparent that some items are specific to only one DHB. These differences also reflect differences in delegations, risk and issues for each DHB. In some areas the content is more operational than governance. Management has agreed that joint papers would include business which is clearly of relevance to both DHBs where there is obvious efficiency in writing only one paper. This would include business relating to NZHP, TAS, Allied Laundry, 3DHB ICT and 3DHB MHAIDS. There are also agenda items which are similar but specific to each DHB including Health and Safety, Infrastructure and Facilities, People and Capability, Workforce and Employment Relations, capital expenditure business cases, internal and external audit reports.

Capital & Coast District Health Board Page 1 December 2018

71 CCDHB Public 12 December 2018 - 3 FOR DECISION

PUBLIC

Some papers while relevant for a joint meeting may need to be considered at a separate meeting in order to have relevant approvals or delegations by a specific deadline such as reporting deadlines for annual reports or delegates for shareholder meetings etc. Areas of difference will need consideration by each Board, i.e. currently CCDHB considers risks while HVDHB FRAC assumes this responsibility. To progress the process of joint meetings and consider all the issues a meeting of CEs and Board Secretaries was held on 15 November where a draft 2019 Work Plan was developed and the options for the meeting schedule were discussed.

Capital & Coast District Health Board Page 2 December 2018

72 CCDHB Public 12 December 2018 - 3 FOR DECISION

Capital & Coast Health District Health Board Workplan 2019

Regular CCDHB items: (Public) Chair’s Report; CEO’s Report; Clinical Council Report; HSC Recommendations; HSC Minutes; 3DHB DSAC Recommendations and Minutes; Children’s Hospital Report; Resolution to Exclude (Public Excluded): Chair’s Report; CEO’s Report; FRAC recommendations; FRAC minutes; Children’s Hospital Programme Status Update.

S Joint Board Health Advisory Board Foundation Health Advisory N Group Group O I Māori Partnership T

O Strategy Accountability Final Draft Regional 2019/20 Manual I S

I Service Services Plan C

E Final Draft Annual 2019/20 TAS Annual Report

N Quarter 2 O I Performance Quarter 3 Quarter 4 S S Report Performance Performance Report

U Capital

C Report S I Funding D 3DHB MHAIDS 3DHB MHAIDS 3DHB MHAIDS Strategic 3DHB MHAIDS update update update Workforce issues update

3DHB ICT Update 3DHB ICT Update 3DHB ICT Update 3DHB ICT Update

3DHB DSAC Report 3DHB DSAC Report 3DHB DSAC Report 3DHB DSAC Report

People & Capability People & Capability People & Capability People & Capability Report Report Report Report

Disability Report Disability Report Disability Report Disability Report

73 CCDHB Public 12 December 2018 - 3 FOR DECISION

74 CCDHB Public 12 December 2018 - 3 FOR DECISION

WEEK ONE WEEK TWO WEEK THREE WEEK FOUR WEEK FIVE MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Key School holidays CCDHB Board Combined JANUARY DAY AFTER CCDHB HSC NYD OBSERVED WGTN ANN. Boards' NYD CCDHB FRAC workshop HVDHB Board HVDHB FRAC HVDHB CPHAC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3DHB DSAC Joint Board 3DHB CR CEs (preceded by 1 hour CCDHB HSC Ntnl CEs mtng DSAC mtng CCDHB only WAITANGI Joint Board FEBRUARY Joint FRAC meeting. 1 hour DAY meeting RGG Ntnl Chairs HVDHB meeting will mtng mtng following the joint meeting) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Joint FRAC Central Region CEs HVDHB FRAC RGG CCDHB HSC CCDHB FRAC Ntnl Ntnl meeting National CEs MARCH CR CEs mtng CEs Chairs National Chairs HVDHB Ntnl CEs mtng mtng CCDHB Board Board mtng meeting meeting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

CR CEs mtng CCDHB HSC APRIL GOOD EASTER Ntnl CEs mtng ANZAC DAY FRIDAY MONDAY RGG mtng

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

HVDHB FRAC 3DHB CR CEs CCDHB FRAC CCDHB HSC meeting DSAC mtng MAY Joint Board Ntnl CEs mtng Joint FRAC meeting CCDHB Board HVDHB Board meeting meeting

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

HVDHB FRAC CR CEs mtng CCDHB HSC CCDHB FRAC Ntnl Ntnl meeting JUNE QUEENS CEs Chairs BIRTHDAY mtng mtng HVDHB Ntnl CEs CCDHB Board RGG mtng Board mtng meeting meeting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

CCDHB HVDHB FRAC MPB CCDHB HSC FRAC meeting JULY CR CEs mtng CCDHB HVDHB Board Board meeting meeting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

CR CEs mtng CCDHB HSC 3DHB DSAC AUGUST CCDHB FRAC HVDHB FRAC Joint Board Ntnl CEs mtng Joint FRAC meeting meeting meeting RGG mtng

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

HVDHB FRAC CCDHB HSC CCDHB FRAC Ntnl Ntnl meeting HVDHB W/S SEPTEMBER CR CEs mtng CEs Chairs or Meeting HVDHB Ntnl CEs mtng mtng CCDHB Board Board mtng meeting meeting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

HVDHB FRAC CR CEs mtng CCDHB HSC CCDHB FRAC meeting OCTOBER Ntnl CEs mtng LABOUR DAY HVDHB CCDHB Board RGG mtng Board meeting meeting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

CCDHB HSC 3DHB DSAC NOVEMBER Joint Board CR CEs mtng MPB Ntnl CEs mtng Joint FRAC meeting

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

CCDHB HVDHB FRAC CR CEs mtng Ntnl Ntnl FRAC meeting DECEMBER CEs Chairs XMAS DAY BOXING DAY CCDHB Ntnl CEs mtng mtng HVDHB Board RGG mtng Board mtng meeting meeting

75 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC BOARD DISCUSSION

Date: 26 November 2018

Author: Leigh McLachlan, Acting Health & Safety Manager

Endorsed By: Thomas Davis, General Manager Corporate Services

Subject: HEALTH AND SAFETY REPORT (FOR THE MONTH OF OCTOBER 2018)

RECOMMENDATIONS (a) Notes the number of reported Health & Safety incidents has decreased slightly this month (b) Notes that there were no reported Notifiable Events this month (c) Notes the number of incidents resulting in lost time injuries at the time of the report production was four (d) Notes the current Health and Safety Risks. All information accurate at time of report production – 26 November 2018

EXECUTIVE SUMMARY

1. This report updates the DHB on Health and safety risks, outcomes and initiatives as at 26 November 2018

2. RISK REGISTER There are currently 7 active health and safety risks identified in section at 4.7 of the October Risk Report 3. INCIDENTS Higher reporting indicates a stronger health and safety culture and provides a more realistic picture of the exposure to hazards experienced by our workers. It is the actual work injury claims that accurately reflect the type of harm occurring in the workplace. ‘Physical Assaults on staff’ was the highest reported incident category followed by ‘Unsafe Staffing’ and ‘Threatening Behaviour’.

24 Hazardous Materials 0 5 Other Assaulted 2 31 Verbal Abuse 12 24 Slip, Trip, Fall 7 2 Pain or Discomfort 2 8 Near Miss 1 0 Patient Handling 16 5 Injured in Restraint 1 1 Collision with Object or Person 3 1 BBFE 14

Page 1 of 9

76 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC

3.1 Performance Summary

Performance Indicator u s h h n o

t t Trend i u e t r n n v r a e o o (Past 12 months) u r Increased Decreased - No Change t C M P M S H&S Incidents ∑ Total Number of Reported Incidents 159 162 - Number of Reported Incidents - Non MHAIDS 96 105 - Number of Reported Incidents - MHAIDS 63 57 ∑ Number of Incidents involving visitors 0 0 ∑ Number of Incidents involving contractors 0 0 ∑ Number of Notifiable Events 0 0 ------

Key Performance Indicators Excluding MHAIDS MHAIDS Indicator Current Previous Target Current Previous Target (*=estimated) % Change % Change Month Month (By June Month Month (By June 2019) 2019) ACC Injury Claims 10 17 -41% N/A 7 9 -22% N/A MFO Claims 8 14 -43% N/A 5 9 -44% N/A LTIFR - 12 mth 7 8 -6% 7 11 12 -6% 12 Severity Rate - 12 mth 11 12 -5% 9 12 12 - 8 TRIFR - 12 mth 6 6 - 5 8 - 7 TRIFR - 12 mth Including 11 11 - 9 10 - 8 BBFE Notifiable Events 0 0 - 0 0 0 - 0

s t t h

u Trend n h e t

Performance Indicator s t o e i g n r n u v r o r t

o (Past 12 months) e a u r a M T t P - Meeting Target - Below Target C M S ∑ % of Pre-Employment Health Screening 72% 65% 100% completed prior to start+ ∑ % of Incidents closed within 14 days (April 2018) 53% 61% 100% ∑ No. of H&S Rep vacancies 21% 21% 20% Data not available ∑ No. of H&S Reps who have attended training 84% 73% 80% Data not available +Submission of Pre-employment Health Declarations with less than 2 weeks start date is usual cause

Definitions ∑ Injury Claims - Any work related injury resulting in an ACC claim ∑ MFO Claims - Medical Fee Only Claims. Any work related injury which results in an ACC claim for treatment but with no lost time ∑ LTIFR - Lost Time Injury Frequency Rate. The number of lost-time injuries (per million hours worked) within a given accounting period relative to the total number of hours worked in the same accounting period ∑ Severity Rate - The average number of lost days experienced as compared to the number of incidents experienced i.e. Number of lost days divide by the number of lost time injuries ∑ TRIFR -- Number of incidents where injuries/illness occurred requiring medical treatment by a medical professional (Number of injury claims X 200,000 / Number of hours worked)

Page 2 of 9

77 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC 3.2 Lag Indicators (last 13 months)

Blood or Body Fluid Exposure (BBFE) Slip, Trip, Fall 25 15 20 15 10 10 5 5 0 0

Physical Assaults - MHAIDS Physical Assaults - Non MHAIDS 30 50 40 20 30 20 10 10 0 0

Patient Handling Object Handling 18 16 10 14 8 12 10 6 8 4 6 4 2 2 0 0

……………… = Trend

Page 3 of 9

78 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC 4. Lost Time Injuries (LTI) Current Month Days Lost to Category of Incident Directorate Department Date Violence (Physical Assault) MHAIDS Haumietiketike 2 Patient Handling Clinical Support Services Security Orderly 10 Object Handling Surgery Women’s & Children ICU 3 Physical Assault MHAIDs TWOM 5

Past 13 months General (Excluding MHAIDS) 12 250 t

10 s

200 o s L '

I s T 8 y L a

f 150 D

f .

6 o o

. N 100 o N

4 l a t

50 o

2 T

0 0 Novem Septem October Decemb January, Februar March, April, May, June, July, August, October ber, ber, , 2017 er, 2017 2018 y, 2018 2018 2018 2018 2018 2018 2018 , 2018 2017 2018 General LTI's 5 4 6 5 2 10 4 4 3 4 2 3 2 Total Days Lost 64 24 37 36 9 78 209 15 36 48 27 10 13

MHAIDS

4 100

90 t

3 s

80 o L

s s 3 ' 70 y I a T

L 60 D

2 f f o

50 o

. 2 . o 40 o N N

1 30 l a 20 t o

1 T 10 0 0 Novem Decem Februa Septem Octobe Januar March, April, May, June, July, August, Octobe ber, ber, ry, ber, r, 2017 y, 2018 2018 2018 2018 2018 2018 2018 r, 2018 2017 2017 2018 2018 MHAIDS LTI's 3 3 3 3 0 1 1 0 3 1 2 0 2 Total Days Lost 9 26 8 88 0 40 9 0 37 3 68 0 7

Page 4 of 9

79 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC 4. Workplace Injury Management 4.1 Cost – Past 13 months $50,000

$40,000

$30,000

$20,000

$10,000

$0 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 ACCPP Case & Claims Management Medical Fees Top-up (payment employeee would have received if in work over and above base salary i.e. shift allowance) Weekly Compensation - 1st Week - Employee not in Work or not working full hours Weekly Compensation - Employee not in Work (week 2+) or not working full hours 4.2 Types of injury 4.3 Claims by Directorate – Past 13 Months

Other 2 Surgery, Women and Children 62 Not Stated 21 Sprain 453 MHAIDS 83 Misc 74 Strategy Innovation & Performance 1 Laceration 58 Noise… 0 Medicine, Cancer & Community 88 Gradual… 6 Fracture 10 Corporate Services 7 Contusion 137 Burn 0 Clinical & Support Services 41 Chief Executive's Office 0

Page 5 of 9

80 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

5. Workplace Violence and Aggression Statistics

General (Excluding MHAIDS) - Last 24 Months 18 16 14 12 10 8 6 4 2 0 Dec - Jan - Feb - Mar Apr - May Jun - Jul - Aug -Sep - Oct - Nov Dec - Jan - Feb - Mar Apr - May Jun - Jul - Aug -Sep - Oct - 16 17 17 - 17 17 - 17 17 17 17 17 17 - 17 17 18 18 - 18 18 - 18 18 18 18 18 18

MHAIDS - Last 24 Months 40 35 30 25 20 15 10 5 0 Dec - Jan - Feb - Mar Apr - May Jun - Jul - Aug -Sep - Oct - Nov Dec - Jan - Feb - Mar Apr - May Jun - Jul - Aug -Sep - Oct - 16 17 17 - 17 17 - 17 17 17 17 17 17 - 17 17 18 18 - 18 18 - 18 18 18 18 18 18

6. OTHER BUSINESS 6.1 Steering Committees ∑ Health & Safety Steering Committee – This Committee meets every two months. ∑ Preventing Workplace Violence Steering Committee – This Committee is meeting on a monthly basis and is in the process of developing a work plan. ∑ Moving & Handling Steering Committee – This Committee is meeting on a monthly basis and is in the process of developing a work plan.

Page 6 of 9

81 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

7. Employee Support 7.1 EAP

Last 13 Months 120

100

0 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

Total number of clients New clients Total number of sessions

Work-related vs Non-work related Referrals 100 90 80 70 60 50 40 30 20 10 0 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

Non Work Related Work Related

Monthly Cost $20,000.00

$15,000.00

$10,000.00

$5,000.00

$0.00 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

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82 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

7.2 Monthly Referrals to EAP: - Work related reasons for referrals (as stated by worker)

Critical Incident Debriefing 1 Workplace safety Drug & Alcohol Management 1 Employment Conditions 2 Mentoring/Supervision 1 Harassment 2 Relationships 3 Pressure/Stress 8 Workplace change Training Professional development Job Performance 3

0 1 2 3 4 5 6 7 8 9

- By Directorate

Strategy Integration & Performance 2

CEO's Office 2

Corporate Services 8

Clinical & Support Services 7

MHAIDS 17

Medicine, Cancer & Community 16

Surgery, Women's & Children's 18

Not Stated 3

0 2 4 6 8 10 12 14 16 18 20

- Referrals – Work related v Non-work related 100 90 80 70 60 50 40 30 20 10 0 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

Non Work Related Work Related

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83 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

WorkSafe Improvement Notices WorkSafe visited CCDHB in September and issued two Improvement Notices related to hazardous substances. These had an initial compliance date of 2 October. Management have developed a plan to address the issues identified. WorkSafe have reviewed progress against the plan and are satisfied with progress to date. The compliance date of the Improvement Notices have been extended until 12 February to allow time for physical works to be undertaken.

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84 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC

BOARD DISCUSSION

Date: 27 November 2018

Author James Crawford, Project Director

Endorsed by Thomas Davis, General Manager Corporate Services

Subject NEW CHILDREN’S HOSPITAL PROGRAMME OF WORKS STATUS REPORT

RECOMMENDATIONS It is recommended that the Board: Health & Safety Report (a) Notes that there has been two minor incident since the last report. New Children’s Hospital Programme of Works (b) Notes the progress with detailed design which will be completed in December.

1. INTRODUCTION

1.1 Purpose The purpose of the paper is to inform the Capital and Coast District Health Board (CCDHB) Portfolio Board regarding progress with the new Children’s Hospital Programme of Works.

2. UPDATE

2.1 Health & Safety There have been two minor incidents since the last report.

SiteSafe have undertaken two safety audits last month, which have been shared and discussed with the construction contractors. Improvements are being addressed.

2.2 Business Case The Crown approval of the Business Case is subject to a number of conditions which management will ensure are met.

2.3 Development Deed The Development Deed between the CCDHB and Benefactor sets out a number of obligations CCDHB is expected to meet in terms of the design process, the site and acceptance of the building at the end of the project. We have extracted a list of those obligations so we can keep sight of them, and manage CCDHB’s compliance with the Development Deed.

2.4 Resourcing the new Children’s Hospital Programme (Programme) Currently the programme is resourced via a combination of internal and external resources. Given the progress of the programme to date and taking into consideration the resourcing required for the work ahead, management are considering the need for suitable resources to plan and manage the works ahead.

Capital & Coast District Health Board Page 1 November 2018

85 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC

Management is in discussion with a candidate for the position of Project Director to the initial project Director who finished on 23 November.

An FF&E (Furniture, Fittings and Equipment) manager will be recruited on a fixed term basis to manage the specification, procurement, logistics, storage, installation and commissioning of FF&E. This will include working with the Foundation to identify FF&E that can be sourced from in kind donations, supporters and existing suppliers of CCDHB.

The FF&E scope is included within the project budget. The CCDHB agreed with Benefactor's team that the CCDHB will identify items which are better sourced by CCDHB and deducted from payment obligation from CCDHB.

2.5 CCDHB and Benefactor progress The CCDHB and Benefactor teams continue to hold monthly joint project control group (PCG) meetings to address project matters. These PCG meetings are proving to be very valuable for all.

The Benefactor’s builder, McKee Fehl, has now mobilized to site and are underway with works to erect the crane and site preparation works.

The detailed design review is in progress as an iterative exercise and should be completed in December.

2.6 Risk Register A summary of current risk items is continually being updated so as to understand the risks and possible mitigation strategies needed to reduce or programme. The updated Risk Register will be provided to the next Portfolio Board meeting.

2.7 Timeline programme High level New Children’s Hospital Programme of Works timelines noted below:

Target % Complete on Task Completion site (as at Sept Comment Date 2018) Civil Diversion 20/8/18 100% All inspections complete and expect CCC Works Project to be issued soon. Demolition Works Project 26/04/19 85% Based on physical work, timeline to complete. Programme still identifies completion as late March 2019. Internal Reconfiguration 1/12/19 0% Concept complete for WRH – L3 works within Regional 80% Concept design to suit 2 options Hospital GNBL3 – Detail design & Consultant procurement is underway. Building Services Works 20/5/19 0% Engineering scope of work yet to be Project (WRH) determined. McKee Fehl Main 4/12/20 1% Foundation pile testing afoot. MKF Children’s Hospital submitted detailed Construction Construction Programme. Practical Completion - 29.10.2020. Hand over -20.11.2020 New Children’s Hospital Apr 2021 0% Time allocation allowance for the CCDHB Project to complete the final fit out / installation of FF&E

Capital & Coast District Health Board Page 2 November 2018

86 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC

2.8 Stakeholders Māori Partnership Board and the new Children’s Hospital project team continue to meet regularly and provide updates on progress. A successful Māori Partnership Board and CCDHB event took place on the 07 November 2018 for laying of the river stones in the ground in the main reception area of the new Children’s Hospital.

CCDHB has provided an update in regards to the new Children’s Hospital design to the Consumers Group and staff.

2.9 Communication Communication with the staff and neighbours continues and is being well received.

The CCDHB held an event on 07 November 2018 to mark the commencement of the new Children’s Hospital works on the site, which was well attended by a wide range of guests, and went very well.

2.10 Procurement

The internal auditor (CTAS) and the terms of reference for the audit have been agreed. Audit work is underway, with a draft audit report planned to be provided to the next Portfolio Board meeting.

3. NAMING AND THEMING OF THE NEW CHILDREN’S HOSPITAL

Discussions continue about concepts for the theming of key spaces of the new children’s hospital building including the entrance area and play area.

CCDHB are establishing a process around how we will work with the Māori Partnership Board, Pasifika and other key stakeholders to ensure we are engaging and consulting with all our key stakeholders around the hospital’s new identity. It is crucial that the naming, branding and theming is reflective of Tikanga Māori.

Capital & Coast District Health Board Page 3 November 2018

87 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC BOARD DISCUSSION

Date: 5 December 2018

Author Rachel Haggerty, Director, Strategy, Innovation and Performance

Endorsed by Fran Wilde, Chair, Health System Committee

Subject HEALTH SYSTEM COMMITTEE RECOMMENDATIONS

RECOMMENDATIONS It is recommended that the Board: (a) Notes the contents of the CCDHB Bowel Screening Programme update; (b) Notes that the Ministry of Health have advised that CCDHB is unlikely to establish the Bowel Screening Programme until March 2020; (c) Notes the contents of the Hospital and Healthcare Services (HHS) Bi-Monthly Performance Report; (d) Notes the Strategy Innovation and Performance Bi-Monthly Update; (e) Notes that a presentation was received on prioritising and aligning with budget setting processes for the 2019/20 financial year; (f) Notes that members of the Citizens Health Council outlined to the HSC their activity to date. They outlined their intention to meet with Citizen and community groups with key questions and messages to explore what they are seeking from their health system.

APPENDIX 1. Draft HSC Minutes 28 November 2018.

1. PURPOSE This report summarises the key discussions at Health System Committee meeting on 28 November 2018. The minutes of the meeting are attached as Appendix one. The full papers from this meeting are available on Boardbooks. The recommendations reflect the summarised minutes and does not repeat all of the recommendations endorsed by the Health System Committee. No decisions are required from this Health System Committee.

2. DISCUSSION ITEMS

2.1 CCDHB Bowel Screen Programme Update Hospital and Health Services (HHS) staff provided an update on plans for implementing bowel screening within CCDHB. Staff advised the Committee that the Ministry has decided to delay roll out to CCDHB to March 2020 at the earliest. Of notable concern for the Committee is the impact of the current age related eligibility criteria for screening on equity of access to services for Māori and Pacific peoples. Staff agreed this is a concern but noted there is further work being led by the Ministry on these access parameters. Staff are more concerned about the expected capacity implications for flow on diagnostic services, which are already experiencing pressure. An opportunity exists however for workforce development through training speciality nurses to deliver some of the additional diagnostic services that will be needed.

2.2 Hospital and Health Services (HHS) Bi-Monthly Performance Report The scale of activity and pressure within the HHS is substantial currently. Demand is high and there was a late peak in influenza admissions, which is now declining. Committee members asked for future advice about the

Capital & Coast District Health Board Page 1 December 2018

88 CCDHB Public 12 December 2018 - 4 FOR DISCUSSION

PUBLIC impact of influenza on Māori and Pacific peoples and any correlation with vaccination uptake from these communities. More broadly, the Committee noted the challenges HHS is experiencing meeting Key Performance Indicators, which suggests we are not meeting demand. The Committee asked staff to show this analysis stratified by ethnicity to provide better insight into the implications of this for addressing equity of access issues and unmet need. Stratifying the data will help to inform investment choices because solutions to these challenges are likely to be different for different groups. That is, the answer is not always doing more of the same.

2.3 Strategy Innovation and Performance Bi-Monthly Update This paper highlighted an ongoing focus on building capability, notably the priority being placed on the CCDHB pro-equity approach. Of significance in this update, was our local achievement of 98% of general practices opting in to the extension of lower cost fees in primary care for people with a Community Services Card (CSC). Additionally all children under 14 years will be able to access zero fee GP visits if enrolled at a CCDHB practice. The extension went live on 1 December and the launch was held with the Prime Minister and Minister of Health at one of our local GP practices. More broadly, localities activity continues to grow as priorities are established within each locality. These were outlined in more detail at the HSC meeting in October. Staff gave an update on progress with the primary birthing unit project, with the first phase report now complete and due to be considered by the steering group in December. Committee members reinforced for staff the importance of maintaining momentum with this work.

3. PRESENTATIONS

3.1 Locality Plan Diagram The Committee provided feedback on the ongoing development of a diagram that accurately reflects the relationship between CCDHB’s locality approach and the role of Community Health Networks within these localities. The Committee was pleased to see the ongoing refinement of this critical part of our local health system planning. The relationship between the localities work and our responsiveness to communities needs to be at the forefront of activity and engagement. Committee members reiterated to staff the need to always consider the audience and ensure that communication tools such as this are easily understood and meaningful.

3.2 Budget and Prioritisation Process Update An outline was given of the steps underway to develop investment proposal for prioritising and aligning with budget setting processes for the 2019/20 financial year. This will be a key feature of the Board’s strategy workshop at the end of January 2019.

4. FOR INFORMATION

4.1 Citizen’s Health Council Update The members of the Citizen’s Health Council establishment group attended for an informal update on progress to establish the Council and determine its key value for supporting the activity of CCDHB and our local health system. The group outlined the intended shift from a “consumer of health services” focus to a wider strategic citizen led contribution to health service development. The Council is working with a Communications Advisor to test discussions with Citizens and community groups to identify what these communities are seeking from their health system.

Capital & Coast District Health Board Page 2 December 2018

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CAPITAL AND COAST DISTRICT HEALTH BOARD DRAFT Minutes of the Health System Committee (HSC) Held on Wednesday 28 November 2018 at 9am Board Room, Level 11, Grace Neill Block, Wellington Regional Hospital

PUBLIC SECTION PRESENT: BOARD: Dame Fran Wilde (Chair) Ms ‘Ana Coffey (arrived at 9.15am) Ms Sue Kedgley via Zoom teleconference (left the call at approx. 11.40am) Dr Roger Blakeley (left the meeting at 11.40am) Ms Eileen Brown Ms Sue Driver Mr Tino Fa’amatuainu Pereira (arrived at 9.20am, left the meeting at 10.30am) Ms Teresa Wall, attending on behalf of Dr Tristram Ingham

STAFF: Ms Rachel Haggerty, Director, Strategy Innovation and Performance Ms Carey Virtue, Executive Director, Operations Medicine Cancer & Community Ms Delwyn Hunter, Executive Director, Operations Surgery Women & Children

CCDHB PRESENTERS: Ms Te Pare Meihana, General Manager, Child, Youth and Localities item 2.1

GENERAL PUBLIC: One member of the public arrived at the meeting at 9.25am. ______1 PROCEDURAL BUSINESS

1.1 PROCEDURAL The Karakia was led by Ms Teresa Wall. Committee Chair, Dame Fran Wilde, welcomed Ms Teresa Wall, public, members and the DHB staff. The Committee took a moment of silence for Peter Hicks who recently passed away.

1.2 APOLOGIES Apologies received from Andrew Blair and Dr Tristram Ingram.

1.3 INTERESTS 1.3.1 Interest Register Actions: 1. Committee Secretary to update the Interest Register for Andrew Blair, to include Chair, Queenstown Lakes Community Housing Trust.

1.4 CONFIRMATION OF PREVIOUS MINUTES The minutes of the CCDHB Health System Committee held on 24 October, taken with public present, were confirmed as a true and correct record. Ms Eileen Brown commented that the discussion item related to Aged Residential Care worker qualifications and work hours was important given the significant implementation challenges with implementing pay equity.

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Action: 1. SIP to look at options for considering employee hours and qualifications for contracted providers and bring this back to the Committee in a future report on Aged Residential Care.

Moved: Roger Blakely Seconded: Eileen Brown Carried:

1.5 MATTERS ARISING

1.6 ACTION LIST The reporting timeframes on the other open action items were noted. Discussion: ∑ Item 3.5 Healthy Housing update. Regional Public Health is drafting both letters. ∑ Rolleston street development: SIP is working closely with Housing New Zealand. The Housing First model creates greater integration of the population with high and complex needs across the housing development. Staff are comfortable that the model is a good option. Some Committee members indicated that not all city Councillors share this confidence. It was suggested that CCDHB staff and HSC members meet with the Mayor and relevant Councillors to discuss the concerns rather than send a letter. ∑ The Committee has previously discussed establishing a position on the HSC for representation from the Wellington School of Medicine. Staff noted the University has been approached but we haven’t managed to secure a member to date. This will be followed up in 2019. Action: 1. SIP to set up a meeting with Wellington Mayor, Justin Lester, relevant city Councillors, Fran Wilde, Roger Blakeley and Rachel Haggerty as soon as possible. 2. SIP to follow up HSC membership with Wellington School of Medicine in 2019.

1.7 HSC Work Programme The Committee noted the plan.

Note the agenda items are presented in the order that the Committee considered them.

3 FOR DISCUSSION

3.1 CCDHB Bowel Screening Programme Update The paper was taken as read. The Committee: a) Noted that CCDHB have been working with the Ministry of Health (MOH) to develop a local bowel screening service b) Noted the initial service implementation plan has been drafted for the Ministry of Health in preparation to submit their Treasury Business case in February 2019 c) Noted the scope of the planned programme will require an increase in colonoscopy capacity at CCDHB. d) Noted that there are two preferred site options for service delivery being considered: Kenepuru and Hutt Valley DHB

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e) Noted that although service delivery will be funded (initially directly by the MOH and most likely thereafter through the standard funding model), the capital investment to establish this new service will come from the existing CCDHB capital funding allocation. f) Noted there will be a treatment impact from early detection of cancers that will bring forward the cost of treating conditions identified through this process. g) Noted that although CCDHB has an indicative time frame to commence bowel screening there is still some uncertainty in the time frames for the national rollout h) Notes that the service is expected to begin screening patients in mid-2019/20.

Discussion: ∑ The Committee was informed that the Ministry has delayed implementing the bowel screening programme at CCDHB to March 2020 at the earliest. ∑ Committee members queried the implications of the screening programme from an equity perspective particularly for Māori and Pacific peoples who present younger with bowel cancer given the eligibility age criteria for this programme is 60 to 74. Ideally, we would like the age criteria to be lowered, however this would require additional government funding. The Ministry is undertaking further analysis looking at access to bowel screening from an equity perspective. All the DHBs are also challenged by the more immediate issue of the ability to access colonoscopy services post screening due to capacity constraints. ∑ Further work is being carried out to consider the implementation options – for example, delivery at Kenepuru and/or Hutt Valley DHB. Ms Sue Driver observed there is a challenge with implementing national initiatives and there is need for the Board to understand whether the marginal cost to the DHB, which is quite significant, delivers substantial impact. Noting that as this is a government priority we are required to implement. ∑ The programme does represent opportunity for workforce development, for example developing the skills of the nursing workforce, to meet some of the increased capacity demands on gastroenterology services.

HSC recommends the Board: a) To note the paper.

3.2 Hospital and Healthcare Services (HHS) Bi-Monthly Performance report The paper was taken as read. The Committee: a) Noted that the contingency planning for the midwife strike is progressing with the focus on maintaining the safety of the women and babies impacted by this action. b) Noted the need to relocate and reconfigure aspects of the Wellington Blood and Cancer Centre in light of plans for the new Children’s Hospital. c) Noted that demand for Coronary Angiography remains higher than capacity which the service is taking steps to address. d) Noted that pressures on the Cardiothoracic Surgery service have led to patients waiting longer for treatment than clinically appropriate. The service has implemented various measures to address this. e) Noted that NICU continue to work with regional partners to manage significant demand for NICU beds.

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f) Noted that the Hospital Frailty governance group has been established to provide oversight and support for the many projects underway considering how best to manage frailty in the aging population during their hospital stay. g) Noted that the Ophthalmology service expect to have addressed the recent waiting list issues by the end of November and are considering ways to manage increased referral volumes sustainably. h) Noted the progress and rollout of Trendcare and the Care Capacity Demand Management programme. i) Noted the Key Performance and Health Target results

Discussion: ∑ Mr Tino Pereira asked about influenza rates for Māori and Pacific peoples and how that compared with influenza vaccination uptake. ∑ Mr Pereira also drew attention to the fact that we are not meeting all key performance indicators and that it would be useful to look at this by ethnicity to understand the impacts on this performance from an equity perspective. It was acknowledged that there were challenging issues for services and that it was important to look at different options rather than jump solutions. For example, there might be different solutions for cardiology services across the region. ∑ Some of the challenges we are facing, including equity are being addressed through investment proposals. ∑ Staff noted that the KPI reporting for waiting lists is driven by accountability reporting requirements but that it is possible to stratify data by ethnicity. Staff observed that equity of access to waiting lists is driven primarily by referral from general practice/primary care. Therefore we need to ensure people are engaged with primary care in the first instance. ∑ Good progress with diagnostics was encouraging. ∑ It was acknowledged that we are in the middle of MERAS strike action and that management were doing a good job maintaining services to minimise impact on women. Mediation was to occur on 5 December.

HSC recommends the Board: a) To note the paper Actions: 1. Provide further information on vaccination coverage for Maori & Pacifica, including information on the numbers vaccinated and not vaccinated and hospital admissions for our local population. 2. Ensure future reporting takes an equity lens with data stratified by ethnicity.

Moved: Eileen Brown Seconded: Sue Driver Carried:

2 PRESENTATION

2.1 Locality Plan The Committee noted the draft locality plan diagram. Discussion:

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∑ The plan shows the place and how we relate to the community, social sector services and local council areas. Mr Roger Blakely noted that this is a good step forward but the diagram is missing the people in the centre. Committee members also considered the diagram would be strengthened by labelling the rings – eg, outcome, activity, service delivery mechanism. ∑ Mr Tino Pereira observed that the localities approach is good however we need to be mindful that existing community networks may create barriers to establishing new relationships. Therefore genuine engagement is critical. ∑ Ms Sue Driver suggested the diagram needs to reflect the “top down” “bottom up” tensions in our work (eg, the wider government policy context). Possibly this could be addressed through a wider circle or a footnote describing the influences of central and local government. ∑ Ms Eileen Brown queried where homebased care fits in with community health networks – this needs to be clearer. Ms ‘Ana Coffey noted, there is also a need to clarify what constitutes inter-sectoral and community leadership (eg, NGOs/providers are not the people/community) ∑ Need to decide who the audience is and work on language accordingly. Actions: 1. Draw up an updated version and circulate to members

2.2 Budget and Prioritisation Process Update The Committee noted the presentation. Discussion: ∑ Members asked about CCDHB responsibilities for the second level government health priorities such as drinking water regulation. Staff noted the role that central government and Regional Public Health play in overseeing drinking water standards. ∑ Demand activity story will assist with budget and prioritisation planning. It starts with the people. Managing demand and how we address provider demand pressure is part of our long term investment planning. ∑ Committee members noted how important it is that the DHB is visibly talking about issues such as institutional racism as these system challenges needs to be addressed if we are to achieve equity. ∑ Committee members asked whether we should be submitting on the DPMC consultation about Child Wellbeing. Staff noted we already have strong influence in this area through representation on the MOH’s Child and Youth Wellbeing Strategy by our senior leaders – Rachel Haggerty (Chair), Te Pare Meihana, Arawhetu Gray, Taima Fagaloa. There is confidence that the committee’s views will be reflected.

Tino left the meeting at 10.30am.

3.3 Strategy Innovation and Performance Report November 2018 The paper was taken as read. The Committee: a) Noted the update on current activity b) Recommends the Board note this update Discussion: ∑ Committee members were interested in progress with the primary birthing unity. Staff advised the first phase report will soon be received and presented to the December Steering group meeting. It includes assessment of the likelihood that this type of service would be used (ie, the likely level of demand) as well as the appropriate use of such a service. The

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next stage is an organisational and financial feasibility study, which will be a six-month piece of work that includes community consultation. It will be presented back to the HSC in June/July 2019. ∑ More broadly staff observed that we are engaged with and aligned with the Ministry’s 15- month maternity work programme. ∑ Members asked about activity to address synthetic cannabis use in relation to mental health and addictions initiatives. Staff noted that these population health areas fall within the areas that Regional Public Health undertake activity on our behalf. ∑ Committee members asked whether there would be engagement with people who have experienced the impact of suicide as part of our suicide prevention work. Staff explained that engagement with whānau, family and friends of people who have suicided is sensitive and involves highly specialised sets of skills, which we cannot provide. Ms Teresa Wall noted that there may be value in strengthened youth engagement more broadly as we develop our approaches.

HSC recommends the Board: b) Notes the report. .

Moved: Teresa Wall Seconded: Roger Blakely Carried: .

4 OTHER

4.1 RESOLUTION TO EXCLUDE THE PUBLIC

Moved: Fran Wilde Seconded: Roger Blakely Carried:

Roger left the meeting at 11.40am.

5 DATE OF NEXT MEETING

13 February2019, 9am, Board Room, Level 11, Grace Neill Block, Wellington Regional Hospital.

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BOARD DISCUSSION

Date: 5 December 2018

Author Andrew Wilson, GM, People & Capability (interim)

Endorsed by Julie Patterson, Interim Chief Executive

Subject PEOPLE AND CAPABILITY REPORT

RECOMMENDATIONS It is recommended that the Board: (a) Notes the contents of the December Bi-Monthly People and Capability Report regarding the Organisation Development updates; (b) Notes the progress being made with CCDHB’s Supporting Safety Culture Programme including the Speaking up for Safety, Speaking up for Support, and Speaking up for Success Initiatives; (c) Notes the planning that is underway in further developing the Programme including exploration of Promoting Professional Accountability (PPA); (d) Notes the utilisation of restorative practices is being developed.

1. INTRODUCTION

1.1 Purpose This report provides the Board with a bi-monthly update of People and Capability related activity with a focus on current Organisational Development activity. An update on Employment Relations matters has been provided separately.

2. ORGANISATIONAL DEVELOPMENT UPDATE

The Organisational Development team, with support from their colleagues across People and Capability continues to focus activity around our Supporting Safety Culture programme, which includes the development and delivery of priorities, based on the People Strategy.

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Supporting Safety Culture Programme

Speaking up for Safety Over 2800 staff have now been trained in Speaking up for Safety, approaching 50% of our people. Our presenters continue to provide sessions at a range of times and places and we are actively working with managers to facilitate attendance.

Our current projections have us achieving 75% of staff trained by end of April 2019. The threshold for going live with the next phase (as set by Cognitive Institute), is 70% and is attainable within the 12 months set aside for this phase of work. Preparation for that next phase (Promoting Professional Accountability is outlined below).

In the New Year, we will begin to congratulate teams who have reached the 80% threshold. The teams will be provided with resources to support embedding the Safety C.O.D.E within everyday work.

C — Checks are a request to review what is occurring. O — If Checks does not adequately address the issue of concern, we suggest you give your colleague Options for their consideration. D — If raising Options does not address your concerns, we suggest you move to Demands that action be taken. E — If satisfactory action does not follow your Demand, consider whether the issue should be Elevated to a higher authority.

We are also focusing efforts on encouraging those areas of the business and workforces with low training completion rates to improve these rates. In this regard there is a strong focus on the SMO and RMO workforces where completion rates are lower than desirable.

Research and Evaluation Activity Last year we promised, that because over 50% of our staff did not feel safe and supported in their work, we would follow up with a survey looking specifically at safety this year.

The Safe and Supportive Workplace Survey ran in August 2018. We are working with the Collaborating Centre for Safe Health Care at Victoria University of Wellington on this project and would like to extend our thanks to Senior Lecturer Brian Robinson and his team for partnering with us in this work.

The Safety Attitudes Questionnaire (the tool we employed for the survey) is an internationally validated measure, designed to help us look at our safety culture and to evaluate the effectiveness of the Supporting Safety Culture programme over the next two years. We will be repeating the survey in 2020 which will help assess the effectiveness of our safe and healthy workplace initiatives.

Results of the survey are currently being disseminated to all, via a mix of staff forums and presentations to leadership teams across the organisation. The next step will be discussions with those leadership teams, to understand the data more fully and to develop a plan for action to target the safety aspects highlighted in the survey results.

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Safety Attitudes Questionnaire (SAQ) Sexton et al 2006

Safety culture or climate

Perceptions of Perception of Stress Working Teamwork Safety Job Satisfaction Unit Organisational Recognition conditions Management Management

Safety Domains

What did the survey find? ∑ The survey had a 25% response rate which will allow us to track changes in safety attitudes over time. The sample was representative of our demographics, occupational groups and sites. The response rate from medical staff was higher than is usually found in safety research.

∑ There were significant differences in safety attitudes across respondent groups, sites and domains.

∑ A number of areas had scores which fall below the score that indicates safety. A small number of areas had multiple comments about bullying, inability to speak up or unwarranted behaviour.

∑ In areas that had low scores, senior leaders have been alerted and services will be provided with further analysis. An important aim of this is to ensure that the right supports are in place for these areas to build a strong safety culture with a focus on staff wellbeing.

∑ We cannot provide data for areas with low response rates or where people are easily identifiable. Requests for data with be assessed on a case by case basis.

∑ Results from a small number of areas showed a strong safety culture, in all domains other than the working conditions domain. We will be working with these areas in the New Year so we can understand what is working well for them.

Area of high risk: Working Conditions All areas across both CCDHB and MHAIDS obtained low scores for working conditions. Of note the international comparison with a study of 15 Danish hospitals, the percent of clinicians reporting safe working conditions is 65% and 58% respectively[1]. The CCDHB result is 33% and the MHAIDS result is 21%. Efforts that focus on the following aspects will increase attitudes to safety in this domain:

(a) Resources match demand in everyday work (b) Necessary information is available to make decisions (c) Trainees are adequately supervised and supported (d) People experience good collaboration (e) Communication breakdowns that lead to delays are removed

[1] Kristensen, S., Sabroe, S., Bartels, P., Mainz, J., & Christensen, K. B. (2015). Adaption and validation of the Safety Attitudes Questionnaire for the Danish hospital setting. Clinical Epidemiology, 7, 149. Capital & Coast District Health Board Page 3 [December 2018]

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Key Questions for discussion and planning: The key questions being used to consider survey feedback are as follows: 1. How are we supporting people to ensure they can deliver safe patient care? 2. How are we creating the conditions where teams can deliver their best? 3. How are we designing systems to account for complexity? 4. How are our leaders supported to make ethical choices, be visible and listen? 5. How are we building a just, restorative culture where everyone feels safe, supported and responded to with respect?

Speaking Up For Support We continue work to develop a wellbeing framework, and to ensure a coordinated and evidence based approach to supporting our people across the organisation.

A second workshop was held in late October to develop the framework. The group looked in particular at how the components of the Te Whare Tapa Whā model of health might apply in our context. This was considered, in combination with the Worksafe model of health, safety and wellbeing, to provide a strong reference point.

A third workshop designed to fine-tune the wellbeing framework and identify priority areas for action, will occur in late January 2019.

Mental Health Awareness week (8-14 October) provided an opportunity to continue the conversation started during SUFSupport launch week. Led by the communications unit, with support from organisation development, a range of wellbeing activities occurred across the 3DHBs. In addition, the Mental Health Foundation 5 Ways to Wellbeing resources were promoted during the week and made available to all staff as an ongoing resource.

Speaking Up For Success Speaking Up For Success is the third element in our programme and builds on Speaking up for Safety (staff and patient safety) and Speaking up for Support (staff wellbeing).

Evidence shows that a strong safety culture is created by learning from excellence and that we can do this most effectively by attending to what we do well. High performance comes when staff feel valued and appreciated for the contribution they make. Our goal is that we are a place where thank you is part of every interaction, people express appreciation freely and recognise good work and compassionate care, speaking up for success.

Key Principles of Speaking Up For Success: 1. We appreciate each other and the contribution we make. ∑ Every day we all come to work to provide safe, compassionate care to our community. ∑ Every person is part of the health team, regardless of role or position, and contributes to our goal of improving the health and wellbeing of the community. ∑ We take time to say thank you and to appreciate the time, energy, thought and care that we all put into our work.

2. We Learn from Excellence. ∑ We notice great work and seek to support and empower excellence. ∑ We seek out excellence and share what we have learned. ∑ We celebrate work well done and take pride in the achievements of ourselves and our colleagues.

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Launch week activities The launch of Speaking up for Success took place during the week of 19-23 November.

The centre-piece of launch week was the Celebrating Our Success Awards. The Awards were coordinated by CCDHB’s Communications team, with support from the organisation development team and were a wonderful celebration of individuals and teams who have achieved amazing things during the year.

In addition our senior leaders spent time during the week, visiting teams across the organisation, individually thanking staff for their contribution this year and challenging them to take a moment to reflect on what they feel most proud of in their work.

Posters from the Improvement Movement and Frontline Leadership Programmes created displays in galleries celebrating success at Wellington Regional Hospital, Kenepuru Community Hospital, Kapiti Health Centre and MHAIDS Porirua to celebrate the projects completed throughout the year. A repository is being developed on the intranet, so that staff can access these resources into the future.

An ‘everyday heroes’ award has been developed and shared with all staff, as a resource to support activities in recognising and appreciating great work every day.

We are currently developing an approach to provide practical support for innovation on the front line. The aim of this mechanism will be to assist teams who have piloted an idea and are ready to step it up and/or there is potential to extend the scope or scale of the initiative across the organisation.

A significant component to providing safe patient care, is ensuring that transition points between services are collaborative and have robust communication. We are therefore also exploring ways to build appreciation across teams and services, in order for positive relationships to support quality communication throughout the patient journey.

Restorative Practice We are working in partnership with our Quality Improvement Patient Safety (QIPS) colleagues to explore restorative practice in the context of healthcare.

We began this exploration with a Grand Round by Dr Chris Marshall, Diana Unwin Chair in Restorative Justice, Victoria University of Wellington (VUW) in early November and have continued with discussions in a number of leadership forums over the past six weeks.

“Restorative justice refers to a relational way of responding to wrongdoing and conflict that seeks, above all else, to repair the harm suffered, and to do so, where possible, by actively involving the affected parties in facilitated dialogue and decision-making about their needs and obligations and about how to bring about positive changes for all involved.” (from Chris’s presentation)

Restorative practice is well established in the criminal justice and education settings and has now moved into the employment space, with mediators at Ministry of Business Innovation and Employment trained in the restorative approach (by Chris’s team).

Principles of Restorative Practice RELATIONSHIPS: Positive interpersonal relationships shape workplace behaviour RESPECT: Everyone wants and needs to belong and feel safe RESPONSIBILITY: Everyone is responsible for their own actions

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REPAIR: When harm occurs, only a commitment to repair overcomes resentment and restores relationships. We see potential benefit in applying these principles to guide the next phase of our Supporting Safety Culture programme. We have focussed to date on the principle of speaking up as a baseline component, but it is of course simply the beginning of changing the way we relate to each other, in particular when there is conflict or harm. Throughout the two surveys completed in 2017 (the Staff Engagement Survey) and 2018 (the Safe and Supportive Workplace Survey) and in the People Strategy workshops, our people told us that they want to be part of a just restorative culture, which is based on respect and where there is a focus on the repair of relationships when harm occurs. Restorative practice offers an approach which can be applied in situations where either patient or staff harm has occurred, thus creating consistency and simplifying processes to support addressing harm. In addition, the relationship principle supports transparency of process, as the people impacted by the harm are part of the resolution process. Importantly the very core of restorative practice is the restoration of relationships, enabling individuals and teams to move forward from an incident of harm and work together. There was clear feedback through both surveys that our people do not feel that current responses to harm protect and restore relationships. The VUW team are interested in potentially partnering with us to develop a programme to introduce restorative practice to our organisation. For them it offers the opportunity to research restorative practice in a health care setting, and for us it offers access to subject matter expertise in the design of our approach. A key component of the approach would be that it is designed by us and is sustainable for us in the longer term. As noted above, we are in the exploratory stage, but see this as an exciting opportunity to support safety culture. We hope to be able to bring you more about this in the new year.

Promoting Professional Accountability (PPA) We are starting to gain a more detailed understanding of the Cognitive Institute’s Promoting Professional Accountability programme.

The Speaking up for Safety programme, which is already well underway, focusses on proximal harm (where there is a high likelihood that the patient or staff member faces an immediate risk of harm), by encouraging and supporting staff to speak up with respect when they have a concern about staff or patient safety.

The PPA programme focusses on distal harm (where behaviour undermines a culture of safety and while it poses only a small risk at the time, if repeated or left unaddressed will likely result in serious harm). It provides a mechanism for circumstances where past concerns have been ignored or where it has not been possible or appropriate for individual staff members to speak up in real time.

Based on the Vanderbilt Model (see diagram below) of graduated intervention to address behaviours which undermine safety culture, the PPA utilises an electronic notification system/portal. Staff can input a notification of concern via the portal, this is then triaged by a team of senior staff and the appropriate intervention (as per the Vanderbilt pyramid) selected.

The lower levels of the pyramid involve the triage team sending a peer messenger to have a ‘cup of coffee’ conversation with the subject of the notification. This conversation is designed to be a respectful feedback mechanism for the person about their perceived behaviour. It does not aim to investigate the issue.

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As the intervention moves up through the pyramid (either due to the seriousness of the behaviour or due to a lack of

behaviour change following the low level intervention) to Level 1, it becomes a coaching conversation. Leaders receive training in coaching and feedback skills from Cognitive Institute in preparation for this.

Levels 2 and 3 equate more with HR type processes of performance management and disciplinary interventions.

The PPA programme has three phases: (a) Commitment phase: when organisational leaders and senior clinical staff commit to the PPA approach and to a ‘no blink’ response to behaviour not aligned with safety culture; (b) Organisational readiness: when we go through a process to see if we have the policies, systems and processes in place to introduce the PPA approach. This includes investment in and development of an electronic reporting portal and identification of a triage team and recruitment of peer messengers; (c) Training: during this phase Cognitive Institute would provide training for all clinical leaders with performance management responsibility, peer messenger training, and consulting support.

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BOARD INFORMATION

Date: 4 December 2018

Author Shayne Hunter, Chief Information Officer, 3DHB ICT

Endorsed by Julie Patterson, Interim Chief Executive

Subject 3 DHB INFORMATION, COMMUNICATIONS AND TECHNOLOGY (ICT) QUARTERLY UPDATE

RECOMMENDATIONS It is recommended that the Board: (a) Notes Dr Peter Hicks, ICU clinical lead and ICT clinical lead was farewelled at a moving funeral held at the Life Flight Trust’s premises at Wellington Airport. His sudden and unexpected loss left many of us in shock. Peter was critical to the success of a number of important ICT advancements and was an important clinical voice on a number of key CCDHB, sub-regional and regional governance groups. His guidance to the ICT team was invaluable, and provided a much-needed patient and clinician perspective. At the request of his family we broadcasted his funeral via Zoom to those who were unable to attend. This included staff across 3DHB, Central Region, and even colleagues overseas; (b) Notes that as currently measured, the availability of key (Category 1) ICT systems over the quarterly reporting period measured 99.78% against a target of 99.90%; the average availability over the last 12 months measured 99.27%; (c) Notes all planned data backups were completed successfully during the reporting period and there were no successful attempts to impact systems or expose data by virus and other electronic attacks or misuse by staff during the reporting period. There have been no successful cybersecurity attempts; (d) Notes CCDHB went live on a new Pharmacy system on the 28 November. This replaces a risky legacy system and sets CCDHB up to further leverage the Pyxis investment for improved patient safety and medication management. All Central Region DHBs are now live on the common Pharmacy system (ePharmacy). (e) Notes the number of ICT projects undertaken this year covering infrastructure upgrades and the delivery of new and beneficial business and clinical applications; (f) Notes the current key risks that ICT management are focussed on and that all areas have mitigations in place and / or actions underway to reduce the risk; (g) Notes that resources have been prioritised to develop ICT asset management information for FY19/20 planning and Long Term Investment Planning following 2017 Treasury Investor Confidence Rating (ICR) review and in preparation for the second ICR review in 2019. (h) Notes that progress is being made across the Central Region with on-boarding to regional systems. Also Notes the Central Region CEOs, CIOs, CFO, and clinical representatives are meeting on 5 December to workshop the regional ICT programme and to confirm the way forward and DHB commitment to this. This will be presented to the Regional Governance Group (RGG) in February; (i) Notes the National Maternity System programme is facing some challenges and the pathway forward is unclear. The National Oral Health Record programme has a pathway forward and is now being led by Central TAS; (j) Notes NZ Health Partnerships (NZHP) have provided an draft business case for what is now called Health Finance, Procurement and Information Management, a working title to replace the National Oracle System (NOS). NZHP is endeavouring to deliver a Board paper in December to be tabled at December and January

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DHB Board meetings. We have raised our concerns that the timeline is aggressive and doesn’t allow sufficient time for review and key issues to be debated; (k) Notes negotiations with Microsoft regarding the replacement for the health sector’s fixed-price, six-year agreement (H2012) have concluded. Under the All of Government (AOG) framework, Heath Sector specific amendments have been negotiated. These amendments addressed specific Health Sector challenges and requirements. Significant discounts (subject to a Non-Disclosure Agreement) have been negotiated. The expected price increase is considerably less than expected and are within the approved ICT budget for FY 18/19 (previously identified as a risk); (l) Notes CEs, ELTs, and Clinical Councils across the sub-regional approved the role of Chief Clinical Information Officer (CCIO). Recruitment will start shortly; (m) Notes planning is underway for the ICT section of the Board Workshop to be held late January.

1. PURPOSE

This report provides the Board with an overview of Information, Communications and Technology (ICT) performance and key local, regional and national projects for the period October 2018 to early December 2018.

2. OVERVIEW OF ICT PERFORMANCE

Key Effective performance to support the requirements of the DHB

Potential degradation in performance; effective mitigation strategies in place

Performance has deteriorated; DHB is adversely impacted, or mitigations are not adequate

Performance Status Comment Area Service Management & Customer Satisfaction During this reporting period: ∑ 83% of Priority 1 support tickets and 60% of Priority 2 support tickets closed within expected service levels. ∑ The number Service Desk requests logged by CCDHB staff was 5067 vs the average monthly 4556 for the past 12 months. There has been considerable work on key actions identified in an external review of the Service Desk and Desktop Support teams. Good progress is being made. Systems availability During this reporting period: ∑ Category 1 system availability during the period of this report was 99.78% against a target of 99.9%. ∑ Average availability over the last 12 months was 99.27%. An issue with the underlying Microsoft operating system for the Medical Application Portal (MAP) caused instability and some data access issues, impacting all clinical staff for approximately 2 hours. It was resolved by 7am. No patients were put at risk. There was a major issue with our Citrix platform which impacted some staff trying to access their work applications. This issue took 115 minutes to resolve. The Citrix environment is currently being upgraded which will improve its reliability and resiliency. No patients were put at risk.

Security & Privacy

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Performance Status Comment Area During the reporting period: ∑ Virus/Malware protection was kept up to date ∑ There were no known, significant security breaches. We are regularly installing software updates and taking other steps to protect our systems. We have continued to progress on its Security Work Programme including completing its Cyber Incident Response runbook (the step by step response to a cyber-security incident.

G We remain vigilant and ensure a high level of staff awareness. We work closely with other DHBs and Ministry of Health. We have resolved the highest priority issues that Internal Penetration Testing identified. An external review (by internal auditors, Central TAS) of ICT processes and controls against the Health Information Security Framework began in November and finding will be presented to the Board next quarter. We will be seeking approval for unplanned investment in capability to resolve the remaining issues and establish more robust security operations.

Data protection and systems recovery All planned data backups were completed successfully during the reporting period. The hardware hosting the backup system for our applications and data will be replaced as part of our backup strategy. A skilled third party has completed a review and analysis of the information 3DHB ICT backup on behalf of the DHBs. From this a policy document has been drafted to outline how backup services are provided and how 3DHB ICT manage the backed-up data. The final document will be a reference in the design and implementation of a new backup solution. A business case for replacement of the current backup system will be drafted in early 2019. Work is also continuing on implementing resilience improvements, disaster recovery platforms and processes.

Quality and maintenance of infrastructure and applications We continue to improve the currency and resilience of the DHB’s ICT infrastructure including Citrix, Storage and Backup platforms. See Section 4 for more detail.

Ability to implement projects in a timely and efficient way Most projects are progressing to plan. We are operating at maxiumum capacity so meeting demand continues to be a challenge.

Quality, capacity and stability of ICT staffing Demand exceeds available capacity and we are very much operating at peak capacity. Staff turnover has steadied since the last ICT report. Recruiting to vacant positions remains challenging. This is in part the gap between what the market is paying vs our salaries. DHB salaries have not kept pace with the market. Fortunately, we have staff who are passionate about health who are willing to work for more than the money. There is also a shortage of available talent. Some skills are in high demand. We have been able to fill some critical roles but gaps remain. We will be undertaking a full market review of ICT salaries in the New Year. The diversion of capital to facilities and clinical equipment is cause for concern, in particular as retention of staff will be a risk.

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Performance Status Comment Area ICT governance and planning The DHB’s ICT Operational Expenditure Budget has been confirmed. Capital Expenditure Budget is still being reviewed. Business cases for some critical investments have been approved and others are in development.

Operating budget The Year-to-date (YTD) ICT Opex budget is tracking to plan.

Key risks They current key risks that ICT management are focussed on are outlined below. All areas have mitigations and / or actions in place to reduce or eliminate the risk. ∑ Budget – Any reduction in capital spend on ICT will impact the ICT budget as it has a capitalisation target built in for internal staff. Unplanned staff resignations and retirements will require us to pay more in order to meet the market. ∑ Staff recruitment / retention – as noted earlier. ∑ Capacity – There is considerable pressure on the team to meet the demands driven by the DHB, the sub-region, the region, the Ministry, the Government Chief Digital Officer, and Treasury. Our challenge is to respond to competing priorities, many beyond the DHBs control. This has flow on effects in terms of people not taking leave, getting the appropriate training and their general wellbeing, the quality of our work, customer satisfaction, and meeting compliance obligations. ∑ Security – This is an area of constant threat and a continued need for investment. ∑ Systems complexity and resilience – The growth in the use of ICT and the reliance on ICT has put pressure on the systems but has also resulted in a very complex ICT environment. In addition, the organisation is unable to tolerate system outages, in particular for an extended period.

3. KEY ICT PROJECTS AND OTHER ACTIVITIES

The section provides a summary of some of the more significant developments and projects during the reporting period.

3.1 Projects in 2018 Since January 2018 we have delivered 23 projects at CCDHB. A further 10 projects have started this year and will conclude in 2019. Projects this year were a mix of clinical, compliance, infrastructure and corporate applications that ranged from simple to significant complexity and cost. In addition there was project work for other DHBs in the sub-region and regional projects. One of the more significant infrastructure investments has been a new Citrix platform. With Citrix applications are hosted on central servers instead of being installed on individual computers, making the process of deploying and managing applications for a large number of users far more efficient. Citrix is used to deliver applications to 65%-70% of staff. The new Citrix platform investment objectives were to improve resilience and ensure rapid recovery in the event of a significant event (disaster recovery), and to provide productivity gains, especially for clinical staff. We are in the early stages of moving staff to the new platform and the gains are obvious: ∑ Anecdotal evidence is that the time taken to log in for the first time each day has reduced by 50%. ∑ Clinical staff need only log in once a day now. This saves some staff 10-15 minutes a day. ∑ We have also enabled new features that enable greater productivity and increase clinician mobility by permitting an application being used to follow a user from device to device. This reduces the

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time required to open an application and get to the point where you left off and improves clinical workflow. Indications are that this can save some staff a further 5-10 minutes a day.

3.2 Current Projects The ICT team is operating at full capacity with a significant number of projects underway. These are outlined below.

Key Project is within budget, scope and on schedule

Project has deviated from plan but should recover. No impact to critical path or major milestones. Project has fallen significantly behind schedule or is significantly over budget and/or scope has changed. Requires Management intervention.

CCDHB Projects Target Status Name Description Comments Completion (RAG)

Replace unsupported e-Pharmacy pharmacy system (Windose) November 2018 Complete with the ePharmacy system

Upgrade of the Pyxis system Pyxis Upgrades (ward medication dispensing November 2018 Complete cabinets) Upgrade Gynae Plus (National Gynae Plus cervical screening) Application November 2018 Complete Upgrade from version 7 to version 9 ProVation - Implement the ProVation Bronchoscopy Pulmonary Bronchoscopy December 2018 Complete Reporting Reporting Module system at Module CCDHB VMAX Replace the current VMAX Respiratory Complete respiratory system with December 2018 Diagnostic Medisoft Replacement Trendcare Trendcare Acuity system December 2018 Complete Upgrade upgrade A critical, multi-phased project to upgrade and Exit Windows Phase 3 rationalise all unsupported Progressing to plan Server 2003 February 2019 Microsoft server and database software Replacement of key computing hardware to Slight delay in delivery of Hardware ensure ongoing system March 2019 hardware but generally Refresh Project stability and performance, progressing to plan and improve systems resilience Implementation of an oncology information Integrated management system Oncology (MOSAIQ) to improve safety April 2019 Progressing to a new plan Management and efficiency of the cancer System service delivery and drug management

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Target Status Name Description Comments Completion (RAG) Continuous stream of work to Electronic Progressing to plan. The deliver updates to whiteboard Patient June 2019 exemplar of future way of functionality and new Whiteboards working whiteboards for services A slight delay after further Deliver a new intranet that analysis was required to Intranet will be modern, easy to use, determine which platform to June 2019 Upgrade and engaging with flexible and use. The steering group has accessible design now confirmed to use Office 365 in the cloud

2DHB & 3DHB Projects Target Status Name Description Comments Completion (RAG) Labs e-Ordering Analysis, design and planning, System – and business case Analysis and development for Electronic October 2018 Analysis Complete Business Case Laboratory Ordering across Development 3DHB using PCs and mobiles Upgrade Citrix Servers to a Citrix Software Slight delays, pilot group supported version an improve December 2018 Upgrade rollout in November system resilience Microsoft Upgrade from Windows 7 to Resourcing issues are still Windows 10 Windows 10 and Office 2010 March 2019 impacting the project’s and Office 2016 to Office 2016 timeline and budget Move from Medtech’s Access Primary Manage My Health to Indici Compass identified further Care Shared December 2018 with access from MAP / delays – 5 months Care Record Concerto and regional A 3DHB programme of work covering Identity Management and Staff Awaiting business case Office 365 Contact Directory, Email, TBC approval. This is a key Mobile Device Management dependency for several pieces and Office 365 Collaboration of work in progress tools Spark to Moving mobile voice and data Vodafone services from Spark to June 2019 Mobile Tracking to plan Vodafone Transition

Has taken slightly longer to Video 3DHB Video Conference December 2018 move into business as usual Conferencing Implementation (Zoom) mode of operation

Identify the business requirements for an ROI completed Delays at posting a closed e-Observations electronic patient observation RFP December tender due to procedural – ROI/RFP system and run an ROI and 2018 discussions taking place RFP to select a supplier 3DHB Storage Progressing to Plan – slight SAN Storage Upgrade December 2018 Upgrade Project delays on hardware builds

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3.3 Sub-Regional items

3.4.1 Chief Clinical Information Officer (CCIO) In the last ICT update there was reference to consideration being given to develop formal leadership through the creation of a Chief Clinical Information Officer (CCIO) role. The CCIO will provide leadership on clinical information system initiatives and innovation, developing a clinical strategic plan for ICT. They will provide a leading role to 3DHB ICT on the positioning, implementation and support of clinical systems and investment prioritisation. This aligns to roles of the same of different titles at a number of DHBs in NZ and health organistions overseas. This role was approved by the CEs, ELTs, and Clinical Councils across the sub-regional. Recruitment will start shortly.

3.4 Regional

3.4.2 Regional Health Informatics Programme (RHIP) Regional workshop The Central Region CEOs, CIOs and CFO and clinical representatives are meeting on 5 December to workshop the regional ICT programme and to confirm the way forward and DHB commitment to this. This will be presented to the Regional Governance Group (RGG) in February.

The workshop will consider: 1. Current Regional Systems View (what's in place today) 2. Timeline for on-boarding (for those who have on-boarded and those still to on-board) 3. Future state – options and considerations o What 'must' continue and why? o What can stop today (or be paused), why, and impacts? o What investment is required (for what outcome/benefits, by when) and divestment opportunities? 4. Regional Governance – options and considerations 5. Regional Funding model

The workshop will be forward focussed (not backwards other than to learn). The clinician and patient view will be the primary lens to consider what it could look like (not how it is implemented technically). Consideration will also be given to how we work differently to get the best value/outcome for our investment and what commitment looks like.

CCDHB and HVDHB have both indicated that they do not intend to move to the regional webPAS Patient Administration System. The investment is no longer justifiable. This decision is supported by the region’s CIOs. This does have implications for WhDHB, McDHB and WrDHB and we are looking at how else we can contribute to regional costs in a way that is beneficial to CCDHB and the other DHBs – a win-win. One example is the investment that CCDHB has made in a solution for radiology orders which will be made available to the region.

Regional Radiology Information System (RRIS) The CCDHB project has slowed while RRIS performance issues have been resolved. Diagnostics to date have narrowed the issues to either data centre infrastructure and/or a network issue. Identification of the root cause and a resolution plan is expected to be complete by mid- December.

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The CEs have agreed to the appointment of a RRIS Service Delivery Manager. The lack of a regional resource dedicated to the service delivery and operational aspects of these systems and to support changes that are required has been a major contributor to the issues being experienced today, as well as the concerns being raised by the DHBs using RRIS and those who have yet to on-board. It is anticipated that this role will pay for itself many times over, through improved use of the storage resulting in a reduction in costs, faster decision making and therefore a reduction in wasted effort, and the earlier realisation of radiology service and patient benefits.

Regional Clinical Portal (RCP) SMOs at CCDHB, HVDHB and WrDHB can now access the RCP. This allows them to access to WhDHB and MCDHB patient information when required.

Work continues on the project to replicate CCDHB’s Concerto data to regional CP. This continues to experience delays due to the dependency on the RRIS work.

Pharmacy All Central Region DHBs are now live on an ePharmacy system. WrDHB went live in early November, and CCDHB went live on 28 November. The timing of this couldn’t have been better with the legacy WinDose system crashing several times a day in the weeks leading up to ePharmacy go-live.

This sets CCDHB up to further leverage the Pyxis investment, in particular what is known as patient profiling which introduces further patient safety measures and improved medication management.

Other There continues to be strong focus on cost management and spend value. Infrastructure has been further optimised resulting in savings and work is underway to implement other changes that will deliver further reductions. Supplier negotiations are expected to result in improved value, i.e. value add at no additional cost.

Work continues on strengthening the regional systems support function. The team currently based at CCDHB will be co-located with the RHIP team at Central TAS. This has been made possible through Central TAS expanding to new premise. This will take place early in the New Year.

3.5 National

3.5.1 National Health Integration Platform (NHIP) This was known as the National Electronic Health Record (NeHR). The business case, being led by the Ministry of Health, is still awaiting Minister and Cabinet feedback. No further update has been provided by the Ministry.

3.5.2 National Oracle System (NOS) As noted in the last update, the Director General of Health has advised DHBs of the outcome of Cabinet’s decision in relation to NOS. NZ Health Partnerships have been instructed to: ∑ Deploy the system to Canterbury, Waikato, West Coast and Bay of Plenty DHBs, and pause the programme;

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∑ Provide a plan for the development of a new business case, overseen by the Ministry with the support of Treasury and the Government Chief Digital Officer (GCDO), previously called the Government Chief Information Officer (GCIO); ∑ Develop a new business case in conjunction with DHBs and PHARMAC that includes the identifications of full costs and benefits.

NZ Health Partnerships have provided an update on what is now called Health Finance, Procurement and Information Management* Business Case. * This is a working title.

The business case development has included a series of investment logic mapping sessions with DHB representatives followed by a workshop with DHB Chief Executives and the development of several business case components following Treasury’s Better Business Case Framework - Strategic Case, Economic Case, Commercial Case, Financial Case, and Management Case.

There has been some confusion regarding the expectations of the Minister of Health and Director General of Health. The misunderstanding was that they both expected NOS to go ahead. This has since been clarified and is not the case. This came from a request from the Director General of Health to merge the business case with the wider business case to mitigate IT infrastructure risks for a number of DHBs.

NZ Health Partnerships is expecting to deliver a Board paper in December to be tabled at December and January DHB Board meetings. Prior to this there are several review points, including DHB CFOs, CIOs, and CEOs, as well a Treasury Gateway Review. NZ Health Partnerships will be seeking DHB Approvals in February.

We are concerned that the timeline is aggressive and doesn’t allow sufficient time for review and key issues to be debated.

In the meantime, we have continued our work to improve our local Oracle system to enable internal efficiencies and purchasing improvements. We have also analysed our options moving forward – an upgrade to our current system, move to the Cloud, or move off Oracle. These options assume that NOS as we know it will not continue or is too far in the future and presents a risk with our current system.

3.5.3 National Maternity Record (NMR) The future of the NMR is now unclear.

The three professional groups most involved with the Maternity Clinical Information System (MCIS) - Midwifery leaders, O&G Clinical Directors, and Obstetric Anaesthetists – have informed the Ministry that, although we were completely committed to a national maternity clinical information system in the beginning, they no longer have any confidence in the process or the system in its current state. They have advised they cannot wait any longer for the system to become fit for purpose and do not support any further rollout into secondary/tertiary care. They have indicated that in the spirit of ongoing cooperation, members of the Obstetric Expert Clinical Advisory Group would be available to work with the MOH to plan the next steps.

The Anaesthetic Department of Middlemore Hospital has also written to the Ministry advising that they agree with all recommendations in the letter sent by representatives of the Midwifery leaders, O&G Clinical Directors, and Obstetric Anaesthetists. They have also advised that as early adopters of the National Maternity Record (NMR) they have been exposed to all the problems of the system and have found few benefits. They are withdrawing from using the system due to safety concerns.

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3.5.4 Electronic Oral Health Record (EOHR) The Ministry of Health has formally advised DHBs that Central TAS has been contracted to lead the final phase of implementation. The contract is for 3 years and will involve implementation of the operating model and standards, and work with the software providers to align to the operating model and standards. This will see DHBs implementing consistent business, system and information management processes that enable a national view of high quality oral health data.

3.5.5 Microsoft Licencing The All of Government (AOG) Microsoft Cloud, Software and Services Agreement (MCSSA) was signed in August 2018 and entitles government organisations to access a range of Microsoft software at newly agreed rates. It is effective from 1 October 2018. The agreement is for 3+3 years.

The MCSSA agreement was negotiated by the Department of internal Affairs (DIA). It replaces previous agreements including the Health Sector agreement (H2012). Prices had previously been fixed under H2012 for 6 years.

The MCSSA agreement enables access to the full suite of Microsoft products including two types of licensing models for Microsoft Office, Exchange and SharePoint applications - 1. On-premise (what we have currently) and 2. Cloud (Office 365), a modern version of these applications with significantly enhanced features and additional applications/tools which are accessible from anywhere on any device.

Heath Sector specific amendments to the MCSSA have been negotiated nationally. These amendments addressed specific Health Sector challenges and requirements. Heath Sector specific amendments to the MCSSA include the option of M365 E3, a Health Sector variant of Office 365. It provides specific discounts and commitments from Microsoft.

The new agreement does not force the use of the Cloud services immediately, so business change can be managed at a pace acceptable to each organisation.

The price increase under the new agreement was expected to be substantial. Significant discounts have been negotiated for M365 licences (vs the on-premise Windows, Office, and SharePoint licences, and the publicly available Office 365 offerings). These discounts are subject to a Non-Disclosure Agreement. The increased costs associated are within the approved ICT budget for FY 18/19.

Microsoft are also providing seed funding to assist all DHBs with transition planning activities to move to M365. DHB CIOs have established a Council to coordinate DHB transition planning and the allocation of seed funding based on target objectives, to ensure early mover DHBs are supported, and to disseminate the learning from those DHBs.

4. ICT OPERATIONAL ASSURANCE

4.1 Security and Privacy Security Governance and Work Programme The 3DHB Information, Privacy and Security Group continues to provide effective oversight of the 3 DHBs Privacy and Security controls and activities.

The following Privacy Impact Assessments were initiated during this reporting period: ∑ 1-Click GP Access to MAP for GPs, rest homes, and community pharmacies; ∑ Mobile Application Development in the Cloud.

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Security reviews were also conducted to identify and mitigate any security threats that use of selected systems may pose: ∑ The use of Survey Monkey to collect patient identifiable information; ∑ Data collection for quality benchmarking across Intensive Care units in Australasia; ∑ The use of Office Lens, a mobile phone picture and document scanning application.

Security Reviews and Audits We have now resolved 11 out of the 27 issues identified as part of the Internal Penetration Test which was reported to the Board last quarter. This Internal Penetration Test was commissioned as part of the DHB’s Internal Audit Programme and attempts to simulate a scenario in which a ‘hacker’ has gained access to our internal network.

We also commissioned a security review by Microsoft which identified a number of security issues that relate to our Microsoft based systems, such as Active Directory.

A business case is currently being developed to secure the resources and tools required to resolve the remaining issues from the Internal Penetration Test as well as the Microsoft review.

A review of ICT processes and controls against the NZ Health Information Security Framework began in November. The findings for this review are due in January 2019 and we will present these to the Board in February.

Security Week We worked with the DHB’s Communications Unit and launched a security awareness campaign for Security Week in October. Activities included a cyber-security quiz for staff, presentations to staff on security, and posters promoting cyber-security. We also launched an email encryption tool during security week for staff to use when sending patient identifiable information to external parties via email.

4.2 ICT Systems Resilience & Business Continuance Steady progress is being made towards improving the resilience of the DHB’s ICT infrastructure. This includes:

Component Status Target Completion Firewall Business case was approved. There have been delays due Q4 2018/19 Replacement to vendor availability. The target date has now been pushed back to Q4 2018/19. CCDHB Citrix New Citrix environment has been built and is being Q3 2018/19 Upgrade released to pilot groups. Storage Area The new storage infrastructure is being implemented and Q2 2018/19 Network tested. 3D Wide Area A Request for Proposal has been developed and will be Q4 2018/19 Network released to the market in Jan/Feb 2019. It is expected that we would have completed our transition to new resilient network services by June 2019. Office 365 Phase 1 (Identity) is underway and will establish a Cloud Q4 2018/19 copy of the DHB’s identity and authentication system (Active Directory). Business case for Email in the Cloud (Exchange Online) is being developed. Roadmap for full rollout of Office 365 is being developed.

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Backup Replacement Backup strategy and approach completed. Analysis and Q1 2019/20 design for a replacement backup and recovery platform has been initiated and is due to be completed by Q1 2019/20.

5. FUTURE FOCUS

The section is intended to provide the Board with some future focus thoughts which will be considered further and advanced by management. The topic(s) will change each report. Some of these topics may be the subject of discussion at a Board workshop.

Software Automation

Software Test Automation One of ICT’s goals is to increase the rate of value delivery by successfully releasing enhancements and upgrades without disruption, and quickly detecting and correcting incidents if they occur. Another is to materially shift our efforts to value-adding activities such as direct fulfilment of a customer request and to optimise those value-adding but necessary business as usual activities that ‘keep the lights running’. An important business as usual task we undertake is software testing. Every change to a system needs to be tested. We undertake a signifcant amount of testing, almost daily. We have been piloting Software Test Automation as a way to reduce effort and risk, and increase the rate of value delivery. In software testing, test automation is the use of special software (separate from the software being tested) to control the execution of tests and the comparison of actual outcomes with predicted outcomes. Test automation can automate some repetitive but necessary tasks within a formalised testing process already in place, or perform additional testing that would be difficult to do manually. Test automation is critical for continuous delivery and continuous testing. The result from our pilot have been outstanding, in summary: ∑ We created test automations for four key system tests we do with our Patient Administration System (webPAS). The tests are patient registration, inpatient activities, referral activities, and waitlist activities. ∑ The automation of these tests took 1 Tester a total of 6 weeks to create. ∑ The results are: Manual test time for all four Automation test time for all four activities with a major upgrade activities with a major upgrade HV – approx. 2 days (960 mins) HV – 15 mins CC – approx. 2.5 days (1200 mins) CC – 10 mins

Assumes an 8hr day of testing Manual test time for all four Automation test time for all four activities for minor changes activities for minor changes HV – approx. 1 day (480 mins) HV – 15 mins CC – approx. 1 day (480 mins) CC – 10 mins

Assumes an 8hr day of testing ∑ These tests are used when we do annual upgrades of the system and through the year when we do minor changes to the system. When extrapolated to our annual upgrade and business as usual activities the potential savings are significant.

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Quantity Manual Automation Savings per Savings per per Effort time annum annum CC and HV annum (mins) (mins) (mins) (days) Annual Upgrades 2 2400 30 2370 5 Business As Usual 50 24000 750 23250 48 ∑ The savings will be offset by the overhead of maintaining the test automation software and amortisation of the set up costs and software licence costs. By our estimates that may reduce the level of savings by around 20% in the first 2 years, and 15% thereafter. We will be looking to expand the use of Software Test Automation for those tests that are repeatedly used for annual upgades and business as usual changes. We will also be working with the regional ICT team to assist them to leverage this technology. Robotic Process Automation (RPA) Robotic Process Automation uses similar technology to Sofware Test Automation and is used to automate business processes. At its most basic level, it mimics the steps of a human when using a computer to do their work. The software is able to consistently carry out prescribed functions and easily scale up or down to meet demand. Process automation can expedite back-office tasks in finance, procurement, supply chain management, accounting, customer service, and human resources, including data entry, purchase order issuing, creation of online access credentials, or business processes that require “swivel-chair” access to multiple existing systems e.g. a person copying information from one application to another. RPA has been successfully applied at HVDHB. One example is GP Referrals. The process is initiated when a GP creates an e-referral in their Patient Management System and send it to HVDHB. Previously the referrals are received and manually assigned to a specialist service queue in Concerto. From the service queue, e-referral registration and processing require manual administration to complete the registration in two primary systems (Concerto and WebPAS). The end-to-end task of processing an e-referral comprises 37 steps and is viewed in two components; the registration of the referral and the processing of the referral. The time required to complete the process manually ranges from 5-10 minutes for the registration and 3-7 minutes for the processing. Based on average volumes, the end-to-end process of manually registering and processing e-referrals is estimated to require over 4,600 hours annually, or the equivalent of 2-2.5 full-time employees. Using RPA, 72% of e-referral registrations and 77% of all processing is completed autonomously and unassisted. The remaining administration is referred to the human workforce because of either system or business exceptions which require further assessment. The estimated annual benefit is over 3,300 hours returned to the business which can now be applied to higher order tasks that enhance patient care and clinical outcomes. The human workforce is not completely discounted from the end-to-end process. Even with software robots completing the end-to-end process, the human workforce is completing business exceptions and tertiary tasks, for example, confirming data quality and assessing input related issues that affect data quality. Based on the HVDHB experience, it is proposed that RPA should be used for referral processing at CCDHB. Subject to the outcome of this investment, the use of RPA will be broadened. A range of opportunities have been identified including clinical coding.

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BOARD INFORMATION

Date: 4 December 2018

Author Valentino Luna Hernandez, Sustainability Manager

Endorsed by Thomas Davis, General Manager Corporate Services

Subject LONG TERM IMPACT OF DISPOSABLE LINEN

RECOMMENDATION It is recommended that the Board: (a) Notes that the long term impact of disposable linen is a complex environmental problem that requires national coordination and collaboration between clinical and non-clinical stakeholders within the DHB.

APPENDICES 1. M Overcash: A Comparison of Reusable and Disposable Perioperative Textiles: Sustainability State-Of-The- Art 2012. 2. F Mcgain: Environmental Sustainability in Hospitals; an Exploration within Anaesthetic and Intensive Care Settings. 3. N Yoshgikawa: Life Cycle Assessment of Reuse System for Surgical Gowns.

1. INTRODUCTION

The purpose of this paper is to inform the Board of the current status of research around long term environmental impacts of disposable linen used within Capital & Coast DHB.

1.1 Previous Board Discussions/Decisions

This paper responds to a request by the Board following the presentation of the Allied Laundry annual report in the November meeting.

2. BACKGROUND

Textile items such as gowns, towels, drapes, scrubs and others can be single use or reusable. In the last few decades, healthcare facilities have favoured single use textiles due to factors such as price, increased microbial and needle strike barrier and user comfort.

Staff purchasing linen for CCDHB hospitals have made number of decisions related to the use of disposable over reusable linen items. These decisions were made over the last 10 years looking at various factors including safety, comfort, costs and environmental impact. Safety and cost have had a greater weight in purchasing decisions to switch from reusable to disposables.

3. DISCUSSION

3.1 Environmental impacts are significant The use of disposable linen has grown organically as convenient alternatives to re-usables came to the market. The convenience of single use items, however ignore environmental considerations which have Capital & Coast District Health Board Page 1 December 2018

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been researched as environmental sustainability has gained traction within the healthcare sector (Overcash, 2012; McGain, 2015; Yoshikawa, 2009). Disposable items have environmental consequences such as plastic pollution, and carbon dioxide emissions. As more environmental regulation develops, issues such as environmental bans in recycling countries, landfill levies and a tax on carbon will all have an influence in the linen choices available to healthcare systems worldwide.

Life cycle analysis research shows that there are substantial sustainability benefits in reusable over disposable textiles in energy, water and carbon footprint (200 to 300% for each) as well as solid wastes (750%).

Until recently, environmental impacts have not been a large factor in procurement decisions related to these items. However, CCDHB has now frameworks in place to assess environmental and sustainability factors as part of purchasing decisions. For example, sustainability performance information is part of the evaluation of tenders for general services currently underway.

As the issue is common to many DHBs, collaborating to create a common framework for these items will be of benefit. Moreover, discussion and direction from the Ministry of Health will also ensure better outcomes. It is noted that no New Zealand-based research exists. There is an opportunity to have New Zealand-specific details of the environmental performance of reusable vs disposable linen.

It is also of note that Allied Laundry is undertaking its own research (including commercial implications) as part of its Business Plan.

4. NEXT STEPS

Clinical and Support services will include a review of reusable vs. disposable linen in the sustainability and procurement work plans for 2019 which will include consultation with Allied Laundry.

The Sustainability Manager will advocate for inter-DHB collaboration and collaboration with Allied Laundry to increase the evidence base pertinent to the New Zealand environment.

It is proposed to report back to the Board in June 2019.

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Life Cycle Assessment of Reuse System for Surgical Gowns

Naoki Yoshikawa,*1 Nobumitsu Kitanishi,1,2 Koji Amano,1 and Koji Shimada1

1Ritsumeikan University, Japan; 2Takasago Thermal Engineering Co., Ltd., Japan *Corresponding author: [email protected]

1. Introduction assumed to be 50 times. After using the reusable gowns 50 tim An important role of surgical gowns is preventing the es and the disposable gowns once, both types of gowns are medical staffs and patients from infection. Suppliers must incinerated. Foreground data of reusable products was obtained ensure that standards of sterilization and liquid barrier from a questionnaire presented to manufacturers of gowns and performance meet this function. Disposable products have a service providers and deliverers of laundry. Data related to large share of the surgical gown market in Japan. However, disposable products in raw material procurement and reusable products and systems recently developed by some manufacturing processes is based on Ponder [1] and METI [2]. companies, which have same level of the function, seem to be The potential of GHG emission reduction was based on a able to reduce medical waste and the consumption of fossil questionnaire to medical institutions. Questionnaires were sent resources because both products are made from chemical fibers. to 994 facilities, of which 9.2% responded. The survey asked However, no existing study evaluates the life cycle about their awareness of reuse systems and the conditions they environmental load of surgical linen reuse systems, including would need to have met to change to such systems. commercial laundries. This study evaluates the life cycle environmental load of reusable surgical gowns as compared to 3. Results disposable gowns. We also surveyed the interest of medical Figure 2 shows the life cycle GHG emissions of the institutions in introducing reuse systems and estimated the reusable and disposable products per use. Most GHG emissions potential reduction of greenhouse gases (GHG) emissions. come from the washing, drying, and sterilizing processes for the reusable products. Manufacturing and waste management 2. Methodology (incineration) processes are the main factors in GHG emissions This study evaluated two types of surgical gown, disposable for the disposable products. Results showed that the reuse and reusable. Details of the gowns are shown in Table 1. Both systems can reduce life cycle GHG emissions gowns have roughly the same level of liquid barrier (0.38kg-CO2eq/use) by 35% in case of 50-times use. GHG performance. Figure 1 illustrates the system boundaries of the emissions start to diminish after 14-times use, which is lower two products. The life cycle stages of the reusable products than expected. consist of raw material procurement, manufacturing, delivery, The results of the questionnaire to medical institutions maintenance, and waste management (disposal). The showed that about 11% of gowns used are supplied by a reuse disposable product stages are raw material procurement, system. Additionally, 11% of medical institutions are manufacturing, delivery and waste management (disposal). The considering introducing reuse systems, if the liquid barrier average number of uses of reusable products in a life cycle is performance and cost of the system meet their demands. This

way, about 500t-CO2eq of GHG can be reduced per year. RawReusable material ManufacturingTable 1. DetailMaintenance of productsTransportation compared Disposal Reusable Disposable 1.2 Disposal

MonomerMaterial WeavingPolyester (100Laundry％) Polypropylene (100％) 1.0 eq/use Transpor- 2 Transportation PolymeriLiquid- barrier Dyeing Level 3 orDrying 2 Level 3 Disposal 0.8 zation Tation CO performance （AAMI Standard）（AAMI Standard） - Sterilization UsageSpinning (time) Sewing 50 Sterilization 1 0.6 Drying Weight 0.460kg 0.115kg 0.4 Laundry Sterilization Autoclaving EOGDispose after Reusable Use Manufacturing 50 times use 0.2 kg emissionGHG RawRaw material material ManufacturingManufacturing MaintenanceMaintenance TransportationTransportation DisposalDisposal Raw material RawReusableReusable material Manufacturing Transportation Disposal 0.0 Reusable Disposable MonomerMonomer WeavingWeaving LaundryLaundry Figure 2. Comparison of GHG emissions from reusable and PolymeriPolymeri-- TransporTranspor-- disposable products zationzation DyeingDyingDyeing DryingDrying TationTationtation DisposalDisposal 6. Conclusion Spinning Sewing Sterilization SSpinningpinning SewingSewing SterilizationSterilization This study compared life cycle environmental loads of

reusable and disposable surgical gowns. Results showed that

DisposeDispose after after after 50-times use, reusable products reduce GHG emission DisposableReusableReusable UseUse 5050 times times use use from disposable products by 35%. Comprehensive assessment

RawRawReusable material material ManufacturingManufacturingManufacturingMaintenance TransportationTransportation DisposalDisposal covering other medical supplies is needed to support decision ReusableReusable making for sustainable procurement by medical institutions.

MonomerMonomer WeavingWeaving Laundry References PolymeriPolymeri-- TransporTranspor-- Polymeri- DyingDyeingDying Drying DisposalDisposal [1] Ponder, C.S. PhD thesis, North Carolina State University, zationzation Tationtationtation 2009, 87–106. SSpinningpinning SewingSewing SterilizationSterilizationSterilization [2] METI, Research report on LCA of fabric products

(clothes) (in Japanese), http://www.meti.go.jp/policy/ Dispose after DisposableReusable UseUse fiber/downloadfiles/LCA-hontai.pdf (Accessed Disposable 50 times use Figure 1. System boundaries 05.09.2014). RawReusable material Manufacturing Transportation Disposal

Monomer Weaving

Polymeri- Transpor- zation Dying tation Disposal

Spinning Sewing Sterilization

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Environmental Sustainability in Hospitals; an Exploration within Anaesthetic and Intensive Care settings.

Forbes McGain

Submitted in total fulfilment of the requirements of the degree

of Doctor of Philosophy

September 2015

The Melbourne School of Population and Global Health

Faculty of Medicine, Dentistry and Health Sciences

The University of Melbourne, Australia

Printed on archival quality paper

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ABSTRACT

In many nations healthcare is responsible for increasing consumption of financial and environmental resources both as absolute amounts and as proportions of GDP. It is debatable whether such resource use is sustainable in the longer term. Hospitals comprise the most resource intensive section of healthcare, using large amounts of energy and water, procuring substantial amounts of equipment and items and discarding enormous amounts of waste. In increasingly financially and environmentally constrained healthcare systems such hospital resource use will receive heightened scrutiny. There is increasing advocacy in several nations to improve hospital environmental (and thus financial) sustainability. Nevertheless, the research base to guide how to achieve greater hospital sustainability is limited.

The operating room (OR) and intensive care unit (ICU) are disproportionate users of hospital resources as they function at high activity for prolonged durations. This thesis explored environmental sustainability within operating theatres and the ICU through the lens of the three Rs: Reduce, Reuse, Recycle. Each of these themes is enormous in its scale, thus in each chapter examples of studies which could be performed for each theme were listed, followed by detailed studies of specific areas. The first study (Chapter 3) was a before-after examination of reducing the frequency of decontaminating anaesthetic breathing circuits. Reducing circuit decontamination frequency from daily to weekly did not increase bacterial circuit contamination numbers or frequency. As a result, the hospital reduced its circuit decontamination from daily to weekly, making environmental and financial savings.

Reuse within the OR and ICU was explored. A comparison was made between single use and reusable items. Why some surgical metalware were labelled as single use was examined; the single use metalware was found to have the same chemical composition as reusable stainless steel, but was less polished than the reusable variant. The environmental and social repercussions of the increasing displacement of reusable with single use equipment were explored.

The method of ‘cradle to grave’ life cycle assessment (LCA) was used to compare the environmental footprint of reusable and single use central venous catheter (CVC)

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insertion kits. In particular, the CO2 emissions and water use of the reusable CVC insertion kits were found to be considerably greater than the single use kits, a finding at odds with many other studies of reusable versus single use hospital equipment. The outstanding finding from this LCA was that steam sterilisation of the reusable equipment was the major contributor to energy use, CO2 emissions and water use.

Further studies were completed of the electricity and water use of the hospital steam sterilisers. A large proportion of the steam sterilisers’ energy and water requirements occurred when idle (in standby). Further, the sterilisers had many light loads, which was an inefficient use of resources. How staff use steam sterilisers was found to have large resource use implications.

Recycling was examined through an analysis of what would most likely make it feasible, followed by audits of what recycling was actually occurring in the OR and ICU. A survey of anaesthetists found that the vast majority of them did not see recycling occurring in their operating theatres, but that most wished to commit time and effort to doing so. Before-after recycling audits in the OR and ICU showed that recycling could be effective (from 15-15% of all waste and free from contamination with infectious and general waste) and at least revenue neutral. The opportunities for recycling within the ICU were less than for the operating suite.

This thesis has highlighted that many aspects of our understanding of hospital sustainability are immature and that there are large research opportunities in the field. The methods used in the thesis are generalisable to many hospitals in developed and developing countries. The studies within could be the foundation for future research to guide healthcare administrators, clinicians, engineers and others to consider environmental sustainability to be business as usual for hospitals. Hospital staff will continue caring for patients as their raison d’être. To complement such patient care in an increasingly resource constrained world there is much opportunity to reduce financial costs; improve efficiency and reduce energy, water and pollution; and augment any associated social benefits by improving hospital environmental sustainability.

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DECLARATION

This is to certify that:

i. the thesis comprises only my original work towards the PhD except where indicated in the Preface,

ii. due acknowledgement has been made in the text to all other material used,

iii. the thesis is fewer than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.

Signature …….… ……......

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PREFACE

Several associated manuscripts and publications occurred during the PhD candidature and were begun after PhD commencement. In addition, several studies that were begun or completed prior to PhD commencement are mentioned in the thesis, but do not form individual chapters and provide only background information to the included chapters. The thesis chapters closely draw upon the following papers:

Chapter Publication Title

2 McGain F, Naylor C. Environmental sustainability in hospitals – a systematic review and research agenda. Journal of Health Services Research and Policy. 2014;19(4):245-252. 2 McGain F, Cox NR, Cecchin SR, McAlister S, Barach PB. Sustainable cardiac services - From the catheterization laboratory to the operating room and beyond. Progress in Pediatric Cardiology. 2012; 33: 81–84. 2 McGain F, Story D, Kayak E, Kashima Y, McAlister S. Workplace sustainability: the “cradle to grave” view of what we do. Anesthesia and Analgesia 2012 May;114(5):1134-9. 3 McGain F, Algie CM, O'Toole J, Lim TF, Mohebbi M, Story DA, Leder K. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia. 2014;69(4):337-4. 4 McGain F, Sussex G, O’Toole J, Story D. What makes metalware single use? Anaesthesia and Intensive Care. 2011; 39(5):972-973. 5 McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single-use central venous catheter insertion kits. Anesthesia and Analgesia. 2012 May;114(5):1073-80. 6 McGain F, Moore G, Black J. Australian Health Review. 2016 (in press). 7 McGain F, Moore G, Black J. Hospital steam sterilizer usage: could we switch off to save electricity and water? Journal of Health Service Research and Policy. 2016 Jan. 16 (epub ahead of print). 8 McGain F, White S, Mossenson S, Kayak E, Story D. A survey of anesthesiologists’ views of operating room recycling. Anesthesia and Analgesia. 2012 May;114(5):1049-5. 9 McGain F, Jarosz KM, Nguyen M, Bates S, O’Shea K. Auditing Operating Room Recycling: A Management Case Report. Anesthesia and Analgesia

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Case Reports. 2015 Aug 1;5(3):47-50. 9 Kubicki M, McGain F, O’Shea K, Bates S. Auditing an ICU recycling program. Critical Care and Resuscitation. 2015 Jun;17(2):135-40.

For Chapters 7 there is a manuscript in press These are entitled ‘Steam sterilisation’s energy and water footprint’, and ‘Hospital Steam Steriliser Usage: Could we switch off to save electricity and water?’ For both manuscripts the authors are McGain F, Moore G and Black J.

I contributed more than 50% for all publications and the two unpublished manuscripts, except for ‘Auditing an ICU recycling program’ where there was equal contribution with Dr. Kubicki. I devised all studies, completed literature reviews, proposed the research questions and methods, obtained results, wrote the manuscripts and prepared the publications.

In addition, there were several publications that are relevant to the PhD that I undertook prior to enrolment. The most important of these publications were an assessment of plastics used in hospitals, two audits of waste pre-recycling, and a life cycle assessment of plastic drug trays:

1. McGain F, Clark M, Williams T, Wardlaw T. Recycling plastics from the operating suite. Anaesthesia and Intensive Care. 2008 Nov;36(6):913-4. 2. McGain F, Story D, Hendel SA. An audit of Intensive Care Unit Recyclable Waste. Anaesthesia 2009; 64 (12): 1299-1302. 3. McGain F, Hendel SA, Story D. An audit of potentially recyclable waste from anaesthetic practice. Anaesthesia and Intensive Care 2009; 820-823. 4. McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaesthesia and Intensive Care 2010; 38: 538-544.

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ACKNOWLEDGEMENTS

Many people have contributed directly and indirectly to this thesis. I thank Associate Professor Jim Black for his wonderful supervisory role. Jim’s incisive questioning honed my ongoing interest in asking precise questions and broadened my curiosity in all things scientific and beyond. Co-supervisor Professor David Story was fantastic, encouraging me to undertake a PhD in a nascent field of healthcare, and providing advice about study design and how to maximise publication opportunities. Associate Professor Grant Blashki encouraged me to proceed with a PhD and was forever optimistic about where I was heading. Associate Professor Graham Moore provided expert engineering and technical assistance and was integral to broadening the studies undertaken.

I am grateful for the love and support I’ve received from my wife Kirsty, and children Ruby and Flynn. This PhD would be lessened without them. My parents, Allan and Diane and brother Sturt buoyed my love of learning.

Thanks be to Scott McAlister who showed me the world of life cycle assessment and how it can be used well to begin to understand the complexities of environmental footprints. Scott collaborated particularly in Chapters 2 and 5, but also elsewhere throughout the thesis.

Mr. Chris Naylor co-wrote the major literature review on hospital sustainability with me. Dr. Eugenie Kayak, Professor Yoshihisa Kashima, (with me, Scott McAlister and David Story) co-wrote the publication ‘Workplace sustainability: the “cradle to grave” view of what we do.’ Dr. Nicholas Cox, Ms. Serina Cecchin and Dr. Paul Barach (with me, and Scott McAlister) co-wrote ‘Sustainable cardiac services - From the catheterization laboratory to the operating room and beyond.’

For the anaesthetic breathing circuits study (Chapter 3): Dr.Tony Lim and Dr. Kate Algie obtained results with me, whilst Dr. Jo O’Toole and Associate Professor Karin Leder imparted expert microbiological (and other) opinion. Associate Professor Mohammadreza Mohebbi gave statistical advice for the circuits’ project.

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For Chapter 4 (‘What makes metalware single use?’): Dr. Jo O’Toole imparted microbiological knowledge and Mr. Graham Sussex contributed expert metallurgical opinion and equipment.

Mr. Andrew McGavin and other members of Western Health’s Engineering Department showed me the basics of hospital engineering, salutary especially for Chapters 5 to 7. Andrew McGavin also contributed to our life cycle assessment (Chapter 5).

Chapters 6 and 7 would have been impossible without members of Western Health’s Central Sterile and Supply Department. Karen Tricker, Carlos Paciocco, Rowena Wilmette, Nancy Trujillo, and others kindly answered my many queries about steam sterilisation. Dr. Rachel Sore of the University of Melbourne Statistical Consulting Service provided expert statistical advice for the study of steriliser energy and water use (Chapter 6).

Dr. Eugenie Kayak, Dr. Simone Mossenson and Dr. Stuart White co-wrote and edited the survey of anaesthetists’ views of hospital recycling. Ms. Catherine O’Shea, Ms. Sam Bates, Dr. Martin Nguyen and Dr. Katherine Jarosz all gave their time and fortitude to assist in the recycling audits (Chapter 9). The staff of Western Health’s operating theatres and intensive care unit were instrumental in undertaking recycling and added useful advice about commencing such recycling. The staff of Atherton (particularly Sean Boston and Martin Harrison) as well as Scancare (Nathaniel Vann) provided expert advice about steam sterilisers and operating theatre quality assurance.

My hospital workplace superiors were very kind in affording me time and advice to complete this PhD. Associate Professor Craig French, Dr. Andrew Jeffreys, Dr. Richard Horton and Dr. Elizabeth Hessian of Western Health’s Departments of Anaesthesia and Intensive Care (Melbourne, Australia) brought counsel and encouragement.

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ABBREVIATIONS

°C degree Celsius GB£ Pounds (Great Britain) 3R's Reduce, Reuse, Recycle AC Aerobic Count ANZ Australia and New Zealand AS/NZS Australian Standards/New Zealand Standards AUD$ Australian Dollars cfu colony forming unit CI Confidence Interval

CO2 Carbon Dioxide CSSD Central Sterile and Supply Department CT Computerised Tomogram CVC Central Venous Catheter DPU Day Procedure Unit EIO Economic Input Output GWP Global Warming Potential ICU Intensive Care Unit IQR Inter Quartile Range ISO International Organization for Standardization kWh Kilowatt hour LCA Life Cycle Assessment LEED Leadership in Energy and Environmental Design MRI Magnetic Resonance Imaging OR Operating Room PE Polyethylene PP Polypropylene PVC Polyvinyl Chloride RCoA Royal College of Anaesthetists SDU Sustainable Development Unit UK United Kingdom USA$ United States of America USD$ United States Dollars VAP Ventilator Associated Pneumonia VRE Vancomycin Resistant Enterococcus

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TABLE OF CONTENTS ABSTRACT ...... I DECLARATION ...... III PREFACE...... IV ACKNOWLEDGEMENTS ...... VI ABBREVIATIONS ...... VIII LIST OF TABLES ...... XII LIST OF FIGURES ...... XIV CHAPTER 1: INTRODUCTION ...... 1 1.1 BACKGROUND ...... 1 1.2 AIMS ...... 3 1.3 OBJECTIVES ...... 3 1.4 RESEARCH QUESTIONS ...... 4 1.5 RESEARCH STRATEGIES ...... 5 1.6 PUBLICATIONS ARISING ...... 6 1.7 OVERVIEW ...... 8 1.8 CONCLUSION ...... 9 CHAPTER 2: LITERATURE REVIEW ...... 10 2.1 INTRODUCTION ...... 10 2.2 REDUCE, REUSE, RECYCLE...... 11 2.3 AN INTRODUCTION TO LIFE CYCLE ASSESSMENT (LCA) ...... 12 2.4 LITERATURE REVIEW METHODS ...... 17 2.5 SUSTAINABILITY WITHIN HEALTHCARE AND HOSPITALS ...... 19 2.5.1 HOSPITAL DESIGN...... 20 2.5.2 ENERGY ...... 21 2.5.3 WATER ...... 22 2.5.4 TRAVEL ...... 23 2.5.5 PROCUREMENT ...... 24 2.5.6 WASTE ...... 26 2.5.6 BEHAVIOUR ...... 26 2.6 SUSTAINABILITY WITHIN THE OR AND ICU ...... 27 2.6.1 PROCUREMENT AND LIFE CYCLE ASSESSMENT (LCA) IN THE OR AND ICU ...... 28 2.6.2 WASTE ...... 30 2.6.3 WASTE-ANAESTHETIC GASES AND THEIR GLOBAL WARMING POTENTIAL ...... 30 2.6.4 REDUCE ...... 31 2.6.5 REUSE ...... 32 2.6.6 RECYCLE ...... 32 2.6.7 REPROCESSING ...... 33 2.6.8 RELATED WORK BY THE AUTHOR PRIOR TO THE BEGINNING OF THE PHD ...... 34 CHAPTER 3: REDUCE ...... 38 THE FREQUENCY OF WASHING ANAESTHETIC BREATHING CIRCUITS...... 38 3.1 BACKGROUND ...... 38 3.2 INTRODUCTION ...... 39 3.3 AIMS ...... 40 3.4 METHODS ...... 40 3.5 RESULTS ...... 43 3.6 DISCUSSION ...... 46 3.7 CONCLUSION ...... 49

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CHAPTER 4: REUSE VERSUS SINGLE USE ...... 50 WHAT MAKES SURGICAL METALWARE SINGLE USE? ...... 50 4.1 BACKGROUND ...... 50 4.2 INTRODUCTION ...... 51 4.4 RESEARCH QUESTIONS ...... 52 4.5 METHODS ...... 52 4.6 RESULTS ...... 53 4.7 DISCUSSION ...... 55 4.8 CONCLUSION ...... 58 CHAPTER 5: REUSE ...... 60 THE LIFE CYCLE OF REUSABLE AND SINGLE USE CENTRAL VENOUS CATHETER (CVC) INSERTION KITS ...... 60 5.1 BACKGROUND ...... 60 5.2 INTRODUCTION ...... 62 5.3 RESEARCH QUESTIONS ...... 63 5.4 METHODS ...... 63 5.5 RESULTS ...... 69 5.6 DISCUSSION ...... 75 5.7 CONCLUSION ...... 79 CHAPTER 6: REUSE ...... 80 STEAM STERILISATION’S ENERGY AND WATER FOOTPRINT ...... 80 6.1 BACKGROUND ...... 80 6.2 INTRODUCTION ...... 81 6.3 RESEARCH QUESTIONS ...... 84 6.4 METHODS ...... 85 6.5 RESULTS ...... 87 6.6 DISCUSSION ...... 95 6.7 CONCLUSION ...... 98 CHAPTER 7: REUSE ...... 100 HOSPITAL STEAM STERILISER USAGE: COULD WE SWITCH OFF TO SAVE ELECTRICITY AND WATER? ...... 100 7.1 BACKGROUND ...... 100 7.2 INTRODUCTION ...... 100 7.3 RESEARCH QUESTIONS ...... 102 7.4 METHODS ...... 102 7.5 RESULTS ...... 103 7.6 DISCUSSION ...... 109 7.7 CONCLUSION ...... 111 CHAPTER 8: RECYCLE ...... 112 A SURVEY OF ANAESTHETISTS’ VIEWS OF RECYCLING...... 112 8.1 BACKGROUND ...... 112 8.2 INTRODUCTION ...... 114 8.3 RESEARCH QUESTIONS ...... 114 8.4 METHODS ...... 115 8.5 RESULTS ...... 118 8.6 DISCUSSION ...... 121 8.7 CONCLUSION ...... 123 CHAPTER 9: RECYCLE ...... 124

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AUDITING OR AND ICU RECYCLING PROGRAMS ...... 124 9.1 BACKGROUND ...... 124 PART A. OR WASTE POST-RECYCLING ...... 127 9.2 INTRODUCTION ...... 127 9.3 RESEARCH QUESTIONS ...... 128 9.4 METHODS ...... 128 9.5 RESULTS ...... 132 9.6 DISCUSSION ...... 134 PART B. ICU WASTE POST-RECYCLING ...... 139 9.7 INTRODUCTION ...... 139 9.8 RESEARCH QUESTIONS ...... 139 9.9 METHODS ...... 139 9.10 RESULTS ...... 141 9.11 DISCUSSION ...... 145 9.12 CONCLUSION ...... 148 CHAPTER 10: DISCUSSION ...... 150 10.1 REDUCE ...... 150 10.1.1 THE FREQUENCY OF WASHING ANAESTHETIC BREATHING CIRCUITS...... 150 10.2 REUSE ...... 152 10.2.1 WHAT MAKES SURGICAL METAL WARE SINGLE USE? ...... 153 10.2.2 THE LIFE CYCLE OF REUSABLE AND SINGLE USE CVC INSERTION KITS ...... 154 10.2.3 STEAM STERILISATION’S ENERGY AND WATER FOOTPRINT ...... 155 10.2.4 HOSPITAL STEAM STERILISER USAGE: COULD WE SWITCH OFF TO SAVE ELECTRICITY AND WATER? ...... 157 10.3 RECYCLE ...... 159 10.3.1 A SURVEY OF ANAESTHETISTS’ VIEWS OF RECYCLING ...... 159 10.3.2 OR AND ICU RECYCLING PROGRAMS ...... 160 FUTURE SUSTAINABILITY RESEARCH ...... 162 REFERENCES ...... 167

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LIST OF TABLES

Table 1 Bacterial contamination of breathing circuits at intervals of 24 hours, 48 hours and up to 7 days. cfu= colony forming unit, IQR= Interquartile Range (25th-75th centile)...... 44 Table 2 Annualised costs associated with decontamination of anaesthetic circuits (for 6-operating rooms). Financial costs are in AUD$ (with the totals in AUD$ and USD$)...... 46 Table 3 Average composition of stainless steel from one each of reusable and single-use scissors and needleholders.1 ...... 54 Table 4 Surface roughness of the single use surgical metal instruments pre- and post-processing.1 ...... 55 Table 5 Itemised financial costs for one reusable CVC insertion kit ...... 71 Table 6 Itemised financial costs for one single use CVC insertion kit ...... 72 Table 7 Effects by life cycle stage for one reusable CVC insertion kit...... 73 Table 8 Effects by life cycle stage for one single use CVC insertion kit...... 74

Table 9 CO2 Emissions and water use for the single use and reusable CVC insertion kits, accounting for different energy sources for the reusable kits...... 75 Table 10 Steriliser Electricity and Water use for 134 °C and Accessory Cycles and Idling time...... 88 Table 11 Average masses of items for different types of 134 °C cycles ...... 89 Table 12 Average electricity and water usage1 per kg of equipment sterilised for all 134 °C Cycles (n= 1,343) and total steriliser use...... 90 Table 13 Hours when the sterilisers were active, idle and off.1 ...... 104 Table 14 Demographics of Survey Respondents and Entire Workforce for Australia and New Zealand, and England...... 119 Table 15 Recycling at home and in the operating suite...... 120 Table 16 Waste and recycling stream masses for the one-week audit...... 132 Table 17 Costs of waste and recycling disposal in AUD$...... 133

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Table 18 Waste as found in each bin type for the seven days, and contamination (i.e. incorrect waste found in the bins). Masses of recyclables add to 73kg...... 143 Table 19 Total mass of waste within each waste stream (post sorting), and the amount of each disposed of appropriately (i.e. into the correct bin)...... 144

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LIST OF FIGURES

Figure 1 System Boundary. Processes examined for the reusable and single use CVC insertion kits lie within the system boundary (i.e. within the large rectangle).1 ...... 67 Figure 2 Location of instrumentation on the steam steriliser...... 84 Figure 3 Frequency distribution of the total mass of steriliser items1 ...... 89 Figure 4 Mass-total versus Electricity for 134 °C cycles.1 ...... 90 Figure 5 Mass-total versus Water-Vacuum Pump for 134 °C steriliser cycles.1 ...... 92 Figure 6 Electricity Cost Curve. Electricity divided by Mass versus Mass.1 ...... 94 Figure 7 Water Cost Curve. Water-Vacuum Pump divided by Mass Versus Mass.1 . 94 Figure 8 Pattern of active steriliser use on week days...... 105 Figure 9 Pattern of active steriliser use on weekend days...... 105 Figure 10 Frequency distribution of steriliser-hours of active use per day for one year for routine practice1 and if one steriliser was to always be switched off.2 ...... 106 Figure 11 Sum of hours idle for idle duration for the 4 sterilisers for one year.1 ...... 108

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CHAPTER 1: INTRODUCTION

“Simply claiming that something is green, without demonstrating empirical benefits for human health and well-being, the environment, and economics, is not enough.”(1)

Howard Frumkin Green Healthcare Institutions Institute of Medicine of the National Academies (USA).

1.1 BACKGROUND

In the setting of climate change and resource depletion there is increasing interest in environmentally sustainable health care. Hospitals are highly energy intensive, consume large amounts of resources and produce much waste(2). It has been calculated that healthcare; in the USA contributes to 8% of that country’s entire

‘carbon footprint’ (CO2 emissions)(3), whilst in England this is a more modest 3% of that country’s CO2 emissions(4). In Australia, no such national ‘carbon footprint’ study has been performed, but it is known that the CO2 emissions from individual hospitals are large(5).

Hospital environmental sustainability is important for other, more prosaic reasons. It is often (though not always) the case that a more environmentally sustainable approach to healthcare is also more financially sustainable, equitable, efficacious and efficient(6). Despite this, knowledge of much of healthcare’s environmental effects is unknown(7).

Environmental considerations of healthcare were thought novel until recently, so research related to most aspects of hospital sustainability has infrequently occurred. Further, unsustainable environmental behaviour has routinely been an uncosted externality (i.e. a factor whose costs are not reflected in the market price of goods and services). CO2 emissions are a good example of an uncosted externality unless a ‘carbon price’ is attached.

Efforts to quantify the ‘carbon footprint’ of hospitals using life cycle assessment (LCA)(8) have been promulgated by the UK’s Sustainable Development Unit (SDU). LCA is a scientific method to analyse an item’s or process’ entire ‘cradle to grave’

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environmental effects, whether these be CO2 emissions, water use, aquatic toxicity(9). LCA’s role in analysing healthcare’s environmental footprint is evolving rapidly, but a nuanced understanding of where to act first and what to do to improve hospitals’ environmental sustainability is lacking(10). There are uncertainties regarding the foundations for LCA within healthcare. For example, it is uncertain what the actual energy (and thus CO2 emissions) requirements are for many devices used by hospital staff in the Operating Room (OR), Intensive Care Unit (ICU), Radiology Department and beyond, thus it is difficult to assign CO2 emissions per procedure performed.

It is useful to consider that the ongoing carbon footprint of hospitals stems from three main areas in descending importance: procurement, direct energy use and travel to/from hospitals(4). Procurement and waste have a greater carbon footprint (and much larger financial impost) than both direct energy use and travel combined. Moreover, if efforts are to be made to improve hospital sustainability one needs to consider the areas likely to have the highest impact, such as the OR and ICU(10). Thus, OR and ICU procurement is the focus of this thesis.

The environmental sustainability of the hospital built environment has been studied in greater detail than other aspects of hospital sustainability(11, 12) and is discussed only briefly in this thesis. Further, this thesis focuses solely upon studies of equipment, activities and behaviours that may directly improve hospital environmental (and financial) sustainability. There are many public health examples which indirectly improve healthcare’s and a hospital’s sustainability. For example, smoking cessation or prevention of obesity and diabetes have self-evident benefits for the individual patient, but also reduce requirements for hospitalisation and thus improve healthcare’s overall sustainability. Such preventative approaches thus indirectly and significantly improve hospital sustainability, but are beyond the scope of this thesis.

First heard in the early 1970’s, the mantra Reduce, Reuse, Recycle(13) has become a household term. The 3Rs have also been influential in developing a research based ‘waste hierarchy’, i.e. it is better to; reduce, then reuse, recycle, incinerate, and finally send to landfill(14). There is ongoing debate surrounding how recycling may/may not curtail overall reductions in the use of materials and the relative importance of each of the R’s(15). Nevertheless the mantra is well known, simple and testable, particularly with the evolution of LCA methods(14). This thesis has thus used the Reduce, Reuse,

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Recycle waste hierarchy to classify hospital sustainability research and investigations within each of the three fields.

Within the Reduce, Reuse, Recycle framework there are a myriad of possible research topics, and if there is to be widespread progress improved knowledge in each of these areas is required. This thesis has examined the; required frequency of cleaning an OR device; life cycles of several equipment; staff use of hospital sterilisers; and opportunities to recycle. At least one example within each of the fields of reducing, reusing and recycling within the OR and ICU has been examined. Commonly used devices and equipment have been chosen, increasing the utility and generalizability of the thesis’ results. Examples are given detailing financial and environmental savings from research findings and opportunities for the future. There is much scope for improving hospital sustainability. This thesis significantly adds to hospital sustainability research and gives examples of real improvements that can be readily achieved.

1.2 AIMS

This thesis aims to explore environmental sustainability within the OR and ICU. Reducing, reusing and recycling within the OR and ICU are examined and comparisons made between single use and reusable equipment. The important role that hospital steam sterilisation plays in the environmental footprint of all sterilised reusable, equipment is quantified. This thesis contributes to our knowledge of, and guides future research and advocacy in the field of hospital sustainability.

1.3 OBJECTIVES

1. Reduce: Consider where possibilities exist for reducing the amount of equipment used per patient within the OR and ICU. i. Examine in detail the reduction in use of one common item, without compromising patient care.

2. Reuse: Contrast reusable versus single use items. i. Critically assess the rationale and significance of medical equipment labelling as single use versus reusable.

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ii. Using a life cycle assessment (LCA) approach compare the environmental effects of single-use and reusable versions of a common item. iii. Examine in more detail the most important components of the ‘footprint’ of reusable surgical equipment: in particular steam sterilisation's energy and water requirements. iv. Explore energy efficiency: observe how hospital staff use steam sterilisers.

3. Recycle: Examine recycling’s potential within the OR and ICU. i. The psychology of recycling: survey anaesthetists' views of OR recycling ii. Audit OR and ICU waste, pre- and post-recycling.

1.4 RESEARCH QUESTIONS

1. Reduce: Focus upon one common reusable item in the OR, i.e. anaesthetic breathing circuits, to determine if it is safe to reduce the thermal disinfection (washing) frequency. i. For anaesthetic circuits, what are the differences in the circuits’ aerobic bacterial load with changes in the frequency of thermal disinfection? How do three washing regimes at 24, 48- hourly and weekly intervals affect bacterial load?

2. Reuse: Contrast reusable versus single use items and how reusable items are sterilised. i. For reusable and single use surgical metalware what are the physico- chemical differences between these items? Are both reusable and single use items stainless steel? Are there differences in the polishing/roughness of the two types of metalware? ii. Using LCA methods: for reusable and single use central venous catheter insertion kits what are the differences in the financial and environmental costs? iii. Steam sterilisers 1: What are the electricity and water requirements of hospital steriliser usage? Over a prolonged time period what are the relative amounts of electricity and water consumption by a steam steriliser during cleaning cycles, accessory cycles and idle modes? What is the

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relationship between the mass and type of items sterilised and the electricity and water used? iv. Steam sterilisers 2: What is the efficiency of patterns of steriliser use by hospital staff? What is the relative proportion of times spent active, idle and off? Is it possible to safely switch off idle sterilisers?

3. Recycle: 1. Is operating suite recycling standard practice in Australia, New Zealand and the United Kingdom? Are anaesthetists willing to increase recycling within the operating suite? In the opinion of anaesthetists what factors enable and impede the introduction of operating room recycling in an operating suite? 2. What are the masses of different waste streams exiting the OR and ICU before and after the introduction of recycling programs? Does the introduction of recycling programs increase infectious contamination rates? Are OR and ICU recycling programs financially viable?

1.5 RESEARCH STRATEGIES

A number of research strategies are used in this thesis.

1. For the study of reducing the washing frequency of anaesthetic breathing circuits: Microbiological techniques to plate out circuit washings are used as guided by a microbiologist.

2. For comparison between reusable and single use items:

Assistance from a metallurgist was sought as to how to measure the roughness of common metal ware devices and their physico-chemical composition (spectrophotometry).

3. For life cycle assessment (LCA) study of common OR and ICU equipment:

Collaboration with an LCA expert and the use of LCA software (SimaPro®) and data inventories (Ecoinvent®).

4. For studies of electricity and water use by sterilisers and how these sterilisers are used by staff:

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Collaboration with engineering staff. The use of Excel® and Access® databases with computer programming input from my supervisor and co-supervisors.

5. For audits of OR and ICU waste and recycling:

Measurements of the masses of waste/recyclables are performed.

1.6 PUBLICATIONS ARISING

(a) Literature reviews

1. Overview of hospital sustainability.

McGain F, Naylor C. Environmental sustainability in hospitals – a systematic review and research agenda. Journal of Health Services Research and Policy. 2014;19(4):245-252.

2. Review of sustainability within the cardiology and critical care areas.

McGain F, Cox NR, Cecchin SR, McAlister S, Barach PB. Sustainable cardiac services - From the catheterization laboratory to the operating room and beyond. Progress in Pediatric Cardiology. 2012; 33: 81–84.

3. Review of life cycle assessment and sustainability as it applies particularly to anaesthetists.

McGain F, Story D, Kayak E, Kashima Y, McAlister S. Workplace sustainability: the “cradle to grave” view of what we do. Anesthesia and Analgesia. 2012 May;114(5):1134-9.

(b) Chapters 3 to 9.

1. An examination of the microbiological effects of washing anaesthetic breathing circuits at different time intervals. McGain F, Algie CM, O’Toole J, Lim TF, Mohebbi M, Story DA, Leder K. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia. 2014;69(4):337-4.

2. An analysis of the composition of medical instruments and what makes metal items single use.

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McGain F, Sussex G, O’Toole J, Story D. What makes metalware single use? Anaesthesia and Intensive Care. 2011; 39(5):972-973.

3. A life cycle assessment of CVC insertion kits. McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single-use central venous catheter insertion kits. Anesthesia and Analgesia. 2012 May;114(5):1073-80.

4. Steam sterilisation’s energy and water footprint. McGain F, Moore G, Black J. Steam sterilisation’s energy and water footprint. Australian Healthcare Review. 2016 (in press).

5. How hospital staff use steam sterilisers. McGain F, Moore G, Black J. Hospital Steam Steriliser Usage: Could we switch off to save electricity and water? Journal of Health Service Research and Policy. 2016 Jan 13 (epub ahead of print).

6. A survey of anaesthetists’ views of OR recycling. McGain F, White S, Mossenson S, Kayak E, Story D. A survey of anesthesiologists’ views of operating room recycling. Anesthesia and Analgesia. 2012 May;114(5):1049-5.

7. OR waste post-recycling. McGain F, Jarosz KM, Nguyen M, Bates S, O’Shea K. Auditing Operating Room Recycling: A Management Case Report. Anesthesia and Analgesia Case Reports. 2015 Aug 1;5(3):47-50.

8. ICU waste post-recycling. Kubicki M, McGain F, O’Shea K, Bates S. Auditing an ICU recycling program. Critical Care and Resuscitation. 2015 Jun;17(2):135-40.

1. McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesthesia and Intensive Care 2007; 35: 808-9.

2. McGain F, Blashki GA, Moon KP, Armstrong FM. Mandating sustainability in Australian hospitals. The Medical Journal of Australia. 2009 Feb 15;190(12):719- 20.

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3. McGain F, Clark M, Williams T, Wardlaw T. Recycling plastics from the operating suite. Anaesthesia and Intensive Care. 2008 Nov;36(6):913-4.

4. McGain F, Story D, Hendel SA. An audit of Intensive Care Unit Recyclable Waste. Anaesthesia 2009; 64 (12): 1299-1302.

5. McGain F, Hendel SA, Story D. An audit of potentially recyclable waste from anaesthetic practice. Anaesthesia and Intensive Care 2009; 820-823.

6. McGain F, Kayak E. Where are hospital “green” committees and officers? Australian Health Review. 2010;34:523–524.

7. McGain F. Sustainable hospitals? An Australian perspective. Perspectives in Public Health. 2010;130(1):19-20.

8. McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaesthesia and Intensive Care 2010; 38: 538-544.

1.7 OVERVIEW

Chapter 2 is the literature review of hospital sustainability and more particularly, OR and ICU environmental sustainability research. Chapter 3 is about Reducing. Although we could reduce the use of many items, packaging and procedures within the OR and ICU it is necessary to consider a device that could feasibly be used less frequently or at least cleaned less frequently. We examine whether the frequency of washing anaesthetic breathing circuits influences the bacterial load count of such circuits.

Chapter 4 introduces Reusing. The seemingly inexorable increase in the use of single use devices is discussed first, with a focus upon why metalware in particular could be considered single use. Life cycle assessment is used in Chapter 5 to examine one commonly used OR and ICU device, the central venous catheter (CVC) insertion kit. Comparison is made with a device (studied prior to the commencement of the PhD) that was not sterilised (a drug tray). Differences in the environmental effects of the reusable and single use variants of the CVC insertion kits are compared and contrasted. Steam sterilisation of the reusable items in particular appears very energy and water intensive. In Chapter 6 it becomes apparent that the energy and water

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requirements of steam sterilisers as they are used in hospitals is incomplete. Chapter 7 thus is an examination of the electricity and water requirements of a hospital steam steriliser. Chapter 8 explores how hospital staff actually use steam sterilisers and the sterilisers’ subsequent efficiency.

Chapters 8 and 9 are about Recycling. Chapter 8 defines what anaesthetists consider to be the most important enablers and barriers to OR recycling. OR and ICU waste audits pre- and post-recycling form the basis for Chapter 9. Chapter 10 ends the thesis with a discussion about what this thesis has achieved, the research significance, the resultant changes to staff behaviour and activity, and the improvements in hospital sustainability, and the future research agenda.

1.8 CONCLUSION

The research studies within this thesis give greater understanding to, and add to dialogue about, the environmental effects of hospital activities. Moreover, examples are given of improvements in OR and ICU sustainability already occurring as a result of this research. The methods used in this study are generalizable to many hospitals in most parts of the world. For example; comparisons between reusable and single use items can be researched with life cycle assessment, steriliser activity and energy/water use can be obtained with relatively straightforward software and waste audits are simple to achieve. Such research will guide future policy makers, clinicians, engineers and others to make rational, informed decisions to improve hospital sustainability, improve efficiency and reduce energy, water and pollution in an increasingly resource constrained world.

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CHAPTER 2: LITERATURE REVIEW

2.1 INTRODUCTION

This chapter begins with the definition of sustainability, briefly traces the history of the sustainability movement, and provides an overview of sustainability in general. Thereafter, environmental sustainability within hospitals becomes the focus of this chapter and the entire thesis. The separation of environmental sustainability from financial and social sustainability is somewhat artificial since all subsets of sustainability are inter-related. Nevertheless, researching all aspects of sustainability was beyond the scope of this PhD.

Some elements of financial sustainability are examined, though the analyses chosen are relatively simple. A complementary approach would be to examine economic sustainability via return on investment and net present value. Another approach is to examine both economic and environmental sustainability via marginal abatement (of

CO2) cost curves. The Sustainable Development Unit of the UK has used such marginal abatement curves to examine how different sustainability strategies could lead to potential CO2 emissions reductions and the associated financial costs needed to do so (16).

The relevance to sustainability of the mantra ‘Reduce, Reuse, Recycle’ is appraised. Life Cycle Assessment (LCA) as a method to examine sustainability is introduced and caveats to this method mentioned. The chapter then centres upon a literature review of sustainability within healthcare and more particularly within the hospital OR and ICU. The factors that are relevant to hospital sustainability compared with other aspects of sustainability more generally are examined. The current understanding and research base of hospital sustainability are explored and knowledge deficits emphasized. Finally, the aims, objectives and research questions as given at the end of Chapter 1 are discussed and justified.

A detailed history of sustainability is beyond the scope of this thesis. Sustainability, A History by J. Carodonna(17) provides a detailed account of the history of sustainability as a concept and way of thinking and is drawn upon in the following

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sentences. ‘Sustainable’ and the verb ‘to sustain’ derive from the Latin, sustinere meaning to ‘maintain, support, endure’ and stems from sub ‘up, from below’ and tenire, ‘to hold’. Various prominent figures in the 18th and 19th Centuries such as Adam Smith (The Wealth of Nations), Thomas Malthus (On Population) and John Stuart Mill (Principles of Political Economy) referred to economic, social and environmental sustainability, warning against the excesses of the industrial revolution and exponential growth on a finite planet. Environmentalism gathered pace gradually after the turn of the 20th Century. John Muir (founder of the Sierra Club), and later Rachel Carson (Silent Spring) were among several prominent environmentalists.

It was not until the early 1970’s however, that the noun ‘sustainability’ entered the English language(17). At the United Nations World Commission on the Environment and Development the Norwegian Prime Minister, Gro Harlem Brundtland defined sustainable development as “…development that meets the needs of the present without compromising the ability of future generations to meet their own needs."(18) Stimulated particularly by concerns such as climate change, ‘peak oil’, inequality and dwindling taxation revenue sustainability became a mainstream word and topic. By the end of the 20th Century sustainability; had evolved from a vague concept to one with solid foundations; taken on economic, environmental and social meanings; and become a research area in its own right, complete with University Sustainability Institutes(19).

2.2 REDUCE, REUSE, RECYCLE

‘Reduce, Reuse, Recycle’(13) was first heard in the early 1970’s, and although the exact origin is unclear it was certainly promulgated at the First World Earth Day with its associated publications(20). Although the ‘3Rs’ mantra has become ubiquitous in many societies its scientific foundation is more recent. Whilst there is certainty that ‘reducing’ will by definition decrease requirements for energy, water, and chemicals and reduce pollution it is unclear whether which of reusing or recycling has lower environmental effects and how this will vary with each item or process. Life Cycle Assessment (LCA) has developed as a method to examine such effects and is discussed in the next section of this chapter.

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LCA has been used to develop a research based ‘waste hierarchy’, i.e. the environmental effects are lessened if our practice is to; firstly reduce the use of materials, then reuse, recycle, incinerate, and finally send to landfill(14). There is ongoing debate surrounding how recycling may/may not curtail the overall use of material resources and the relative importance of each of the ‘3R’s’(15). In certain circumstances some environmental effects may be greater when reusing rather than recycling or even disposing to landfill(15). Nevertheless the ‘3R’s’ mantra is well known, simple and testable, particularly with the evolution of LCA methods(14).

The Reduce, Reuse (reprocess), Recycle (and segregate) waste hierarchy provides a useful framework to consider hospitals’ environmental effects. Methods for reducing resource consumption, CO2 emissions and waste amounts (including toxic by- products) range from minimizing hospital admissions (improvements in primary health care and increasing out-patient procedures) to reducing the use of drugs and equipment in daily practices. Reducing not just the amount, but also the variety and diversity of equipment may well lead to improved healthcare financial and environmental sustainability, though this area of research is not examined.

2.3 AN INTRODUCTION TO LIFE CYCLE ASSESSMENT (LCA)

Life cycle assessment (LCA) is a scientific method to determine the entire ‘cradle to grave’ environmental and financial effects of processes and products(9, 21). In 1991, the Society for Environmental Toxicology and Chemistry defined the components of an LCA of an item to be analysed; 1. raw material acquisition, 2. processing and manufacturing, 3. distribution and transportation, 4. use, reuse and maintenance, 5. recycling, and 6. waste management(9). Everything we use and do has a footprint, whether this be for any product or service (e.g. admission to hospital). LCA allows for rational product and medical practice choices that reflect true environmental and financial costs beyond short-term effects. LCAs have a ‘system boundary’, i.e. a limit to which one examines the environmental effects of a product or process. This system boundary is defined by local Australian and international standards (22, 23). For example, if we are examining a plastic syringe the system boundary could be defined to include the manufacture of the plastic and ongoing maintenance of installed infrastructure, but not the actual manufacture of such installed infrastructure used in turn to make the syringe.

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Environmental factors beyond CO2 (‘carbon’) emissions, including water consumption, petrochemical use, eutrophication (excessive nutrient enrichment of watercourses) and release of toxic by-products can be accounted for in an LCA. Comparisons between items may indicate relative advantages for one outcome (e.g.

CO2 emissions), which may be contrary to other outcomes (e.g. water use and contamination). In the late 1990s, standardization of how LCAs should be conducted was achieved when the International Organization for Standardization (ISO) released the ISO 14000 series(22).

LCAs make use of life cycle inventories (LCIs). An LCI is a catalogue of flows to and from nature; with inputs such as energy, water and raw materials, and outputs (releases) to air, land and water. There can be a large number of inventory flows numbering in the hundreds; for example even a simple plastic syringe’s LCI requires flows of petrochemical resource extraction, manufacture, transport and use. To examine all of these details de novo every time an LCA was undertaken would be exhaustive and expensive. So, whilst it is ideal to obtain as much primary data as possible (e.g. measurement of a hospital steriliser’s direct energy and water use) secondary sources of information are usually required for LCAs (e.g. details of plastic manufacture). Large, national and international databases are the routine sources for such information, such as Gabi®(24) and EcoInvent®(25) which incorporate geographically specific average industry data. For example, the estimated CO2 emission from burning coal from a defined region is obtained from such environmental databases. Such average industry data can have greater associated uncertainty than directly measured (primary) data(26, 27). Care must then be taken to ensure that the secondary data indicates the local conditions of the LCA in question (e.g. local coal fired electricity versus gas fired electricity used for the secondary data). It is important to be aware that the CO2 emissions per kWh of electricity produced in Victoria, Australia, are very high by world standards as the electricity is sourced from CO2 emissions intensive brown coal(25).

Re-iterating, the LCI has inputs (such as electricity from coal) that are combined to form an output (e.g. a plastic syringe). Every input from secondary databases has a degree of uncertainty associated with it. This uncertainty routinely cannot be derived directly from the available information, so a standard procedure was developed to derive uncertainty factors from a qualitative assessment of the data, known as the

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Pedigree Matrix(27). The Pedigree Matrix is a commonly used qualitative scoring system derived from the secondary data’s reliability, completeness, temporal and geographical proximity to the process or item being assessed, and further technological factors(26, 27), with a score from 1 (good) to 5 (poor) for each factor.

The Pedigree Matrix relies upon expert judgement. For example, if the secondary data for CO2 emissions per kWh of electricity produced was obtained recently from all local coal fired power stations this would have better reliability, completeness, and temporal and geographical proximity than secondary data from an overseas derived database which sampled one coal fired power station a decade ago. As the Pedigree Matrix is based upon expert opinion it is open to a perception of irregularities. The Pedigree Matrix has been updated to incorporate some of these concerns with greater emphasis upon direct empirical values for each of the factors (28).

Similarly, there are also uncertainties associated with all LCA primary inputs that are directly measured. For example, our prior LCA study of plastic drug trays required transport of such trays from China to Australia. There is little uncertainty associated with the CO2 emissions from such shipping as the distance travelled is well known and the variability in fuel consumption of container ships is small. On the other hand, for the reprocessing of the reusable plastic drug trays, if we had measured just once the electricity use of the washer rather than over several days with different load types, the CO2 emissions from such electricity use would have a greater associated uncertainty. As for secondary data from LCI databases, the Pedigree Matrix for primary input data is a qualitative scoring system.

For every LCA potentially hundreds of mostly secondary inputs contribute to output data, each with associated uncertainty distributions. The Pedigree Matrix for each of these inputs determines the degree of uncertainty. How does one then combine the values and frequency distributions of these hundreds of inputs to obtain outputs such as CO2 emissions and water use? Monte Carlo methods are a broad class of computational algorithms that rely on repeated random sampling to obtain numerical results. Monte Carlo methods are useful when there are large numbers of inputs and where it is not pragmatic to obtain data for each of these inputs de novo and are used routinely in LCA.

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When there is a range of possible values for a result there are a number of approaches to how to determine the best estimate and the frequency distribution around this result. Monte Carlo methods take data points from within the frequency distributions for all inputs to develop a final output result, frequency distribution and the plausible range including the central tendency of the frequency distribution(27) . The greater the number of ‘runs’ by Monte Carlo analysis the better the estimate of the most likely value and the associated frequency distribution.

Starting with Coca-Cola bottles in 1969(29), a multitude of LCAs from a diverse range of industries have been undertaken. In industry LCAs are common as they identify high energy and water use as well as waste production, e.g. in the steel industry(30). In architecture and building construction LCAs have guided knowledge about ‘green buildings’ for the Leadership in Energy and Environmental Design (LEED). In government there has been less emphasis upon LCAs although in some countries with CO2 emission reduction plans this is beginning to change. For example, the UK plans to reduce the entire country’s CO2 emissions by 34% by 2020 from 1990 levels(31). LCA such as that performed by the UK Sustainable Development

Unit (SDU) will guide future CO2 emission reductions within the UK’s healthcare system(4). Nevertheless, comparatively few LCAs have involved medical items and practices(32) (detailed later in this chapter, Sections 2.5.5 and 2.6.1).

There are several types of LCA of which two are particularly relevant to healthcare sustainability; Economic Input-Output LCAs and process based LCAs. Economic Input-Output LCAs assign an environmental effect to an item, process or service via knowledge of a monetary value. National economies are divided into many sectors (e.g. pharmaceuticals) with at least 100 sectors in developed countries (33). Each sector receives inputs from many other sectors and conversely has outputs to many sectors. Each sector has a different ‘intensity’ of environmental effect per financial cost. Such intensities are developed by government departments, e.g. by the Department of Commerce in the USA.(34). Briefly, for each sector, data are obtained of the monetary inputs from each financial sector, and likewise the monetary outputs (i.e. dollars produced) to each financial sector. Through calculations an environmental cost/$ for each sector can be developed.

Different sectors of the economy have different environmental impacts.

Pharmaceutical production will have a different carbon intensity (CO2 emissions) for

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every dollar spent on producing a drug compared with the CO2 emissions of producing one dollar of foodstuffs or manufacturing plastics. For example, if a plastic syringe costs $0.10 there is a carbon, water etc. footprint associated with that syringe based upon the $0.10 that will be different to the environmental footprint of producing drugs.

When attributing an environmental cost to a sector, e.g. pharmaceuticals, areas such as research and development, lawyer fees and fees and travel for drug representatives are all included. The advantages of Economic Input-Output (EIO) LCAs are that they are all encompassing (‘broad brush’) and relatively inexpensive to perform once the initial expensive data gathering has occurred. Thereafter one only has to find the financial cost of any item or process in order to arrive at an environmental cost.

Process based LCAs arrive at an environmental cost for an item or activity based upon measured inputs. Process based LCAs thus examine the immediate inputs, but not more distant inputs, i.e. they have a smaller ‘system boundary’ than input output LCAs. For example, the aforementioned $0.10 plastic syringe has a weight and petrochemical composition that would be linked to environmental effects, but all of the associated effects resultant from petrochemical industry activity such research and development and the manufacture of machinery for drilling and exploration are not included. The environmental effects of process based LCAs are thus routinely less than EIO LCAs.

Process based LCAs do not encompass all of the effects of an item or process and are more expensive to perform than EIO LCAs. They do, however provide a detailed analysis of an individual item or activity and are useful when comparing two similar items/activities. Further, EIO LCAs are less precise for many products and processes in healthcare. Consider a drug, medical device or operation that costs twice as much as another: an EIO LCA would consider that the more expensive process has double the environmental effects, which could be unrealistic. On the contrary, it may be impossible to obtain details of pharmaceutical manufacturing for a process based LCA, leaving a questionable EIO LCA as the only manner in which to assess a drug’s environmental effects. Hybrid LCAs; (combinations of EIO LCAs and process LCAs) are used infrequently to attempt to overcome any knowledge gaps(35), but should be used with care when comparing two products or processes as input-output data will overestimate environmental effects in distinction to process based data.

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2.4 LITERATURE REVIEW METHODS

This literature review is based upon a publication by McGain and Naylor(36). The aim of the literature review was to identify all articles that added new findings to the evidence base of environmental sustainability within hospitals. The bibliographic databases PubMed and Engineering Village were searched for articles published in English between 1/1/1990 and 1/6/2015. The Cochrane library, the King’s Fund (UK) library database, and the websites of the Sustainable Development Unit (SDU) and the Sustainability for Health and Evidence Base for Action were also examined for the same period.

A search of PubMed for ‘sustainability’ alone revealed more than 12,000 references. Assessing the title and/or abstract of the first 200 of these, the majority were found not to pertain to environmental sustainability. To improve the search specificity a search algorithm was developed based on: 1. the main themes related to environmental sustainability found in the first 200 references, and 2. an existing conceptual framework developed by the SDU(4) Evidence relating to the following themes was identified: Hospital design, Energy, Water, Travel, Procured goods, Waste, and Staff Behaviour.

The search algorithm required that articles include the term ‘sustainability’ AND at least ONE of the following: ‘hospital’, ‘green’, ‘environment’, ‘architecture’, ‘energy’, ‘water’, ‘travel’, ‘life cycle assessment’, ‘waste’, ‘recycling’, ‘reusing’, ‘reprocessing’, ‘psychology’ and ‘behaviour’ and ‘behavior’. Further studies were found by review of other publications’ references, in particular recent related reviews(37, 38) and books(1, 7, 11) To avoid missing important studies in this review the first 200 (of >12,000) references found using ‘sustainability’ alone as a search term were rechecked. The more focussed search algorithm included the same studies as those found in the broader search.

The inclusion criteria were that studies had to be relevant to environmental sustainability within hospitals (as defined by the previous search algorithm) and either introduce new data or provide the latest review of a topic. There are a number of advocacy groups in several countries promulgating more sustainable approaches to healthcare, particularly within hospitals. These groups tend not to produce new research, but are mentioned here as they are influential in suggesting novel

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approaches to more sustainable healthcare. Examples include: 1. in the USA- Healthcare Without Harm(39) and the Green Guide to Healthcare(40), 2. in the UK- the Centre for Sustainable Healthcare(41), 3. in France, le Comité pour le Développement Durable en Santé (the Committee for Sustainable Healthcare Development)(42), and 4. in Australia- the Climate and Health Alliance(43) and the Doctors for the Environment Australia(44).

Novel approaches or trends to the study of sustainability within hospitals (such as life cycle assessment, reprocessing and behavior change) were included. Comment or advocacy pieces were excluded unless they introduced new themes or topics. Studies that were older or very specific and covered by more general or newer reviews were also excluded. A formal quality appraisal tool was not used, as the objective was to assess the breadth of the evidence base, including all methodologies and study designs. Web searching and review of reference lists did not identify significant numbers of additional articles, indicating that the database search had been sufficiently comprehensive.

The articles were analysed using the same thematic framework that formed the basis of the search algorithm (see above). For each article, there was a summary of: 1. research findings which provided an assessment of the scale of the environmental impacts of hospital care; and 2. findings which provided an evaluation of the effectiveness of interventions to mitigate these impacts.

The findings of this literature review are presented as the research foundation for: 1. sustainability within healthcare and hospitals in general, and 2. sustainability within the OR and ICU with a particular focus upon life cycle assessment (LCA) and procurement. Many areas of research can contribute indirectly towards improving sustainability, but this review focuses upon research that has at its primary aim improvements in hospital sustainability. Many public health measures will indirectly improve hospital sustainability, e.g. demand for health services can be reduced through measures that confer health and environmental co-benefits (smoking cessation)(45). This review is primarily of hospitals in high income countries, but there is a large potential for research about hospital sustainability in other income settings, where the effects of unsustainable practices such as climate change will be particularly large.

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2.5 SUSTAINABILITY WITHIN HEALTHCARE AND HOSPITALS

Evidence relating to healthcare and hospital sustainability is given following the themes identified in the Methods section above: i.e. hospital design, energy, water, travel, procured goods, waste, and staff behaviour. Evidence relating to OR and ICU sustainability is detailed in Section 2.6 and primarily details procurement, waste and life cycle assessments of specific products or procedures.

While healthcare is likely to use a significant proportion of the world’s total natural resources (including oil, food, water and minerals) precise estimates are unavailable.

The delivery of healthcare contributes substantially to total CO2 emissions(3, 8), adding to the health effects of climate change(46). Further, healthcare systems are at risk of the effects of climate change on building infrastructure, human health, supply chains and resource security(47).

The focus of healthcare sustainability research is often on direct energy consumption and the related but not identical focus of reducing CO2 emissions. The National

Health Service (NHS) in England accounts for 3% of the nation’s CO2 emissions(4) while healthcare in the USA (with higher health expenditure per unit of GDP) is responsible for 8% of total CO2 emissions(3). In England, 19% of NHS CO2 emissions in 2010 were related to direct energy use in healthcare facilities, with 16% related to staff and patient travel, and 65% resulting from the production of procured goods (e.g. pharmaceuticals, food and medical equipment)(48). In Australia, a national analysis of healthcare’s ‘carbon footprint’ has not been performed, but the calculation of CO2 emissions from metropolitan hospitals in Melbourne(5) had similar results to CO2 emissions for hospitals in England(48).

Despite the evolution of sustainability as a field of interest and research more broadly, within healthcare the issue has lagged as hospitals in particular are focussed upon immediate patient needs and there has not routinely been a culture of sustainably(37, 49). There are numerous voluntary organisations supportive of sustainability within healthcare and hospitals(39, 41, 42, 44). As of mid-2015, however, the United Kingdom (UK) was the only nation that has a government institution within healthcare specifically devoted to improving environmental sustainability, the Sustainable Development Unit (SDU). In 2008 the UK Government introduced the

Climate Change Act, mandating a nationwide reduction in CO2 emissions by 80% by

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2050 compared with 1990. As a direct result of this mandate, the SDU has been measuring the National Health Service’s (N.H.S.’s) carbon emissions(4) and identified carbon hotspots(8). Differences in opportunities to improve healthcare sustainability between a country with mandated carbon emission targets (the UK) and those without (Australia) have been examined(50).

Sustainability may not be considered within healthcare for other reasons. Specifically, healthcare sustainability is not solely about the environment, and could be reframed(2). Being more sustainable means; improving patient care, avoiding ineffective treatments, increasing healthcare equity, raising efficiency and thus saving money, and improving environmental outcomes(6, 37, 51).

This literature review did not provide a detailed examination of general attempts to improve the sustainability of any building unless they were specific to hospitals (e.g. the energy efficiency of operating room ventilation). Thus, ongoing general improvements in wall cladding or air conditioner energy efficiencies are not examined.

2.5.1 Hospital design

Sustainable architecture has an extensive research base, including textbooks with hundreds of references and standards focussed specifically on healthcare(11, 12) For example, the Green Guide for Health Care details methods to improve hospital design, construction, operation and maintenance and provides a toolkit for self-assessment towards best environmental practice(40). Such guidelines and textbooks specific to healthcare design arose from earlier efforts to improve the environmental standings of all buildings such as the Leadership in Energy and Environmental Design (LEED), developed by the US Green Building Council(52). The work of the group ‘The Design & Delivery of Robust Hospital Environments in a Changing Climate’ (led by Short et al) at the University of Cambridge (UK), is also acknowledged(53).

Incorporating energy efficiency at the planning and design stage is important for securing longer-term efficiencies(54). Energy usage per unit area (m2) for hospitals is the second highest for all building types(55), but varies considerably between hospitals depending on design(56). Most modern hospitals are built on a deep-plan design (with a large distance from the centre to the periphery), requiring high electricity consumption for ventilation of the building’s core(56).

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There have been some encouraging research findings regarding the benefits of ‘healthy’ buildings to staff and patients. For example, Ulrich(57, 58) found that having a ‘room with a view’ (i.e. a view of a tree versus a brick wall) reduced hospital length of stay and analgesia requirements post-operatively but as the sample size was small further research is needed. On the contrary, Wunsch et al found that the presence of a window room for ICU patients with subarachnoid haemorrhage had no effect upon patient outcomes(59). The purported benefits of healthy buildings remain somewhat contentious and require further research.

Absenteeism appears to be less in sustainable work environments, though this has been rarely studied in healthcare environments(58). There are potential areas of conflict between greater upfront capital costs and reduced recurrent costs. Single patient rooms may be associated with reduced infection rates, but have greater initial costs and energy requirements compared with multi-use patient rooms(11, 58). Two reviews(60, 61) suggested that the benefits of single patient rooms are not yet proven and that further research is needed to investigate the balance of costs and benefits, as indicated by ongoing controversy about the clinical and social advantages of single patient hospital rooms(62).

2.5.2 Energy

Direct energy use by healthcare accounts for approximately 20% of all public sector energy consumption in Victoria, Australia(63) and is likely to be similar in other developed countries. Heating, ventilation and air conditioning typically account for at least half of direct hospital energy usage, with lighting and equipment accounting for most of the remainder(64) How much energy use arises from individual hospital areas such as the operating suite is not well established. Further, there is incomplete information on the energy consumption of many common machines as they are actually used within hospitals rather than being determined by the manufacturers’ specifications(65).

A large body of architectural and engineering research focuses on reducing direct energy consumption in buildings of all types. There are several instances in which the large and continuous energy requirements of hospitals have stimulated research into specific technologies and energy sources, such as gas-fired co-generation, solar thermal cooling and ground-sourced heat pumps(64). Co-generation (combined heat

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and power) is ideal for hospitals which require continuous electricity and heat, provides added energy security, and can have reasonable payback times(55).

There has been a limited amount of hospital-specific research examining energy usage for heating, ventilation and air conditioning. Tensions can exist between protecting the patient and the environment, often due to infection control concerns(66). A one degree Celsius rise in room temperature in summer or reduction in winter can reduce annual cooling and heating costs by 5%(7). Methods to reduce hospital energy consumption by widening the permitted temperature range, particularly during extreme weather events, without compromising safety or alienating patients or staff are largely unexplored.

Ventilation within most buildings is routinely mixed ventilation (supply air mixes with room air) or, less commonly, displacement ventilation (supply air spreads from the floor and rises as it warms)(67). Displacement ventilation can produce equivalent air quality with lower energy consumption, but quantification of savings is unclear within hospitals(67). Hospital ventilation is routinely left running continuously, including within operating rooms (ORs) that are unoccupied overnight. There is, however, evidence of no difference in the microbiological load of air samples from ORs where the ventilators are turned off in idle ORs overnight compared with ORs with continuous ventilator usage(68).

Several models estimating healthcare energy use occurring with inpatient and outpatient admissions and different types of surgeries have been developed by Pollard et al(69, 70). The aim of such modelling is to improve the financial and environmental sustainability of healthcare without impeding patient care. Work occurring at the UK SDU (48) will assist in guiding hospital staff to reduce energy use and carbon footprints.

2.5.3 Water

Hospitals use considerable amounts of water – e.g. 1% of a city’s total water consumption(71). Within a hospital the majority of water use occurs in four areas; wash basins, sinks and showers (20 to 40% of total); toilets (15 to 30%), laboratories, cooling towers, macerators and sterilisers (15 to 40%); and food preparation (5 to 25%)(71).

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Water savings of 10 to 25% can be achieved through simple means which do not require further innovations or research: auditing usage including installing data- logging meters and sub-metering; checking for leaks; applying flow restrictors on hand basins and showers; installing dual-flush toilets; and reclaiming water from dialysis units and sterilisers(71). Areas of ongoing research have focussed upon the operating suite and the dialysis unit. Significant water savings are possible (hundreds of litres/tap/day) from altering the surgical hand scrub whether through water-saving devices such as automatic tap timers or replacing water with disinfectants(72). Water savings of several thousand litres/day are also possible from dialysis units(73-75).

2.5.4 Travel

Hospital travel incorporates ambulance, private and public transport. Car travel in particular is a major contributor to CO2 emissions as well as being an inactive, unhealthy form of transport. The UK SDU estimates that 16 percent of carbon emissions related to healthcare are attributable to staff and patient travel(4). Improving the sustainability of hospital travel can be subdivided into technical, financial and social changes. Technical changes include any incremental improvements to vehicle technologies and service transformation to reduce travel. Financial interventions include incentives to increase active and public transport or increasing car parking fees to reduce car travel. Social and cultural factors shape the forms of transport used by hospital patients and staff.

Technical changes may lead a transformation of hospital travel. Improved teleconferencing or telemedicine can reduce travel demand for business, patient and staff leading to financial, environmental and time savings(76, 77) Other clinical innovations, however may increase patient travel. Replacing thrombolysis in local hospitals with interventional cardiological procedures in more distant, larger hospitals will increase ambulance CO2 emissions(78) highlighting conflicts that can arise between protecting the patient and the environment(66).

Whether altered financial or tax incentives can change travel pathways to hospitals is an important topic for future research. Perverse incentives may mean that the pecuniary interests of hospitals are at odds with sustainability; e.g. rent from car parking vs. lower fees for pooled cars, or tax reimbursements for inter-hospital travel(79).

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Social factors are also likely to be important in altering hospital transport. Large reductions in car transport to hospitals are possible with improved public transport services, car-pooling and encouraging cycling. For example, at Addenbrooke’s hospital, Cambridge, UK, by doubling the number of bus services and greatly improving hospital bicycle facilities the proportion of journeys made by car was reduced from 60% in 1999 to 38% in 2006(80). Social norms and peer influence within the hospital workforce may shape staff decisions regarding how to travel to work. Research regarding the most important determinants of travel behaviours is limited.

2.5.5 Procurement

Several studies have found that procured goods represent by far the largest contributor to healthcare’s carbon footprint(8). Research on haemodialysis, for example, has shown that dialysis consumables are responsible for similar CO2 emissions to total dialysis transport and dialyser energy use combined(81). Over the past 30 years many reusable products have been replaced by disposable ones across most specialties, such that “…hospitals are now awash in throwaway supplies”(12). The research base of the environmental effects of hospital procurement is far less developed than for hospital architecture and engineering.

There is a natural tension between the potential environmental and financial benefits of reusable medical devices and their possible infection control concerns(66). The move to single use items has not been well studied and appears to be driven by other factors beyond infection control practices, such as cost, ease of use, difficulty making some reusable items patient ready again, individual (doctor) preferences and marketing(12).

Efforts to understand the entire ‘cradle to grave’ environmental and financial costs of items or processes are based upon the method of life cycle assessment (LCA), introduced previously in Section 2.3 in this chapter. Despite being common in other fields, LCAs are relatively new to healthcare. Most medical LCAs have occurred in the fields of anaesthesia, surgery and dialysis units. LCAs within the OR and ICU are examined in Section 2.6.1 of this chapter.

Within nephrology there have been several recent LCA studies. Connor compared the carbon footprint of UK home and hospital dialysis finding that home dialysis had a

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greater footprint, and disposable dialysis items have a considerably larger footprint than other components to dialysis such as electricity use or transport to and from hospital(81). A similar Australian study found comparable results, noting further that regional variation in the source of energy (e.g. coal, gas, hydroelectric) dramatically altered the relative importance of the carbon footprint of the electricity used for dialysis(82). One study of the life cycle of receiving a CT scan in Kansas, USA found that the electricity used when the CT scanner was idle was an order of magnitude greater than the energy used for an actual scan received by the patient(83). Follow up studies examining the ability in a busy hospital to turn CT scanners off rather than leave them in standby are required. LCAs are rare in other fields of medicine (e.g. general practice, physician subspecialties).

Pharmaceuticals appear to have high environmental and financial costs as they appear to be energy intensive to manufacture(8). Openly available LCAs of pharmaceuticals will become increasingly important due to their high costs and large carbon footprints(84). Pharmaceutical companies have rarely engaged with LCA researchers and published in peer-reviewed journals, perhaps due to concerns regarding commercial confidentiality. In December 2012, however, a UK guideline Carbon footprinting pharmaceuticals and medical devices was promulgated by a collaboration of pharmaceutical representatives, health services employees, clinicians and LCA experts(85).

Chemists and chemical engineers, responding to concerns regarding the environmental footprint of their products and processes, have established a scientific foundation to ‘green chemistry’ which could be emulated in medicine(86). There has been some engagement of manufacturers of healthcare products and organisations such as Healthcare Without Harm to reduce the effects of packaging and waste(87). There is also renewed interest in return of unused medicines, one study finding that one quarter of all returned medicines were suitable for reuse(88).

Interest in the environmental effects of treating dialysis patients has been stimulated by funding from the UK Green Nephrology Scholarship. The frequency of dialysis has a greater effect upon CO2 emissions than dialysis duration(89) With the rise of home dialysis delivered more frequently, innovative approaches will be required to prevent the predicted doubling of CO2 emissions per dialysis patient, including methods to reduce consumables and waste disposal(89). Embedding sustainability

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into overall hospital procurement is still in its infancy and faces financial (real or perceived) and attitudinal barriers(90).

2.5.6 Waste

Hospitals in the USA alone generate an average of 5,500 tonnes of waste every day(91), indicating considerable opportunity to reduce hospital waste leading to financial and environmental improvements. The environmental and financial benefits of improving waste management processes are generally greater when moving progressively through the ‘waste hierarchy’ from discarding, through recycling, reuse, reduction and finally to avoidance of creating waste materials in the first place(14).

Avoidance of unnecessary or unproven hospital procedures is likely to have a greater effect than all current hospital recycling initiatives. There are many examples within medicine of unnecessary procedures, e.g. routine preoperative chest-x-rays(92) or coagulation tests(93).

Hospital recycling does, however, have an established research base. Examination of waste disposal shows financial and environmental benefits stemming from treating infectious waste by microwaving rather than autoclaving, lime or incineration(94). Approximately 30% of all hospital waste is paper and cardboard and a similar proportion is plastic, indicating high recycling potentials(95). Infection control concerns regarding hospital waste recycling can be managed provided there is appropriate education and action(96).

2.5.6 Behaviour

The psychological and social factors that shape hospital staff and patient behaviours is an important research topic(49). While an interest in the environment in their personal lives has been found to increase the likelihood that individuals would recycle at the hospital, often environmentally sustainable personal behaviours are not carried into the workplace(96).

Topf examined staff indifference to unsustainable hospital practices such as excessive lighting, consumption and waste(97). This research suggested that hospital environments encourage environmental ‘numbness’, and elicit a range of coping mechanisms including denial that unsustainable behaviour is occurring; overly critical thinking that may prevent change; myths that green practices and buildings are

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prohibitively expensive; temporal justification (i.e. staff being too busy dealing with short term goals to become involved in enduring concerns); and the so-called ‘moral offset’ - “I’m doing enough good just being a doctor.”(97).

Group coping mechanisms include diffusion of responsibility (someone else will solve the problem) and ‘groupthink’ (the illusion of unanimity due to the leader’s influence)(97). By supporting employees to make ethical decisions that align with their own values, employees are more likely to take action to address these concerns(98). There has been minimal research within healthcare about which of these psychological factors (e.g. the moral offset or groupthink) are the most important to address in order to encourage sustainable practice amongst hospital staff. Further, there is minimal understanding of patients’ views of healthcare sustainability(97).

OR and ICU sustainability research has occurred particularly within the fields of procurement and life cycle assessments of specific products or procedures, in addition to waste management (including reduce, reuse, recycle and reprocess). Themes such as the built environment, energy and water have been discussed previously as part of the more general topic of hospital sustainability. Although there are OR and ICU- specific energy saving areas such as reducing theatre ventilation when not in use(68) the majority of energy saving possibilities are likely to stem from more generalized improvements in overall heating, ventilation, air conditioning and lighting(99).

The Association of Anaesthetists of Great Britain and Ireland(100), the Association of Surgeons of Great Britain and Ireland(101) and the American Association of Anesthesiologists(102) have all separately issued policy documents to promote consideration of, and research about, the sustainability of anaesthesia and cost- effective and sustainable surgery. General reviews of sustainability efforts to reduce energy and water use and waste indicate the potential financial and environmental cost savings(32, 103-105).

2.6 SUSTAINABILITY WITHIN THE OR AND ICU

Operating room (OR) and intensive care unit (ICU) sustainability research has occurred particularly within the fields of procurement and life cycle assessments of specific products or procedures, in addition to waste management (including Reduce,

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Reuse, Recycle and reprocess). Themes such as the built environment, energy and water have been discussed previously as part of the more general topic of hospital sustainability. Although there are OR and ICU-specific energy saving areas such as reducing theatre ventilation when not in use(68) the majority of energy saving possibilities are likely to stem from more generalized improvements in overall heating, ventilation, air conditioning and lighting(99).

2.6.1 Procurement and Life Cycle Assessment (LCA) in the OR and ICU

Procurement is the purchase of goods and services. Within the OR and ICU large numbers of single use devices are procured(32) and in addition, the OR particularly makes use of reusable steam sterilised items. The LCA method is being used increasingly to determine the environmental effects of these products and processes within the OR and ICU, particularly when comparing reusable and single use variants of a product and to examine entire surgical operations.

The environmental effects of procurement include the device or product itself, whether it be single use, reused, recycled or reprocessed and the effects of the packaging associated with that device. There is little information regarding the environmental effects of the significant packaging used to transport medical devices and which may have larger effects than the product itself. Further, despite the increasing interest in sustainability, the majority (70%) of OR suppliers do not promote sustainability practices(106).

Operating theatre LCAs have primarily been comparisons between reusable and single use variants of medical devices: surgical drapes(107), gowns(108), suction canisters(109), laparoscopic ports(110), and laryngeal masks(111), and dental burs(112). In the majority of these cases the reusable versions were found to be less financially expensive and had lower environmental effects (CO2 emissions, water use,

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and land and water pollution) than the single use variants. Such environmental effects varied greatly according to the energy source used (e.g. coal has far higher CO2 emissions than renewable energy sources)(112). Further, the environmental effects of the reusable items varied considerably with the relative efficiency at which the steam steriliser was loaded(112).

Input-Output LCAs attach an environmental effect to a financial value (as noted in Section 2.3) and have now been performed for entire operations. The carbon footprint of one cataract operation was found to be approximately 180 kg(113) (i.e. similar to burning 80 litres of petrol)(114). A process based LCA of the environmental effects of vaginal childbirth deliveries versus caesareans found that the former had approximately 40% of the carbon footprint of a caesarean operation(115). A recent hybrid model of input-output and process based LCA compared different types of hysterectomies, finding that robotic surgery had higher environmental effects than standard hysterectomies(35) and that the anaesthetic gases used during the operations contributed to approximately 30% of the total CO2 emissions for the entire operation. Such LCAs of whole procedures complement studies of individual devices.

Despite the ubiquity of pharmaceuticals there have been few openly available LCAs examining their environmental effects(105). It is often easier to perform LCAs of medical equipment rather than pharmaceuticals because there is usually open access to the manufacturing methods for the former (e.g. plastic and steel production). The fundamental barriers to performing process based LCAs of pharmaceuticals appear to be primarily industry resistance (i.e. the commercial implications of comparing processes or items) and the costs of performing the study. Process based LCAs are expensive to perform (usually greater than AUD$10,000) primarily because of the labour costs of data gathering and validation. Sherman et al examined the environmental life cycles of several general anaesthetic drugs, finding that the carbon footprint of the intravenous drug propofol was less than one hundredth of desflurane’s(116). Nevertheless, this LCA relied upon generic data as no pharmaceutical companies were involved in the study despite invitations(116).

With collaborators I completed a process based LCA of plastic drug trays prior to PhD enrolment which is detailed further in Section 2.6.8 of this chapter(65).

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2.6.2 Waste

The Reduce, Reuse (reprocess), Recycle (and segregate) waste hierarchy(14), in tandem with life cycle assessment, provides a useful framework to consider the environmental effects of work within the OR and ICU(32). ORs and ICUs are highly active parts of the hospital and correspondingly generate large amounts of waste. As examples of this intensity, the daily landfill waste from all operating rooms in the USA is more than 1,000 tonnes of rubbish(91). Beyond physical waste there are also the consumption of gases (e.g. inhalational anaesthetics) and pharmaceuticals.

Approximately 20% of all hospital waste stems from the operating room(95). Plastics form approximately 30% of operating room waste(95, 117). It has been known for more than 20 years that the recycling potential of the OR is large and that reducing the incorrect labelling of infectious waste can have significant financial benefits(118).

The recycling of waste is discussed further in this chapter under ‘Recycling’ (Section 2.6.6). With collaborators, I completed several waste audits of OR and ICU waste(119, 120) prior to PhD enrolment which are detailed further in Section 2.6.8 of this chapter.

2.6.3 Waste-Anaesthetic Gases and their Global Warming Potential

A special case of healthcare ‘waste’ relates to anaesthetic gases, divided into volatile gases (desflurane, sevoflurane, isoflurane and halothane) and non-volatile (nitrous oxide). These gases can be used in both the OR and ICU, but in Australia tend to be used only in the OR. Such gases provide general anaesthesia, are metabolised and degraded in only minimal amounts, and are subsequently vented via hospital scavenging systems to the atmosphere where they have a direct Global Warming Potential (GWP)(121, 122). GWP is defined as the relative potential of a gas to absorb energy in the infrared spectrum and thus warm the planet, compared with the baseline gas CO2(122). Worldwide, anaesthetic gas use is estimated to have the same carbon footprint as one million average passenger cars(122). Nitrous oxide, for example has a

GWP 300 times that of CO2 and providing anaesthesia with it for one hour at a standard rate is comparable to driving an average car several hundred kilometres(123).

Volatile anaesthetic gases with similar chemical structures may have GWPs which are an order of magnitude different; e.g. sevoflurane has a GWP of 130 whilst

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desflurane’s GWP is 2,540(122). Such volatile anaesthetics may be used interchangeably with no clinically different outcomes(32) indicating that the individual anaesthetist has an ability to significantly alter their carbon footprint according to their work practices(32).

Using anaesthetic gases at the lowest flow is the most obvious method to reduce the global warming effects of anaesthetic gases(124). Alternatively, for some operations, one could use intravenous anaesthetic drugs which have no direct GWP in lieu of anaesthetic gases(116). Further, there are technologies available that absorb the volatile anaesthetic gases and avoid their release to the atmosphere(125, 126). Despite these promising technologies used primarily in North America, they are not available in Australia as of mid-2015.

Other gases are also ‘wasted’ in the OR and ICU, e.g. oxygen and ‘medical air’ (i.e. filtered air). In the ICU high flows of oxygen and air are used, whilst lesser amounts are used in the OR due to the low gas flows and resorption of CO2. There has been little focus upon these gases, including an examination of the energy required to compress them (e.g. conversion of oxygen to the liquid state for storage) and their environmental footprint is unknown or unpublished.

2.6.4 Reduce

It is very likely that to reduce the use of products and processes will decrease financial and environmental costs, yet such ‘reductions’ must avoid reduced patient care. Methods for reducing resource consumption and environmental effects in the OR and ICU range from; minimizing hospital admissions (improvements in public health care to reducing trauma rates and increasing out-patient procedures), and reducing the use of drugs and equipment for each procedure(32).

There are a number of behaviours in the OR and ICU that reduce the environmental footprint without impeding effectiveness: opening equipment only when needed, removing cotton gauze from pre-packed anaesthetic trays(65) turning off anaesthesia monitors between cases(127), using low flow anaesthesia(124), switching off lights and air conditioning or ventilation (including ICU isolation rooms) when not in use(104). Despite these and other possibilities to Reduce there is an ongoing increase in the amounts of waste stemming from ORs and ICUs(105).

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2.6.5 Reuse

Comparisons between the life cycles of reusable and single use devices used in the OR and ICU have been discussed previously in this chapter (Section 2.6.1). Comparing reusable versus single use medical devices, the limited literature suggests that it is both an environmental and financial advantage to consider reusable devices where these exist (surgical scrub gowns, metal instruments, plastic trays), although caveats exist. Methods used to re-sterilise reusable equipment have rarely been subject to environmental assessment. Greater scrutiny of and comparisons between different methods of sterilisation (e.g. steam, gamma radiation, hydrogen peroxide) would add significantly to knowledge about the environmental footprint of reusable items.

There appears to be much opportunity to increase the research foundation for ‘Reuse’ in the OR and ICU. In the ICU in particular, but also in the OR in many developed nations there are very few remaining items that are actually reused. Anecdotally, for example, in the USA it is routine in many places that each patient in the ICU and OR has a single use; blood pressure cuff, heating blanket, pulse oximeter and anaesthetic/ICU breathing circuit. In Australia it would be unusual to have single use; pulse oximeters, breathing circuits and blood pressure cuffs. Studies regarding the infection control concerns and legislative requirements for the use of common medical equipment of different jurisdictions are warranted.

2.6.6 Recycle

An important first step in recycling hospital waste is to separate infectious from non- infectious waste as infectious waste is costly in both financial and environmental terms and cross-contamination of infectious waste into recycling streams can cease such recycling(117). Recyclable, non-infectious waste should then be further separated (at least one-third of all OR waste)(117, 119). There are still many ORs and ICUs where separating infectious and general waste occurs to a limited degree and there are inadequate recycling arrangements(103, 117, 119). Efforts to recycle have been promulgated by many organisations mentioned previously (e.g. Healthcare Without Harm). Manufacturing products from recycled rather than raw materials is often environmentally attractive when the entire life cycle is considered, particularly

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for metals and plastics, although this will depend closely upon the proximity of the recycling facility(128).

Recycling of metals is potentially easier than other recycling streams as they are easily identifiable and valuable. Paper and cardboard products can be correctly recycled due to their readily identifiable composition and kerbside home recycling programs. Recycling of glass(129) does occur although glass generally has low financial value and glass ampoules which have contained pharmaceuticals can be challenging to recycle.

There are multiple varieties of medical plastics which may be inadequately labelled, though guidelines exist to aid recycling which have been mentioned in Section 2.6.2 (130). It can be important to separate some plastic types, such as polyvinylchloride (PVC), that are processed differently. PVC is used for items including intravenous fluid bags and oxygen tubing and can comprise approximately 20% of a hospital’s plastic waste(95). Anecdotally, in Australia and elsewhere plastic recycling of polyethylene and polypropylene has been occurring for several decades in some hospitals.

There is evidence from psychological studies that there may not be a strong positive correlation between those who recycle and those who also reduce and reuse(131). Recycling is a very obvious activity that is often observed by other staff members; whilst reducing or reusing may be inconspicuous (e.g. one may be unaware that a drug tray is reused after thermal disinfection rather than single use). Such differences may explain why recycling is avidly approached by groups of staff, whilst reducing or reusing is less enthusiastically welcomed(131).

2.6.7 Reprocessing

Medical devices can be divided into three groups according to their usage: 1. single use, i.e. one use only (disposable), 2. reusable, i.e. able to be washed and sterilized for patient reuse generally within the hospital and 3. reprocessed devices, i.e. undergo assessment, repair, sharpening, smoothing, cleaning and sterilizing before being reused. Typically reprocessing is performed external to a hospital by a third party, with the device returned to the hospital for less than half the financial cost of the original ‘single use’ purchase price(132). Reprocessing of medical devices is a multi-

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billion dollar industry in the USA(132), although as of mid-2015 it does not exist in Australia.

Currently, manufacturers determine whether their product is single use and lodge this information with the relevant regulatory body(133). Further research on the validity of labelling devices as single use may have significant environmental and financial advantages. It is unclear if reprocessing is more environmentally sustainable than purchasing new items, although reprocessing is less expensive and appears to decrease landfill waste(132).

2.6.8 Related work by the author prior to the beginning of the PhD

(i) An LCA of anaesthetic, plastic drug trays

I completed a process based LCA of drug trays in early 2010 with the collaboration in particular of an LCA expert at our six-operating room hospital in Melbourne, Australia(65). We compared the financial and environmental life cycles of reusable and single use plastic anaesthetic drug trays. We were particularly interested in the global warming potential (CO2 emissions) and water use. The reusable drug trays are washed (decontaminated), but are not required to be sterilised. Further, we examined the effects of adding cotton and paper to the drug trays, which is routine for all single use tray packages at our hospital. Cotton gauze and a paper napkin are added for fluid or blood spills, although anecdotally these are required by anaesthetists for less than half of operations. Our LCA included measurement of the labour costs to process a reusable tray to be patient ready again.

We found that the financial cost of single use drug trays with cotton and paper included was considerably greater than the reusable trays such that a conversion to the reusable trays would have saved the hospital approximately AUD$5,000 in 2010. We factored in the cost of requiring the cotton and paper to accompany the reusable trays half of all cases (likely to be an over-estimate).

The CO2 emissions for one reusable and single use drug tray was110g CO2 and 126 g

CO2 respectively (similar to driving an average Australian car one kilometre(114)) .

The CO2 emissions from the reusable and the single use plastic trays alone was similar primarily because the source of electricity for our hospital was brown coal, an energy source with very high CO2 emissions, whereas the electricity source for the single use drug tray was a combination predominantly of black coal and nuclear.

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The effect of adding just 3g of cotton gauze and 6g of paper added another 80g of

CO2 emissions. Further, the water use for growing cotton was an order of magnitude larger per gram than for plastics manufacture. Thus, although reusable drug trays processed in Melbourne’s hospitals rather than single use trays resulted in similar CO2 emissions, if cotton and paper were added routinely to trays (as is the case for all single use trays) the CO2 emissions appreciably increase and the water use is greatly augmented. Our study gave the worst case scenario for reusable trays due to the brown coal based energy mix in Melbourne, Australia. As a result of our LCA in late 2010 the hospital anaesthesia department changed from routinely using single use to using reusable drug trays, saving money and reducing the environmental footprint of drug trays. This LCA of (unsterilised) drug trays formed the basis for a second LCA examining the life cycle of a common sterilised ICU and OR item and which becomes a thesis chapter.

(ii) OR and ICU waste audits prior to recycling.

In 2009, with the assistance of hospital collaborators (at Footscray, Melbourne, Australia) I completed waste audits of OR and ICU waste, prior to formally commencing this PhD (119, 120). Prior to 2010 there was no recycling occurring within the hospital’s OR and ICU beyond paper and cardboard recycling in administrative areas. In order to perform the waste audits correctly we firstly obtained further details about the common medical items used in the OR and ICU and subsequently discarded as waste. Further, as recycling of such OR and ICU ‘waste’ was being considered post-2009, we needed to discover what types and amounts of recyclables were present.

Recycling plastic, cardboard, metals and household plastics could be straightforward as they were readily identifiable. Recycling medical plastics, however, could be problematic as there was limited information regarding different plastic types. We thus developed a simple guideline prior to the OR and ICU waste audits that enabled us to distinguish the plastic types that comprise common medical equipment such as intravenous fluid bags, oxygen masks and theatre wraps(130).

We then audited the waste exiting the OR and ICU for 5 and 7 days, respectively weighing 357 kg of OR waste and 540 kg of ICU waste. For the OR waste we examined in detail only the anaesthesia waste (i.e. stemming from anaesthesia waste

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bags contained on anaesthesia trolleys) which formed approximately one-quarter of all OR waste. The major findings from both the OR and ICU waste audits were:

1. Approximately 35-40% of the total waste could have been recycled 2. At least 40% of the recyclables were plastics 3. There was incomplete separation of infectious (clinical) waste from general waste leading to unnecessary hospital expenditure. This finding is similar to prior studies of hospital waste segregation(96, 117) (infectious waste costs at least four times as much per kg to dispose of compared with general waste) 4. Contamination of infectious waste in the general waste stream was minimal (less than 1%).

With these findings from our waste audits recycling programs were commenced within the OR and ICU. Audits of these post-recycling programs form ‘Chapter 9: Recycling. Waste audits in the OR and ICU post-recycling’.

Summary

This chapter briefly reviewed the history of sustainability as a concept and movement. The ‘3R’s mantra: Reduce, Reuse, Recycle and life cycle assessment (LCA) were introduced respectively as an approach and a method to begin to be able to quantify the environmental effects of products and processes. Thereafter followed a review of hospital sustainability for which common research themes were identified: hospital design, energy, water, travel, procurement, waste, and behaviour. Finally, the literature review focussed upon the evidence base for sustainability within the OR and ICU. A particular emphasis was placed upon OR and ICU procurement, waste and ‘the 3Rs’ as other themes had been reviewed previously.

Research regarding hospital design is at a relatively mature stage. Similarly, there is a developed research base regarding generic devices and technologies used within hospitals (such as air conditioners) to reduce the environmental effects of direct hospital energy and water use. Less well developed are analyses of how hospital staff use such devices, particularly those integral to the OR and ICU such as steam sterilisers. Less is known also about the clinical, psychological and social factors that influence how healthcare professionals use resources, travel to and from hospital, and interact with the buildings and technologies available.

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This systematic review of hospital environmental sustainability and in particular OR and ICU sustainability was focused on particular themes, thus potentially overlooking other relevant literature. Studies that were covered more broadly or recently elsewhere were also excluded. Nevertheless, the themes were based on existing frameworks as well as the initial examination of the literature, and are likely to capture the most important ways in which hospital activities affect the natural environment.

Most research on hospital sustainability (e.g. architecture and engineering features) has been performed by specialists in isolation, with minimal clinician participation. Due to the broad nature of hospital sustainability, collaboration will be needed to improve research outcomes. This collaboration includes; clinicians, engineers, architects, chemists and pharmacists, life cycle assessors, and social scientists. Joint work between different specialties is now occurring, e.g. LCAs of medical devices. Collaboration between engineers and clinicians to achieve energy and water efficiencies while also improving or at least not adversely affecting patient outcomes would be valuable. Clarifying barriers to change, particularly behavioural, will be the domain of social scientists working with clinicians.

In this review relevant research findings of environmental impacts and natural resource use within a variety of academic disciplines were found, yet there remain substantial knowledge gaps. In particular, sustainability research in the OR and ICU is at a nascent, but expanding stage. At each level of reduce, reuse and recycle there are substantial opportunities for research.

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CHAPTER 3: REDUCE THE FREQUENCY OF WASHING ANAESTHETIC BREATHING CIRCUITS.

3.1 BACKGROUND

Following the ‘Reduce, Reuse, Recycle’ paradigm, Chapter 3 examines one example of ‘reducing’ to improve hospital environmental sustainability. Within the Operating Room and Intensive Care Unit one could reduce the use of many items, packaging and procedures. It is reasonable to consider however, a device that could feasibly be used less frequently or at least cleaned less frequently. Further, there are many devices/procedures where it would be impractical to reduce the use of without protracted discussions with multiple clinicians (e.g. surgical equipment). Finally, researching the environmental effects of an item in the field of the researcher’s specialty (i.e. the OR and ICU) may be influential if one then wishes to research environmental sustainability in related fields with other clinicians.

Within the ICU of many developed countries most devices beyond the machines used to provide invasive physiological support are single use. For example, all drugs and drug syringes, airway equipment, ventilator circuits, humidifiers, invasive venous access catheters and the kits used to insert these catheters are single use. Although it is possible to reduce the use of expensive pharmaceuticals by choosing less expensive variants or simply to use less of each drug, such studies are more within the domain of audits rather than new research. There was thus thought to be limited research opportunity to reduce the use of what were primarily single use items in the ICU.

Within the OR in Australia, many common anaesthetic items could be either reusable or disposable: e.g. face masks, breathing circuits and various airway devices. Anaesthetic breathing circuits are either reusable or disposable (i.e. used for a variable number of patients prior to disposal). There is variation between hospitals as to how frequently breathing circuits are changed. At our hospitals reusable circuits are used and changed daily. A study was undertaken to determine whether it would be possible to reduce the frequency of washing anaesthetic breathing circuits without increasing

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potential risks to the patient leading potentially to reduced usage of equipment, energy and water.

This chapter is mostly based upon the following publication: McGain F, Algie CM, O'Toole J, Lim TF, Mohebbi M, Story DA, Leder K. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia. 2014; 69(4):337-4.

3.2 INTRODUCTION

A natural tension exists between protecting the patient and protecting the environment(66). For example, re-using clinical equipment can lead to financial and environmental savings, but is tempered by possible patient safety concerns. When single-use filters are used, anaesthetic breathing circuits are changed at different frequencies according to jurisdiction (134) – between patients in the United States (135), from daily in the United Kingdom (136), and weekly in Germany (137). In Australia, there are guidelines recommending single-use filters and how to clean anaesthetic circuit(138, 139), but the frequency of circuit cleaning is unspecified. Anecdotally, anaesthetic circuits are changed most often on a daily basis, but often more and occasionally less frequently.

Two previous studies have examined extended use of anaesthetic breathing circuits (140, 141). Hartmann et al studied the microbiological effects of extending the duration of use of breathing circuits prior to decontamination from 24 hours to up to 72 hours(140). Hartmann found no evidence of a clinically important change in circuit contamination rates with extended use up to 72 hours (140). Hartmann’s study was useful as it indicated that there was unlikely to be harm when reducing circuit decontamination to every 72 hours. Our aim was to study circuits for up to 7 days between decontamination. Hubner et al studied prolonging the use of breathing circuits prior to decontamination to up to 7 days and also found no change in circuit contamination(141). In Hubner’s study only 55 patients had circuit changes of 7 days and there was no statistical analysis included making it difficult to draw conclusions from the data(141).

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3.3 AIMS

1. To examine circuit use for up to seven days, to investigate whether extending the use of reusable breathing circuits from 24 hours (standard interval between decontamination at our hospital) to 7 days resulted in a significant deterioration in the hygienic quality of breathing circuits.

2. To quantify any equipment, electricity and water cost savings resulting from extended circuit use.

3.4 METHODS

This study was a prospective microbiological examination of reusable anaesthetic circuits (Parker Healthcare, Victoria, Australia) at the Western Hospital, a 6-theatre, 300-bed, University-affiliated hospital in Melbourne, Australia. All surgical subspecialties except for cardiac surgery, obstetrics and cranial neurosurgery are represented at the Western Hospital. The Western Hospital Low Risk Ethics Committee approved this study (Approval Number: HREC/2011/WH/52). In accordance with local guidelines(138), a new, single-use airway filter was used (DAR electrostatic filter-350 U5879, Covidien, Boulder, Colorado, USA) for each operation.

Professional standards in Australia/New Zealand require that thermal disinfection of breathing circuits ‘destroy(s) non-spore bearing vegetative organisms’ (142). In line with this standard, we used aerobic heterotrophic plate counts (HPC) (143, 144) as a sensitive indicator of bacterial contamination by non-spore bearing organisms, and therefore circuit ‘cleanliness’ (145). The 3M Petrifilm™ plate used is an inexpensive thin-film version of the conventional Petri dish agar plate, and gives quantitatively comparable results (146, 147). Petrifilm™ plates are commonly used for hygiene testing (148), and their use is supported by the American Public Health Association and the Association Francais de Normalisation (149). They have also been used in operating theatres (150) and dentistry (151).

Decontamination (thermal disinfection) involves washing a device with water at either 80°C for 10 minutes, or 90°C for one minute, as per the Australian and New Zealand Standards-4187 (AS/NZS-4187)(139). The same Standards (AS/NZS-4187) require steam sterilisation to be performed for ‘critical devices’ (i.e. those which contact normally sterile places) at 134°C for 3 minutes(139). Routinely anaesthetic breathing

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circuits are not ‘critical’- i.e. they do not require sterilisation, but do require thermal disinfection. As per the AS/NZS-4187, Hospital Central Sterile Supply Department (CSSD) staff placed the reusable circuits in an industrial washing machine at 80 degrees for 10 minutes with appropriate detergent. A minimum of one anaesthetic load/day was required to wash all anaesthetic items.

Thermal disinfection of all reusable equipment (i.e. circuits, masks, laryngoscopes, laryngeal masks etc.) occurs in the same ‘anaesthetic load’. Initially, standard care was examined, i.e. 24-hourly circuit changes and decontamination/washing to verify baseline microbiological circuit loads. After a period of personnel education in how to drain circuit condensate appropriately, loads were examined after 48-hourly circuit changes and then after changes up to 7-days. Initially, when an extension to 48-hour circuit changes was piloted, there was an increase in visible fluid accumulation and a coincident increase in circuit contamination counts (results not shown). After holding one education forum to remind personnel of local hospital policy about emptying circuits of visible fluid, the study was recommenced and contamination counts fell.

There could be several reasons for circuit changes occurring more frequently than the proposed time interval. For example, if a patient was deemed infectious or if blood contaminated the circuit, the circuits would be changed. Patients identified with an infection requiring a change of circuit after use (Vancomycin Resistant Enterococcus, i.e. VRE) or infections reportable to the Victorian Health Department (Australia) were excluded from the study.

Microbiological samples were obtained at the end of each theatre list before thermal disinfection (washing), by one of three researchers according to an agreed sampling protocol(140). Under aseptic conditions, the breathing circuit and heat moisture exchanger were disconnected from the anaesthetic machine and a sterile plastic film (Tegaderm, 3M Health Care, St. Paul, Minnesota, USA) was applied to each end of the circuit tubing to prevent fluid escaping. Fifty mL of sterile 0.9% saline was poured into the inspiratory limb, followed separately by the expiratory limb, combining with any pre-existing circuit condensate. The tubing was shaken vigorously for 30 seconds to dislodge potential tubing biofilm. Solution from each limb of the circuit was decanted into a sterile bottle.

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Microbiology samples were plated immediately. Five sets of 1mL sample solution for both the inspiratory and expiratory circuit limbs (i.e. 10mL total) were pipetted in a sterile fashion onto the surface of aerobic count (AC) Petrifilm™ (3M, St. Paul, USA) plates. These were incubated for 48 hours at 37°C, and then quantified for colony- forming units (cfu). We defined ‘contamination’ as one colony or more per 10mL of rinse water (expiratory and inspiratory lines).

The financial implications of moving from daily to weekly circuit decontamination, including requisitioning data for circuits, were examined. For one month each during the 24-hourly and 7-day decontamination periods the number of ‘anaesthetic loads’ for the disinfection of anaesthetic equipment were audited. Details of decontamination loads were not routinely kept by the hospital sterile supply department (unlike all sterilised loads). The costs for water, electricity, gas and detergent use for anaesthetic loads were based upon a previous study at the hospital(65). Records were obtained of the procurement of reusable anaesthetic circuits at the 24-hourly and 7-day time periods. Gas analyser tubing was attached to the anaesthetic machine side of the single use filter (i.e. away from the patient and protected by the filter). Gas analyser tubing is used to detect the concentrations of O2, CO2 and anaesthetic gases. The frequency of changing gas (CO2 and volatile agent) sampling tubing was not altered, i.e. staff (conservatively) waited until the study’s conclusion.

All six operating theatres were assumed to be used for 5 days per week for 48 weeks p.a., and that two operating theatres were used every day (‘emergency theatres’). There were thus approximated savings for reduced procurement of gas sampling lines. A detailed labour time and motion analysis was not performed. A currency converter (152) on the 17/6/2015 to convert AUD$1 to USD$0.77.

Statistical analysis

STATA 12 software (StataCorp LP, Texas, USA) was used for statistical analysis. The sample size was calculated from pilot study data showing a 25-35% circuit contamination rate; assuming 80% power, we determined 100 circuits per group would demonstrate a clinically significant 7% effect size. The proportion of contaminated circuits was compared between study groups using Fisher’s exact test. Circuit contamination was quantified as: the median bacterial cfu count, the 25%-75% Interquartile Range (IQR) and the lowest and highest count. Median bacterial counts

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at 48 hours and at up to 7 days were compared to 24 hour counts using the Mann- Whitney U-test. A significant difference was determined by p<0.05.

3.5 RESULTS

Over a 15-month study period between the 1st September, 2011 to the 22nd December, 2012, 305 breathing circuits used for 3,864 patients were analysed microbiologically (Table 1). Of the 100 circuits tested in the ‘up to 7 day’ category, 87 of 100 circuits were used for the entire 7 days. The remaining 13 of 100 circuits were changed due to patients with known infections, with 2 circuits sampled after 2 days, and 11 after 3-6 days.

There was no significant difference in the proportion of contaminated circuits when changed every 24 hours (57 of 105, 54%, 95% CI 45 to 64%) compared to 48-hours (43 of 100, 43%, 95% CI 33 to 53%, p=0.12) and up to 7 days (46 of 100, 46%, 95% CI 36 to 56%, p=0.26).

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Table 1 Bacterial contamination of breathing circuits at intervals of 24 hours, 48 hours and up to 7 days. cfu= colony forming unit, IQR= Interquartile Range (25th-75th centile).

Group Group Group 3: 1: 24hrs 2: 48 up to 7 hrs days Number of operations 557 998 2,309 performed during the sampling period Complete circuits - any 57/105 44% - 43/100 33% - 46/100 36% - bacterial contamination (54%) 64% (43%) 53% (46%) 56% (proportion of total) 95% CI Complete circuits - 1 0 0 Median bacterial count (cfu/10mL) Complete circuits - 0-4 0-1 0-3 Bacterial count IQR (25th – 75th centile). Complete circuits -Range 0-2,610 0-12 0-671 (lowest and highest counts) Inspiratory limb 28/105 (27%) 25/100 (25%) 22/100 (22%) contamination (proportion and % of total) Expiratory limb 41/105 (39%) 25/100 (25%) 31/100 (31%) contamination (proportion and % of total)

Compared to the 24-hour circuit change group, there was a significant difference in the median bacterial counts/circuit for both the 48-hour (p=0.02) and 7 day (p=0.04) groups (Table 1). There was no significant difference in the median bacterial counts/circuit between the 48-hour and 7 day groups (p=0.70). At all time periods the proportion of contaminated expiratory limbs was equal to or greater than the contaminated proportion of inspiratory limbs of the anaesthetic circuits (Table 1). Each of the six individual operating theatres had circuits examined with similar frequency (range: 14% to 18% per theatre).

Table 2 details the non-labour costs of decontaminating circuits every 24 hours compared to circuits with up to 7 days between decontamination. Requisitioning data for the circuits was obtained: for the 12 months prior to the study, 90 circuits were purchased and for the 9 months from the time of commencement of ‘up to 7 days’ changes, 30 circuits were purchased. For the four weeks of auditing the number of

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anaesthetic thermal disinfection loads during the 24 hour and 7 day decontamination periods there were 68 loads and 28 loads, respectively (or 17 and 7 loads/week respectively). In Table 2 the electricity, water and detergent costs were based upon the aforementioned number of washer loads. That is, the financial and environmental costs of electricity and water were estimates. The annual number of gas sampling tubing used for the 24 hour and 7 day decontamination periods were also estimates based upon the findings of this study (Table 2).

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Table 2 Annualised costs associated with decontamination of anaesthetic circuits (for 6-operating rooms). Financial costs are in AUD$ (with the totals in AUD$ and USD$).

24 hour circuit Up to 7 day circuit decontamination decontamination No. circuits purchased 90 40 p.a. Cost of circuits p.a. (at AUD$1,800 AUD$800 AUD$20/circuit) No. gas analyser tubings 4 (theatres) x 5 (days) x 48 6 (theatres) x 52 (weeks) / p.a. (non-holiday weeks) + [2 0.87 (% used for entire (theatres) x 7 (days) x 52 week) =360 (weeks)] =1,680 Cost of tubing (at AUD$3,200 AUD$690 AUD$1.90/tubing) Washer- no. of 17 loads/week x 48 (normal 365 loads (1 load/day) anaesthetic loads p.a. weeks) + [7 loads/week x 4 (holiday weeks)]= 844 loads Washer- electricity p.a. 5,060 kWhrs 2,200 kWhrs (6 kWhr/load ) Cost of electricity p.a AUD$560 AUD$240 (AUD$0.11/kWhr) Washer-water 84,400 36,500 (100 litres/load) Cost of water p.a. (at AUD$168 AUD$74 AUD$2.00/kilo Litre) Cost of washer detergent AUD$2,280 AUD$985 p.a. (at AUD$2.70/anaesthetic washer load) Total non-labour costs AUD$8,000 (USD$6,160) AUD$2,790 (USD$2,150) p.a. (to nearest AUD$10)

3.6 DISCUSSION

This study provides evidence that it is possible to reduce the frequency of anaesthesia breathing circuit decontaminations resulting in financial, energy and water savings without any increase in bacterial contamination, provided circuits were routinely emptied of visible condensate. It is likely that condensate accumulation may have occurred routinely in the 24-hour group, and that reinforcing standard protocols accounted for lower circuit contamination in the 48 hour and 7 day groups.

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These results agree with earlier studies from other countries (134, 140, 141) that found extended use of breathing circuits beyond 24 hours does not increase the risk of circuit contamination, particularly as a more sensitive method of detecting microbial contamination has been used and there was analysis of a greater proportion of the rinse water volume (10mL/circuit) (which explains the higher proportion of contaminated circuits in our study (43%-54% vs less than 5%)). Furthermore, the sample size was correctly powered to detect any significant difference in contamination rates.

This study has limitations. With collaboration from the infection control staff a prospective, before and after cohort design was chosen as the most appropriate and pragmatic methods to minimize risks to patients and operating room productivity. Randomizing individual circuits, which would have eliminated selection bias, would have been desirable, but was considered impractical. The circuit exterior was not examined. In our hospital the circuit exterior is routinely cleaned between uses with chlorhexidine, reducing the risk of cross-contamination of circuits and patients(153). The microbial testing was limited to bacterial contamination count with no speciation.

It is possible that similar rates of bacterial contamination between groups could have resulted as much from personnel education as from prolonging the interval between decontamination. This study did not compare the environmental effects of using reusable and disposable anaesthetic circuits as this was primarily a microbiological study. Financial and environmental savings estimated by this study could be further validated by auditing of CSSD decontamination loads and requisitioning of anaesthesia circuits and gas sampling lines.

The presence of prions or viruses in the circuits was not tested for. Prion transmission occurs very rarely via oral, parenteral or direct intracerebral inoculation. Prions are not usually considered to be airborne, but prions can be efficiently transmitted to mice through aerosols(154). Although aerosol-transmitted prions have never been found under natural conditions(154), there will be ongoing interest in the perceived prion transmission risks of all medical equipment.

The ultimate aim of cleaning or disposing of anaesthetic circuits is to avoid cross- contamination of patients who may develop viral infections and/or ventilator associated pneumonia (VAP). Accordingly, testing for viruses of concern would be

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ideal, but specific testing for all possible respiratory viruses is not practical based on the availability and cost of suitable methods. Examining the rate of VAP in patients who receive breathing circuits with different periods of use, would be useful. Studying VAP rates is difficult because of the very low rates of VAP in patients presenting primarily for elective surgeries and thus the need for large numbers of patients to conduct such a study. A formal examination of the rates of VAP in patients over the 15 month study period was not performed although anecdotally at our hospital, such pneumonia is very rare beyond patients who develop VAP in the ICU. As noted previously, in lieu of speciating viruses and bacteria it was chosen to examine several hundred circuits, quantitating aerobic bacterial counts, as this was a feasible, practical method to indicate circuit ‘cleanliness’.

Due to the possibility of circuit cross infection with Hepatitis C virus(155-157), guidelines advocate that for each operation either single-use filters or single use or clean reusable circuits be used(136-139). In our hospital circuits are reused and single-use filters are discarded for each case. Each filter costs approximately AUD$2, while disposable circuits cost AUD$10.

Converting from circuit changes every 24 hours to every 7 days led to annual savings for our hospital (6 operating theatres) of: AUD$5,210 (USD$4,010). Requisitioning of reusable anaesthetic circuits fell from approximately 90/annum pre-study to 40/annum post-study, despite no significant change in the number of operations. Circuits are perhaps most likely to be damaged when they are hot post-washing. Since each reusable circuit costs approximately AUD$20 per circuit, savings of more than AUD$1,000 per annum have been achieved due to reduced circuit requisitioning. Further, significant financial savings of more than AUD$2,500 (USD$1,925) per annum are made possible by changing the gas sampling tubing once a week rather than once a day.

There was a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2,760kWh of electricity and 48,000 litres of water - i.e. similar to the consumption of a one-person Australian household(158). Financial savings would be much larger in institutions where circuits are changed with every patient, such as is required in the USA(159). If our 6 operating theatre hospital used disposable circuits (AUD$10 each), converting from daily to weekly disposable circuit changes would save AUD$5,200 (USD$4,840) for the reduction in circuit use alone. Converting from

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single-use circuits to weekly disposable circuit use would save more than AUD$25,000 (USD$23,200).

3.7 CONCLUSION

Extending the interval between anaesthetic circuit decontaminations from daily to weekly is not associated with increased bacterial contamination, results in reduced financial and environmental costs, and complies with Australian and New Zealand professional standards(142), provided daily emptying of circuit condensate is undertaken. This change in practice is commended, as is already routine in Germany, as a safe method of reducing the environmental effects of clinical anaesthesia. This study adds to calls for greater sustainability within the operating room and challenges current guidelines requiring anaesthesia circuit changes for each and every patient in some countries including the USA(159).

As a result of this study there was a change of policy at our hospital; from circuit changes every 24 hours to circuit changes every 7 days. Such a change led to an estimated annual financial saving of AUD$5,210 (USD$4,010), with associated water and energy savings. These study findings are generalizable: small financial and environmental savings from reduced circuit changes at one hospital could become much larger savings for an entire healthcare system. Research opportunities examining the potential for ‘reducing’ the use of other products and processes without compromising patient care or staff workflow patterns are likely to be significant.

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CHAPTER 4: REUSE VERSUS SINGLE USE WHAT MAKES SURGICAL METALWARE SINGLE USE?

4.1 BACKGROUND

Chapter 3 studied one example of ‘reducing’ the use of equipment without compromising patient care in the Operating Room (OR). It was found that prolonging the interval between anaesthesia breathing circuit decontaminations results in financial, energy and water savings, without any significant increase in bacterial contamination.

The focus of this chapter moves from Reduce to Reuse. Within the OR particularly and to a lesser extent in the Intensive Care Unit (ICU), there are many items that are reused such as surgical instruments, linen drapes and garments, and plastic containers. It is unclear in many instances what the environmental effects of OR and ICU reusable items are, or of the comparable single use variants(10). Prior to further chapters examining particular reusable items and comparing them with single use items it is important to consider what makes something single use in the first place.

Medical devices can be divided into three groups according to their usage: 1. single use, i.e. one use only, 2. reusable, i.e. able to be washed and sterilized for patient reuse generally within the hospital and 3. reprocessed devices, i.e. undergo assessment, repair, sharpening, smoothing, cleaning and sterilizing before being reused. Currently, manufacturers determine whether their product is single use. A minority of reusable devices are recommended to be used for a limited number of times due to wear and tear (e.g. reusable plastic laryngeal masks used in anaesthesia). Such devices are generally not made of metal and remain classified as reusable both by authorities and in this thesis.

A variety of different materials are used in the manufacture of medical items. Common items used in the OR and ICU could be considered to be made of linen, metal or plastic. Several different plastics are used for medical products, making comparisons between reusable and single use versions difficult. It is possible (though currently unclear) that single use linen may not be constructed for longevity beyond one use. On the contrary, single use metalware appears robust for more than one use.

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Stainless steel is robust, can be repeatedly sterilised, and has a high carbon footprint

(4.2 kg of carbon dioxide (CO2) per kg steel)(160).

This chapter expands upon the following publication: McGain F, Sussex G, O’Toole J, Story D. What makes metalware single use? Anaesthesia and Intensive Care, 2011, 39; 5, 972-3.

4.2 INTRODUCTION

In the hospital setting, single use metal ware is found in suture sets, in vascular access insertion kits, and as individual items such as scissors. Anecdotally, in Australia and elsewhere the use of these items has rapidly increased over the past few decades. There is literature comparing the relative clinical merits of reusable versus single use devices(161, 162). There are few comparisons, however, of the financial and environmental costs of reusable and single use medical devices(109, 111, 163). It is less clear why some devices are single use and why these devices are replacing reusable variants.

As examples of national regulators of medical devices the USA Food and Drug Administration, the UK Medicines and Healthcare Products Regulatory Agency, and the Australian Therapeutic Goods Administration, all accept at face value the manufacturers’ designation of an item as single use(133, 164, 165). Reported legitimate reasons for labelling medical devices as single use include: 1. device design precludes adequate decontamination, 2. malfunction is likely with reuse, or 3. reprocessing is difficult because of concerns such as material degradation(133).

The International Organisation for Standardization (ISO) details the requirements for stainless steel surgical instruments, including the chemical composition and corrosive resistance (ISO-7153-1 and ISO-13402(166, 167). Stainless steel must contain at least 10.5% chromium, although most surgical instruments should have at least 11.5-12% chromium and are generally of the Martensitic subtype, (i.e. relatively hard, with high carbon content and good machining characteristics(168, 169).

The aims of this study were to question if and why there had been a significant increase in the use of single use metalware and what were the physico-chemical differences between reusable and single use metalware?

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4.4 RESEARCH QUESTIONS

1. Why are some craft groups of doctors using more single use rather than reusable surgical instruments? 2. Why are some simple surgical metal devices labelled as single use and how is their composition different from traditional reusable metalware? 3. What are the broader ecological and social issues that might influence a decision to purchase single use surgical metalware?

4.5 METHODS

The trend to single use surgical metal ware was investigated at Footscray and Sunshine Hospitals (total of 600 beds), Melbourne, Australia. The hospitals’ Human Research Ethics Committee manager approved this observational study. Central Sterile and Supply Department (CSSD) staff noted that although expensive single use metal surgical devices, such as laparoscopic ports, had become more common, surgical preference and their cost had prevented a significant increase in use. Correspondingly procurement was obtained for the following surgical metalware: scissors, needle-holders, artery forceps, scalpel holders, chest tube clamps and ‘sets’ of metal instruments such as those used for basic surgical, anaesthetic, emergency department and ICU procedures.

Cost data were obtained in Australian dollars (AUD$) for single use metalware procurement examining all medical subdivisions (e.g. operating suite, ICU, surgical wards etc.). Data were reliable from 2007 (when a new dataset was installed) to 2010. Subsequently various packages of single use metalware were opened and the metal items weighed on digital scales precise to the nearest gram. Advice pertaining to single use metalware was sought from multiple hospital staff and from reference infection control material(170-172).

Single use and reusable scissors and needle holders available in our hospital were compared. Both were equally easy to decontaminate and appeared equally sturdy for routine use. Possible differences in composition and design that rendered the single use items unsuitable for repeated washing and sterilisation were sought, and whether such differences could be inexpensively eliminated by local processing.

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The chemical composition of one each of a reusable and single use needle holder and scissors (i.e. 4 items) was determined by requesting such information of the manufacturers and then verifying this by independent spectrographic examination (Spectrometer Services Pty Ltd, 206 Newlands Rd, Coburg, Victoria, 3058, Australia).

The physical design of two each of the reusable and single use scissors and needle holders were examined, noting in particular the surface smoothness and corrosion resistance by naked eye examination. To further examine surface smoothness a stylus surface roughness meter (Accretech, Tokyo Seimitsu Co.) was used, taking the average of five readings from several locations on each of the metal items.

To reduce the roughness of the single use items two each of scissors and needle holders underwent successive reprocessing by phosphoric acid bathing, mechanical polishing and nitric acid bathing (Alimtype Pty Ltd, 65-67 Canterbury Rd., Montrose, Victoria, Australia). Reusable surgical metalware undergoes identical processing at our hospitals after every 100 uses or if there is evidence of rusting.

Subsequently, two each of the unprocessed and processed single use scissors and needle holders were each run through the hospital washer and sterilizer for five cycles. Experienced hospital sterile supply staff were involved in the washing, examining and comparison of the unprocessed and processed items.

A currency converter (152) on the 17/6/2015 to convert AUD$1 to USD$0.77.

4.6 RESULTS

At the two hospitals the value (rounded to the nearest AUD$10) and weight of single use metal surgical items purchased rose from AUD$6,030 (USD$4,640) and 65kg for the year 2007 to AUD$47,130 (USD$36,290) and 850 kg in 2010. For the operating suite alone the value and weight rose from AUD$2,820 (USD$2,170) (32kg) in 2007 to AUD$8,710 (USD$6,706) and 116 kg in 2010.

Hospital CSSD and infection control staff noted that the shift to single use medical items was not driven by any infection control concerns. While microbiological contamination of reusable metal devices can occur from processing failure, no episodes of contamination had occurred and quality assurance control by the hospital’s CSSD staff had remained unchanged. Instead the loss of relatively more

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expensive (AUD$10-15) simple reusable surgical metalware, combined with the greater availability of inexpensive (AUD$1) single use items was driving staff to purchase more single use items. Loss of metalware was particularly prominent when; instrument counts (by two nurses/doctors) did not occur at the end of procedures, e.g. when anaesthetists performed central line insertions in theatre; and in locations remote from the operating suite, such as the ICU, emergency department, outpatients and hospital wards.

Interestingly, as individualised hospital ‘cost centres’ (based on wards and medical units) became the norm, the CSSD moved from routinely compensating for the loss of reusable instruments, to charging other hospital cost centres for this loss. Due to this cost imposition from losses of reusable instruments on wards and medical units such wards/units converted from reusable metalware to less financially expensive single use metalware.

Table 3 presents the spectrographic analysis of the single use and reusable surgical metalware and shows that there was no functionally important difference in the stainless steel content. Most importantly, reusable and single use metalware were stainless steel (Chromium content greater than 11.5%), and had low levels of impurities (silicon and sulphur). There was some variability in the concentrations of other elements within the reusable and single use metalware, but such variation would not alter the steel’s integrity. There was also minimal variation in the composition of the metalware between our results and the manufacturers’ specifications.

Table 3 Average composition of stainless steel from one each of reusable and single-use scissors and needleholders.1

Element % in reusable metalware % in single use metalware Carbon 0.14% 0.17% Chromium 12.0% 11.9% Copper 0.01% 0.11% Manganese 0.25% 0.20% Molybdenum 0.04% 0.08% Nickel 0.15% 0.36% Phosphorus 0.02% 0.03% Silicon 0.37% 0.41% Sulphur 0.02% 0.02% 1Data for Table 3 obtained from Spectrometer Services Pty Ltd, 206 Newlands Rd, Coburg, Victoria, 3058, Australia.

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A naked eye examination indicated a rougher mechanical finish on the unprocessed single use surgical items when compared with the reusable variants which was confirmed with a stylus surface roughness meter (Table 4). Surface roughness is indicated by average roughness (Ra). Above an Ra of 0.5 micrometres there is a significant increase in the likelihood of corrosion and conversely there are minimal changes to corrosive resistance with lower levels of roughness(173, 174).

Table 4 Surface roughness of the single use surgical metal instruments pre- and post-processing.1

Surgical metal item Average Detection of rust pits roughness following 5 cycles of washing (micrometres) and sterilisation? Reusable scissors 0.1 No Reusable needle holders 0.4 No Single use unprocessed scissors 0.9 Yes Single use unprocessed needle 0.5 Yes holders Single use processed scissors 0.2 No Single use processed needle 0.2 No holders 1Data for Table 4 obtained using a stylus surface roughness meter (Accretech, Tokyo Seimitsu Co.).

After reprocessing (for AUD$5 per item) the surface roughness of the reprocessed single use items was less than 0.5 micrometres, as for the reusable items (Table 4). After washing and sterilisation fine rust pits were found in the unprocessed, single use items, but not the reprocessed ones. No visible difference was detected between the reprocessed single use and reusable metalware by CSSD staff (i.e. they were visually indistinguishable).

4.7 DISCUSSION

Single use surgical metalware rapidly replaced reusable variants at our hospitals. Infection control concerns had not led to the increase in single use metalware, the use of these being mandated in Australia only for those at high risk of prion disease(171, 172). The shift to single use metalware occurred primarily outside the operating suite due to staff misplacing more expensive reusable surgical instruments and the

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subsequent decision by individual cost centre staff to purchase cheaper, single use items.

The results showed that for two simple surgical instruments single use and reusable variants were composed of essentially the same stainless steel. Chromium imparts resistance to rust, while sulphur and phosphorus increase the risk of rusting. The higher nickel and copper levels (Table 2) in the single use items would not significantly alter the quality of the Martensitic steel(168), although the higher molybdenum content of the single use items would provide greater corrosion resistance. Whilst the single use items were found to have a rougher finish which precluded their reuse we found that with simple, inexpensive reprocessing, these single use items could withstand multiple cycles of washing and sterilisation without evidence of rust. Reprocessing (for AUD$5), and resterilising (considering CSSD labour costs etc.) is probably not, however, cost competitive with buying another AUD$1 single use item.

This study shows that it is inexpensive to reprocess single use stainless steel items. Particularly in the USA, companies do legally reprocess single use medical items, though this questions the entire concept of ‘single use’(175). In addition, it is likely that reprocessing external to the hospital is more energy consumptive than simply resterilising instruments. The increasing use of single use metalware leads to the discarding of tons of energy dense stainless steel (4.2 kg CO2 per kg steel)(160) which does not assist national healthcare efforts to reduce CO2 emissions(4).

An alternative approach could be to recycle single use items, although this also is likely to be more energy intensive than resterilising reusable metalware. Stainless steel has one of the highest recycling rates (70%) of any material(160), although the recycling rate from healthcare seems to be virtually zero. Unfortunately, in order to recycle the used metal items (or even donate them to less developed nations) first requires decontamination by washing, with the attendant hospital labour costs, negating the whole purpose of purchasing the bargain priced single use metalware.

The single use surgical metalware examined in this study originated in Pakistan. More than 85% of the world’s surgical instruments are made in Pakistan or Germany(176). Concerns regarding the ‘fair trade for surgical instruments’ have been raised previously(176, 177) to which we add the complexity of single use metalware. It is

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unclear whether it is beneficial to labourers in Pakistan to be producing as many inexpensive, single use instruments as possible. It is concerning that Pakistan, where 21% of the employed population survives on less than USD$1.25 per day(178) and many do not have adequate access to healthcare, produces a large proportion of the world’s surgical metalware that the citizens of more affluent nations now discard after one use.

This study measured only simple, single use metalware as the use of more complex, expensive, single use metal surgical devices had not changed significantly. Due to altered electronic records reliable data were present for only a four-year period, although these indicated a significant increase in single use metalware. Further large procurement increases in single use metalware are not envisaged since at our hospitals very few reusable metal items are now used outside the operating suite and the ICU.

The findings of this study may not be applicable to all hospitals in developed nations, although at least in the UK, New Zealand and the USA there is similar anecdotal evidence of single use surgical metalware replacing reusable variants. A spectrographic analysis was performed of just one each of a single use and reusable scissors and needle-holder. Although many more spectrographic analyses could have been made this would be unlikely to reveal notable differences as worldwide, most reusable and single use surgical metalware is made from the same grade of stainless steel in relatively few countries(176).

Naked eye assessments of many other single use metalware suggested that performing further detailed surface roughness assessments would not be revealing. Unprocessed (i.e. ‘rough’) single use metalware rusts after even a few washes. Although the processed single use items could rust after more than five washes, this would be unlikely as they have the same chemical and physical composition as the reusable metalware.

This study is aims to draw the attention of health departments and all healthcare providers, but particularly anaesthetists, surgeons and ICU physicians, that there is no scientific merit behind the term ‘single use stainless steel’ and that similar concerns could exist for other single use items. Tonnes of stainless steel are being discarded to infectious waste because hospital staff in the more affluent nations do not consider it important to retain reusable surgical instruments and/or they see a short term ‘bargain’

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in purchasing the single use items. This practice is wasteful of energy, water and stainless steel itself and may also be encouraging a ‘race to the bottom’ for labour costs in Pakistan.

Double counting of items outside operating theatres generally does not occur, emphasising that the count is performed to prevent loss within the patient, rather than any concern for tracking of the surgical metalware. Regardless of the location within the hospital, staff could emulate the operating theatre ritual of ‘count correct’ at completion of a procedure. Placing radiofrequency tags on surgical items to track their location or loss is possible, but has not been frequently explored in medicine(179).

Purchasing supply agencies could follow the lead of the UK Sustainable Development Unit in at least developing an ethical business approach that complies with international ethical standards(176, 180). National regulatory bodies of medical devices could also contribute to the transition towards improved environmental, social and financial sustainability in healthcare and at least ask of manufacturers why any stainless steel items are ‘single use’.

4.8 CONCLUSION

Within the past decade there has been a 10-fold increase of single use stainless steel surgical metalware in our hospitals, driven by losses of the alternative expensive reusable metalware, and occurring primarily where instruments were not ‘double counted’ such as in the ICU and emergency department (i.e. outside of the OR).

‘Single use metalware’ was found to have the same chemical composition as reusable metalware, i.e. both were stainless steel. Physically, the single use metalware had a rougher surface, leading to rusting when steam sterilised. When this single use metalware underwent simple reprocessing it became physically and visually indistinguishable from reusable metalware. It is, however, unlikely to be financially attractive and to reprocess such single use metalware is made challenging by current Australian regulations. There are broader ecological and social issues that might influence a decision to purchase single use surgical metalware such as the ‘fair trade for surgical instruments’(176), to which this study adds the complexity of single use metalware.

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There is a profound disconnect between our reuse of stainless steel cutlery at home thousands of times and similar stainless steel for surgical instruments discarded after a single use. Prior to comparing common reusable and single use medical equipment in the following chapters this study questioned the foundation of what makes an item single use.

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CHAPTER 5: REUSE THE LIFE CYCLE OF REUSABLE AND SINGLE USE CENTRAL VENOUS CATHETER (CVC) INSERTION KITS

5.1 BACKGROUND

Prior to making any comparisons between reusable and single use items Chapter 4 examined what makes a subset of medical equipment single use in the first place. Single use stainless steel metal ware was compared with and found to have very similar physico-chemical composition to reusable metal ware(181). Retailers of medical products decide whether equipment is single use with perhaps unforeseen environmental, financial and social consequences.

This chapter examines Reuse and life cycle assessment (LCA) for a simple item used commonly in the operating room (OR) and intensive care unit (ICU). Introduced in Chapter 2, section 2.3, LCA is a useful method to examine the environmental effects from the ‘cradle to grave’ of a product or procedure. Process based LCAs arrive at an environmental cost for an item or activity based upon measured inputs - e.g. the amount of plastics and metalware contained within a surgical tray. Process based LCAs make comparisons possible between reusable and single use variants.

As noted in the thesis literature review (Chapter 2, section 2.6.8) an LCA was performed prior to PhD enrolment by the author and colleagues, examining the environmental and financial effects of reusable and single use anaesthetic, plastic drug trays(65). The reusable plastic trays required thermal disinfection (‘washing’), but not sterilisation, to be made patient ready again. The major findings of that LCA were that the reusable trays cost less money (inclusive of labour) and used less water, but had similar global warming potential (CO2 emissions) when compared with the single use drug trays. Further, as the single use tray routinely had cotton gauze and a paper towel included (which were not required for the majority of patients requiring an operation), the combined CO2 emissions for the single use tray with cotton and paper were almost twice as high as for the reusable tray alone. The CO2 emissions for the reusable trays were high as a result of the state of Victoria’s (Australia) electricity mix which remains predominantly brown coal with a very high CO2 emissions factor(114).

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The LCA of plastic drug trays did not analyse the environmental effects of sterilisation. Steam sterilisation remains the most common method to sterilise most reusable surgical devices(182). Since: (i) sterilised items are ubiquitous in the OR (and to a lesser extent the ICU), and (ii) it was possible that sterilisation contributed materially to the CO2 emissions and water use of reusable items, a comparison LCA was undertaken of a common OR and ICU reusable item and its single use counterpart.

Process based LCAs provide a detailed analysis of an individual item or activity and are useful when comparing two similar items or activities. Further, Economic Input- Output LCAs are less precise for many products and processes in healthcare. Consider a medical device that costs twice as much money as another: an Economic Input- Output LCA would consider that the more expensive process has double the environmental effects, which is probably unrealistic.

Process based LCA can be either attributional or consequential(22). Attributional LCA assigns (attribute) flows and potential environmental impacts to a specific product system typically as an account of the history of the product. Attributional LCA predates consequential LCA and is considered to be simpler as there are no assumptions about the environmental changes that occur as a result of a decision. Consequential LCAs study how environmental flows may change because of the possible decisions made in the LCA(22).

The system boundary of consequential LCA is broader than attributional LCA and includes the activities contributing to the potential future environmental consequence of the change. As an example, for this LCA comparison of reusable versus single use CVC insertion kits a consequentialist approach would be to examine what would be the changes to CO2 emissions from moving completely from single use to reusable kits. In Victoria, Australia, the main source of electricity generation is brown coal. Nevertheless, because of certain government policies to increase natural gas and renewable electricity generation, each new kWh of electricity would not be primarily sourced from brown coal. The CO2 emissions from moving to reusable kits would be less than predicted from an attributional LCA which would model any CO2 emissions arising from reusable kits upon the current electricity mix of Victoria.

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Life Cycle Inventory databases usually include information about the marginal producers of electricity, resources, and many products and processes to allow for consequential LCAs to be performed. There is, however, always more uncertainty surrounding consequential than attributional studies as assumptions are made about future sources of materials. This LCA study of CVC insertion kits is attributional as the study is relatively simple in nature, and the focus was upon examining the most important contributors to the environmental effects of the reusable and single use kits.

This chapter expands upon the publication: McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single use central venous catheter insertion kits. Anesthesia and Analgesia 2012 May;114(5):1073-80.

5.2 INTRODUCTION

The manufacture, purchase, and acquisition of equipment and drugs contributes more to healthcare CO2 emissions than direct hospital energy consumption and transport to and from hospitals combined(4). Life cycle assessment (LCA) is a ‘cradle-to-grave’ approach for determining the financial and environmental costs of a product over its entire life(9, 21) There are few published life cycle assessment studies of medical items and processes (35, 65, 108, 109, 111, 113, 116, 163), although there is expanding interest in the field(32).

To recapitulate Chapter 2, section 2.3: there are two common types of LCAs; process based and Economic Input-Output. Process based LCAs arrive at an environmental cost for an item or activity based upon measured inputs (e.g. amount of electricity, gas and water required to wash a plastic tray as well as the mass and type of plastic used to make that tray). Process based LCAs thus examine the immediate inputs, but not more distant inputs, i.e. they have a smaller ‘system boundary’ than input output LCAs (and thus routinely smaller environmental effects).

Our prior LCA of plastic drug trays did not include the environmental effects of sterilisation as this was not required for such items. This study examined a common medical item that was sterilised since it was unclear if there were financial and environmental benefits in using reusable instead of disposable versions. Both reusable and single use central venous catheter insertion kits are commonly used in anaesthesia and other critical care areas. These kits are used to assist insertion of single use plastic

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central venous catheters. The insertion kits are typically composed of metal ware (scissors, needle holders and tissue forceps) and plastic (bowls and wrap). The disposable central venous catheter sets themselves, which included the catheters as well as various other plastic items, were not examined as they were common to both reusable and single use approaches to central line insertion.

5.3 RESEARCH QUESTIONS

1. What are the complete financial costs of the reusable and single use CVC insertion kits when used in hospitals?

2. What are the environmental effects (CO2 emissions, water use, metal use, toxicity) of the life cycles of the reusable and single use kits?

3. What effect does the source of electricity have upon CO2 emissions?

5.4 METHODS

This observational study of central venous catheter (CVC) insertion kits was performed at Western Health in Melbourne, Victoria and at Atherton’s’ Sterilisers Factory, also in Melbourne, Victoria. Ethical approval was granted by the Western Health Ethics Committee (Quality Assurance Number 2010.27). Using SimaPro life cycle assessment (LCA) software (Pre Consultants, The Netherlands) we modeled the financial and environmental life cycles of reusable and single use central venous catheter kits that are used to aid insertion of disposable central venous catheters.

An LCA uses different types of data for modelling. Some data are directly collected. Most LCA data, however, are not directly measured, but obtained from life cycle inventories calculated as a weighted average from a number of production sites. One example is the average amount of CO2 emitted/kWhr of electricity produced from coal burning power stations. Average industry data are often used in LCA modelling because collecting all such data would make most LCAs unviable. Average industry data, however, have greater associated uncertainty than directly measured data. Other data are collected from international data bases. Where local data were not available we used an internationally recognized LCA database (Ecoinvent v3.1, Swiss Centre for Life Cycle Inventories, Zurich, Switzerland)(25) using transparent

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methodologies(183) . These data were used in accordance with The International Organization for Standardization standards for LCAs(22).

We analysed the environmental effects of the CVC insertion kits including CO2 emissions, water use, mineral use, aquatic and terrestrial Eco toxicity, and solid waste. A sensitivity analysis examines how changes in the inputs affect the outputs (results). For example, we could examine the effects of altering an input (electricity source) on an output (CO2 emissions). We performed sensitivity analyses of altering the source of electricity for the reusable CVC insertion kits: brown coal, gas co-generation, and the American (USA) and European standard electricity supply. We did not perform such sensitivity analyses for the single use CVC insertion kits as cogeneration is an unusual source of electricity for plastic and metal manufacture, and the single use plastic and metal items are almost exclusively sourced from China and Pakistan.

Both single use and reusable CVC kits contained a plastic kidney dish, two plastic gallipots, three surgical metal items (needle holder, scissors and artery forceps) and plastic wraps (one for the kit cover and one to provide a sterile field). For the reusable central venous catheter kit the two plastic wraps were single use, while for the single use CVC kit all items were single use. All items were weighed with an electronic balance accurate to +/- 0.5g (Satrue KA-1000, Shang Chuen Co., Taiwan). Other items such as cotton gauze and antiseptic were not examined as they were common to the insertion of all central venous catheters.

The International Organization for Standardization-14040 series are standards for conducting LCAs(22). An attributional LCA (see section 5.2 of this chapter for further detail) was performed based on currently available sources of electricity. As per standard protocol, items such as washers and sterilisers that were already in place were not included in this LCA (22). Data for life cycle assessments were either directly collected or obtained from life cycle inventories; i.e. local industry or internationally recognized databases(25, 26). Direct data for the washer and steriliser electricity and water use were obtained, but most other inputs were acquired from databases. Processes included in this study (the System Boundary) were raw material extraction, manufacture, packaging, transport, washing, sterilization, and disposal (Figure 1).

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The metal components of both of the reusable and single use CVC insertion kits were fabricated from stainless steel(181). Details of the types of plastics used for the central venous catheter kits were provided by the manufacturer, which we confirmed with the ‘burn test’- i.e. the colour and odour of the burnt plastic(184). The reusable CVC insertion kit’s metal components were made in Germany and the plastic items in Australia. The single use CVC insertion kit’s metal components were made in Pakistan and the plastics were fabricated in China. No life cycle inventory data were available from Pakistan and there were only minimal Chinese data available. Local Australian inventory data for the manufacture of the reusable and single use plastic items were thus used(185) and European data for the reusable and single use metal components(25). Direct life cycle inventory data have not been collected in China or

Pakistan. It is likely that electricity sourced from China and Pakistan has a higher CO2 emissions per kWh produced than electricity sourced from the European grid (due to the high coal use), thus the results will tend to under-estimate the CO2 emissions for the single use items.

A Pedigree Matrix(26, 27) was developed, a qualitative scoring system that allowed LCA input uncertainty to be quantified based upon the data’s temporal and geographical proximity to the study site, as well as reliability and completeness. For example, as the steriliser’s electricity consumption was directly measured on multiple occasions the data’s temporal and geographical proximity was high.

An LCA has inputs (such as the CO2 emissions for electricity from brown coal), which are combined to form a process (such as the CO2 emissions for making plastic trays). Every input has a degree of uncertainty associated with it, which is expressed as a probability distribution and is derived from a qualitative scoring system. A final 95% confidence interval (95% CI) for a process is achieved based upon the repeated random sampling anywhere within the 95% CIs for all inputs (Monte Carlo analysis)(26, 27).

Monte Carlo analysis is the random sampling of data, repeated thousands of times, to obtain a probability distribution(26, 27). Monte Carlo analysis is used when examining large amounts of stochastic (random) data where it is infeasible to obtain an exact result. For example, the CO2 emissions emanating from just the manufacture of stainless steel (an output) requires many hundreds of inputs, such as the production and transport of iron, chromium, and other metals, each with their own variations in

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CO2 emissions. It would be infeasible to obtain direct data from the source for each and every one of these inputs for each new LCA study.

A Monte Carlo assessment will randomly assign the data from each input based on its individual distribution to create a probability distribution that describes the aggregate data. The Monte Carlo SimaPro software analysis involves at least 1,000 ‘runs’ of random sampling to reduce the likelihood of unusual results which can be a lengthy process requiring hours of computer work.

The purchase costs for the single use and reusable central venous catheter kits for our hospitals (Table 5) were obtained. These prices were similar to central venous catheter kits obtained by other local hospitals. For the single use central venous catheter (CVC) insertion kit costs were also determined for storage, logistics, and metal components disposal into sharps bins. An assumption was made that all other waste from both the reusable and single use CVC insertion kits was placed into infectious (clinical) bins.

For the reusable CVC insertion kits the following were included: electricity, water, gas for hot water, chemical and biological indicators, and maintenance costs for the washer and steriliser, as well as washer detergents and packaging. Steriliser accessory loads (warm ups and infection control cycles) were also included. Washing and sterilisation was assumed to conform to the Australian and New Zealand Standards(139). On a conservative estimate the reusable metal components and plastic items were known to have a lifespan of 300 uses by Central Sterile Supply Department staff, with the metal components requiring reprocessing (sharpening) every 100 uses. No assumption of loss of reusable items was made, although investigation was separately made of the effects of loss of reusable CVC insertion kits at our hospitals.

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Figure 1 System Boundary. Processes examined for the reusable and single use CVC insertion kits lie within the system boundary (i.e. within the large rectangle).1

1Only data for the washing of the reusable tray are directly measured, while all other data are average industry inputs.

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The entire financial costs of making the reusable CVC insertion kits ‘patient ready’ again were examined. With Central Sterile and Supply Department (CSSD) staff a time and motion study that compartmentalized labor costs was developed. The following time periods were included: carriage of the reusable CVC insertion kits from the intensive care unit to CSSD, decontamination, loading and unloading the washer, inspection, barcoding and scanning, second checking, loading and unloading the steriliser, and packaging. CSSD staff used stop clocks to time the duration of each segment of the processing of the reusable central venous catheter kits and entered these times onto sheets. Staff entered their estimate of how full (as a percentage) the washer and steriliser were with each load. For the time-in-motion study to be representative all staff were encouraged to complete the study, but no more than twice per staff member.

The hospital washer used was a Steris Reliance synergy disinfector (Steris Corporation, Mentor, Ohio, USA) while the steriliser was an Atherton’s Gorilla (Atherton, Melbourne, Australia). The volumes of hot (gas heated) and cold water used by both devices and the kilowatt hours of electricity were measured. The steriliser has three sources of water use for: 1. steam generation, 2. the vessel jacket to keep the steriliser warm and 3. the liquid ring vacuum pump to ‘pull a vacuum’ for efficient sterilisation. Sterilisers can either have an internal electric element to heat water to steam or rely upon an external steam source such as a gas boiler. Since gas boiler dependent steam heating within hospitals in Australia is becoming less common the hospital electric steriliser was examined.

The electricity consumption of the washer and steriliser was measured with a ‘power clamp’- a Hioki 3197 Power Quality Analyser, accurate to +/- 3% (Hioki Corporation, Japan). Electricity consumption calculations were verified both with external consultant engineers (Aquaklar, Melbourne, Australia) and by measurements at the Atherton’s steriliser manufacturing facility in Melbourne. On each of these three occasions the steriliser’s electricity consumption over a 48 hour period was measured, including routine and accessory cycles. Steriliser water consumption was measured by direct flow meters at the Atherton’s factory. Water consumption of the hospital washer was measured with flow meters with an error rate of +/-5%, (S-100 and V-100 water meters, Elster, Essen, Germany).

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The details of the sterilisation of the single use CVC insertion kit with ethylene oxide (by Steritech, Melbourne, Australia) were examined. Sharps bins waste and infectious waste was treated with sodium hypochlorite or incinerated. Despite requests to the infectious waste company contracted to our hospitals it was impossible to examine directly the environmental effects of such waste disposal processes, instead relying upon industry data(25).

As is routine for modelling(27), where it was not feasible to obtain first order data for a process the most conservative (lowest) estimate for CO2 and water consumption was used. Since considerably more first order data were available for the reusable CVC insertion kits than for the single use kits, this study likely under-estimates the environmental effects of the single use kits. All financial costs and the energy and water consumption of the washer and dryer for reusable plastic trays were directly measured. External industry data were used for all environmental costs for the single- use tray, and all other environmental data except energy and water consumption of the washer and dryer for the reusable trays. A currency converter (152) on the 17/6/2015 was used to convert AUD$1 to USD$0.77.

5.5 RESULTS

The cost of the reusable CVC insertion kit to the hospital was AUD$6.35 (95% CI 5.89 to 6.86), (Table 5), while the single use CVC insertion kit cost AUD$8.65 (Table 6). There was little variation in the cost of the single use CVC insertion kits in other hospitals in Melbourne, Australia (thus no 95% CIs are given). CO2 emissions and water usage for the reusable and single use CVC insertion kits are given in Tables 7 and 8. Energy and water use based on brown coal electricity generation were three and ten times greater respectively for the reusable kits compared with the single use CVC insertion kits. Other environmental effects (such as terrestrial and aquatic pollution) were either similar or of minor difference for the two approaches.

Steam sterilisation was almost 70% of the total CO2 emissions for the reusable CVC insertion kit (Table 7), while for the single use CVC insertion kit, manufacture of plastics contributed 70% and stainless steel metal components 25% (Table 8). The reusable kit weighed 627 g, including approximately 50 g of single use wrap, while the single use kit weighed 171 g including wrap.

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At the time of this study there were 33 CSSD staff employed at various fractions at the Western Hospital, Melbourne, Australia. The time and motion study was completed on 29 occasions with no staff member completing the study more than thrice. The mean labour time to make one reusable CVC insertion kit patient ready again was rounded up to 9 minutes (range of 5 to 12 minutes, 80% between 6 to10 minutes). The mean hourly pay rate for CSSD staff in November 2011 was AUD$31.22 (including all on-costs such as sick leave and superannuation). Other financial costs (washer detergents and maintenance of the washer and steriliser) were relatively minor (Table 5). The washer and steriliser at full capacity were measured to take 32 and 48 reusable central venous catheter kits respectively. The CSSD staff estimated that on average the washer and steriliser were 90% full for the 29 occasions (Table 5).

Labour contributed 70% (AUD$4.45 of $6.35) of the financial costs for the reusable CVC insertion kits (Table 5). The cost of repackaging the reusable CVC insertion kit in single use plastic was the next most expensive component (AUD$1.20, 19% total). The financial costs of all detergents, gas, electricity and water were relatively minor.

Table 5 gives the financial costs for one single use CVC insertion kit. Of the total costs of AUD$8.65 (USD$6.65), more than 90% is due to the purchase cost of the kit. Waste disposal via the relatively expensive sharps and infectious waste routes was less than 10% of total financial cost.

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Table 5 Itemised financial costs for one reusable CVC insertion kit

Item Cost (AUD$) Labour for an average of 9 minutes at AUD$31.40/hr to wash, $4.45 sterilize, etc. for each reusable CVC kit. Single use packaging of the reusable CVC kit- plastic theatre $1.20 wrap (AUD$0.83), chemical and biological indicators, barcode label, internal chemical indicator, plastic cover. Reusable plastic items (assuming 300 uses): $0.04 ($13.20/300) 1 plastic kidney dish and 2 gallipots (200g) Reusable metal ware (assuming 300 uses): $0.07 ($22.00/300) 3 stainless steel surgical instruments (100g) Reprocessing (sharpening etc.) of reusable metal ware every 100 $0.30 ($30/100) uses (AUD$10 for each of the 3 metallic items) Electricity-for washer and dryer- 4.1 kWh at AUD$0.11/kWh at $0.02 ($0.45/29) a max. of 32 kits per cycle with an average of 90% capacity (i.e. 29 kits) Gas-for washer hot water $0.01 ($0.10/29) 25.2 MJ at AUD$0.004/MJ Washer- water- 200 litres at AUD$1.30/kilolitre $0.01 ($0.30/29) Detergents for washer: $0.08 ($2.60/29) Alkaline- 150ml at AUD$5.70/litre= AUD$0.85, Neutralizing agent- 150 ml at AUD$11.20/litre= AUD$1.70, Drying agent -8 ml at AUD$6/litre= AUD$0.05 Maintenance for washer $0.01 AUD$1,600 for > 160,000 items/annum Electricity for steriliser-27.3 kWh at AUD$0.11/kWh at an $0.08 average of 90% capacity (max. 48 kits/load, i.e. 44 kits) Maintenance and validation for steriliser $0.05 AUD$6,000 for 3,350 loads/annum Entire reusable CVC kit Total $6.35 (AUD$) $4.90 (USD$)

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Table 6 Itemised financial costs for one single use CVC insertion kit

Item Cost (AUD$)

Single use CVC kit $8.00 Cost of logistics to store, transport etc. item from warehouse $0.30 ( 4% of purchase price) Sharps disposal 60 g metal= 300ml. $0.25 22 litre sharps bin disposal costs AUD$20- i.e. AUD$0.91/litre Infectious waste disposal (110g) at AUD$1/kg $0.10 Entire single use CVC kit in AUD$ $8.65 (AUD$) $6.66 (USD$)

The water and electricity use of the washer was determined on 19 occasions over a 48-hour period. The mean washer electricity usage was 4.1 kilowatt hours/load, gas fired hot water (65 degrees) use was 79 litres/load and cold water use was 126 litres/load. The washer was assumed to be 85% efficient and thus use 25.2 MJ of gas to heat the 79 litres of water from 15 to 65 degrees.

The steriliser electricity and water usages were measured for two separate periods at the hospital (a total of 23 routine and 8 accessory cycles) and at the Atherton’s factory. The Atherton’s factory steriliser performed 6 routine and 5 accessory loads, using an average of: 22.3 kilowatt hours/routine load, 30 litres of steam, 72 litres of heat exchanger water and 434 litres of vacuum pump water. Since an average operating day consists of several accessory steriliser loads these were also included in the energy and water calculations, i.e. four accessory loads per 10 routine loads per 24-hour period. The final steriliser electrical consumption per load was thus 27.3 kWh. Due to difficulties in obtaining accurate steriliser heat exchanger water use at the hospital and because the electricity usage at the factory was by direct measurement these factory data were used in the final analysis. The electricity usage per cycle for the steriliser when measured at the factory when compared with the hospital was up to 10% greater.

Table 7 gives the effects on CO2 emissions and water use for the reusable CVC insertion kit processed with electricity sourced from brown coal (the overwhelming source of electricity for the state of Victoria, Australia). Steam sterilisation contributes 830 of 1,211g (69% total) of CO2 emissions, with the remainder arising from washing; 256 of 1,211g (21%) CO2; and single use plastic wrap, 121 of 1,211 g

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(10%) CO2. The manufacture and production of the reusable plastic and metal ware as well as transport of such items and waste disposal together contributed to less than 2% of the CO2 emissions. A similar pattern was seen for water use, although the washer contributed to relatively more of total water use, 11.2 of 27.7 (40%) litres of water.

Hospital procurement documents of CVC insertion kits showed that loss of items was very rare in the operating rooms, but that loss of scissors or needle holders occurred on average once per five uses in the intensive care unit (ICU). Loss of a single AUD$10 reusable scissors for every five kit uses would increase the overall cost of the central venous catheter kits to 5x AUD$6.35 + AUD$10= AUD$41.75 for 5 uses, approximately the same (AUD$8.35) as five single use kits at AUD$8.65 each. Adding new, reusable instruments to CVC insertion kits has little effect on carbon dioxide emissions and water use as such reusable items are used hundreds of times.

Table 7 Effects by life cycle stage for one reusable CVC insertion kit.

Process/Item CO2 Water use produced (litres) (grams) Washing (thermal disinfection) 256 11.2

Steam sterilisation 830 15.7

Single use packaging- 121 <0.05 polypropylene plastic theatre wrap (32g) clear polypropylene plastic cover (15g) Nylon plastic kidney dish (280g) <5 <0.05 two plastic gallipots (100g each) (used 300 times) 3 stainless steel surgical instruments (100g total) <5 <0.05 (used 300 times) Trucking <5 <0.05

Infectious waste disposal for plastic theatre wrap and clear <5 <0.05 plastic cover (50g) 90% hypochlorite treatment, 10% incineration Total for all items and processes 1,211 g 27.7 L

For the single use CVC insertion kit only 5% of the total environmental effects were due to processes other than manufacture of the plastic and metal components (Table 8). Such processes as international shipping transport, ethylene oxide sterilisation,

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infectious waste treatment, and discard to landfill were relatively insignificant from an environmental and toxicological perspective.

Other environmental effects of the CVC insertion kits examined included aquatic and terrestrial Eco toxicity, carcinogens, solid waste and mineral use. The reusable kit had greater environmental effects except for solid waste and mineral use, but these differences were minor.

Table 8 Effects by life cycle stage for one single use CVC insertion kit.

Process/Item CO2 Water use produced (litres) (grams) Polypropylene plastic kidney dish (25g), 114 0.1 Two galley pots (8g each) Polypropylene plastic sheet for sterile field (41 g), 170 0.1 packaging wrap (25 g) Three stainless steel surgical instruments (60g) 104 1.7

Rubber ends on sharp instruments (4g) 10 0.4 Shipping and trucking 8 <0.05 Ethylene oxide sterilisation <2 <0.05 Sharps disposal (60g metal). 90% hypochlorite treatment, <2 <0.05 10% incineration. Infectious waste disposal (110g). <2 <0.05 90% hypochlorite treatment, 10% incineration

Total 407 g 2.4 L

Table 9 compares the CO2 emissions and water use for different sources of electricity for the reusable CVC insertion kit. As noted in 5.4 Methods, the European electricity mix was assumed for the single use CVC insertion kit as imprecise data were available for China’s and Pakistan’s electricity generation. Further, gas cogeneration is an unusual source of electricity for plastic and metal manufacture. Gas cogeneration is a more efficient form of electricity production since there is both electricity production and heat capture, both of which are useful for hospitals.

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Table 9 CO2 Emissions and water use for the single use and reusable CVC insertion kits, accounting for different energy sources for the reusable kits.

Type of CVC insertion kit (and energy CO2 emissions (grams) Water use (litres) source) with 95% C.I.s with 95% C.I.s

Single use (European energy mix) 407 (379-442) 2.5 (2.1-2.9)

Reusable - brown coal 1,211 (1,099-1,323) 27.7 (27.0-28.6)

Reusable- hospital gas cogeneration 436 (410-473) 26.0 (25.8-26.2)

Reusable- USA electricity mix1 764 (509- 1,174) 46.3 (36.6-62.6)3

Reusable- European electricity mix2 572 (470-713) 40.5 (36.4-45.8)3

1In 2012 the USA electricity mix was: coal-49%, nuclear-20%, natural gas- 17%, hydro-7%, oil-3%, other renewables-<1%.(25) 2In 2012 the European electricity mix was: coal-43%, nuclear-21%, natural gas- 18%, hydro- 9%, oil-5%, other renewables-4%.(25) 3The USA and European electricity mix use large volumes of water primarily, because nuclear power stations use large amounts of water for cooling(25).

5.6 DISCUSSION

The financial and environmental costs of a reusable and a single use central venous catheter (CVC) insertion kit were modelled using LCA. The reusable kit was less financially expensive, but had greater environmental effects except for solid waste and mineral use. In a hospital in Melbourne, Australia, to make the reusable CVC insertion kit patient ready again produced three times the CO2 emissions and required ten times the water use of the single use CVC insertion kit. Sterilisation contributed to the majority of the environmental effects for the reusable kit, while for the single use kit, plastic and metal ware manufacture were the most prominent. A reusable CVC insertion kit made patient ready in a hospital on gas co-generation instead of brown coal would produce similar CO2 emissions to a single use kit, although water use would be greater for the reusable CVC insertion kit.

Compared with using brown coal, using electricity from the current American and

European mix would have resulted in approximately 33% and 50% less CO2 emissions to process the reusable CVC insertion kit(25). Some hospitals have on site gas boilers for steam generation that would have less than 50% of the CO2 emissions compared with brown coal sourced electrical sterilisation. Water use was greater for

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reusable CVC insertion kits with electricity sourced from the American and European mix because of the large amount of water required for nuclear energy.

There are limitations to this study. As for most LCAs the majority of data were not directly measured, but sourced from reputable databases(25). It is likely that the CO2 emissions in particular have been underestimated for the single use CVC insertion kit as we used European data for metal components production as direct data measurements from China and Pakistan had not been performed. Source data were obtained for ethylene oxide sterilisation of the single use CVC insertion kit, but infectious waste processing data were incomplete.

Despite imprecise data many processes such as the manufacture of stainless steel and different plastics do not vary considerably between locations and the environmental effects of such processes are in the public domain. Further, because many processes were common to both CVC insertion kits (e.g. stainless steel and plastic manufacturing) not having source data available is unlikely to lead to significantly different conclusions. It is more important for LCAs to have as much direct data for processes that are different between two alternative products; in this case washing and sterilising the reusable CVC insertion kits.

A loss of reusable items was not accounted for, even though this contributes to the drive towards single use items(181). Loss of reusable items was found to be infrequent in the OR due to double counting and checking to prevent loss (or retention within patients) of items. Loss of metal items in the ICU was more frequent, because of the lack of double-checking and the presence of single use metal items creating confusion and increasing discard of reusable items into the sharps bins.

It is likely that there will be a large variation in the loss of reusable items both within and between hospitals and these losses can quickly negate any potential financial savings. The reusable CVC insertion kits (627g) weighed almost four times as much as the single use kits (171g), but unless large numbers of reusable kits were being lost the subsequent environmental effects due to this weight difference would be relatively insignificant compared with the carbon dioxide and water costs of sterilisation and washing. Recycling of infectious or sharps waste (from single use CVC insertion kits and the like) does not occur in Australia unless there is prior decontamination which is often prohibitively expensive.

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It was beyond the scope of this study to examine CVC insertion kit reformulation (i.e. altering kit componentry). Considerable environmental and financial improvements could be made by reformulating these (and other) kits to routinely include or exclude cotton gauze, sutures and antiseptic. The reusable CVC insertion kits included a single use polypropylene wrap (‘blue wrap’ in many hospitals). Such a plastic wrap could be replaced by reusable steel cases, but the requirement for a sterile field to achieve central venous line access would still necessitate the use of either a single use plastic or a reusable linen wrap.

On multiple occasions the electricity and water use of the washer and steam steriliser to make the reusable CVC insertion kit patient-ready again were directly measured. This LCA was modelled upon the routine steam steriliser without alterations. Our findings that the reusable item had worse environmental effects for most parameters than the single use item is at odds with the few other medical life cycle assessments of steam sterilised items. LCAs of sterile gowns(107), laparoscopic instruments(110), laparotomy pads(163), surgical drapes(108),and laryngeal masks(111) found that the reusable items had lower CO2 emissions and water use than single use variants. The three German studies(108, 110, 163) had reusable devices reliant to some degree upon nuclear powered electricity. LCI databases that contain information about electricity sourced from nuclear power routinely include the environmental effects of uranium mining, purification and nuclear power plant decommissioning(25). Nuclear power has significantly lower CO2 emissions than the Australian brown coal used as the electricity source for the washer and steam steriliser for the reusable CVC insertion kit in this study.

The small size and relatively light CVC insertion kits compared with large surgical trays(110) and heavy linen packs(107) are also greatly contributory to the findings of this study. Although it is possible to load 48 reusable CVC insertion kits into the steriliser examined this represents 5kg of metal components, similar to just one major orthopaedic instrument tray. It may be possible to alter the design of the steriliser racks to accommodate more CVC insertion kits whilst conforming to local sterilisation standards.

It is not standard hospital practice to load only reusable CVC insertion kits into steam sterilisers, but rather to prepare a mixed load of such kits with larger surgical trays, linen and plastic ware. Thus, actual hospital steam steriliser loads have greater masses

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than a 5kg, ‘fully loaded’ CVC kit steriliser cycle. The energy efficiency of the steam steriliser (kWh per kg of mass sterilised) would likely be improved with the larger mixed loads of various heavier items, although this has not been well studied. Finally, this study does not account for the energy and water consumption during inactive periods of the washer and steriliser - i.e. when these machines are idle, or on, but not in an active cycle processing equipment.

In this study the reusable CVC insertion kits were found to have considerably greater electricity and water consumption, other environmental effects were similar, but the reusable kits were less expensive than the single use kits. These findings were primarily explained by the hospital’s brown coal based electricity and steriliser energy and water inefficiencies. For similar hospitals that use about 500 CVC insertion kits yearly, using reusable CVC insertion kits would save AUD$1,000 (USD$770), but produce 400kg more CO2 and use 12,500 more litres of water compared with the single use variant. This amount of extra CO2 produced from using the reusable CVC insertion kit equates to driving an average Australian car approximately 2,000km(186) and a fortnight’s water use for an average household in Melbourne, Australia(187).

It is relatively common for hospitals to use gas fired co-generation for electricity and heat production. For Australian hospitals using electricity from gas fired co- generation, using reusable CVC insertion kits compared with single use kits would result in similar CO2 emissions (i.e. one-third that of the reusable kit dependent upon brown coal for steam sterilisation), and AUD$1,000 financial savings, but 12,500 litres increased water consumption. Although the environmental effects of the CVC insertion kits could be extrapolated to any hospital according to the energy source, financial costs would be region specific.

The large amounts of water use for the reusable CVC insertion kits are a concern: water used for sterilisation may preclude its use for other activities, which is particularly pertinent in the many areas of the world under water stress. Water increasingly has an energy ($ and CO2) content also, as it may be sourced from desalination or pumped long distances from dams and rivers. Investigation of more water efficient washers and sterilisers and opportunities for water reuse or recycling could be fruitful.

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The solid waste for the single use CVC insertion kits was greater than for the reusable variants. Most of the wastes were plastics or metals that are minimally toxic in landfill and have low environmental flows. As a result, these solid wastes are of minor importance despite the large numbers of CVC insertion kits used at our hospitals. Financial costs to dispose of infectious and sharps waste will vary greatly between countries. Further, although discard of single use stainless steel metal components appears wasteful, since the metals used are relatively abundant (iron, chromium) and inexpensive for small instruments, mineral use for the single use CVC insertion kits was minor. Other ecological effects such as carcinogens and aquatic and terrestrial toxicity for the two different kits, including the effects of ethylene oxide sterilisation, were either not statistically significant or of minimal difference. The environmental effects of the mode of waste disposal (incineration, steam autoclaving or chemical treatment) are likely to vary and require further research. The overall environmental effects of shipping from distant countries were minor.

5.7 CONCLUSION

Discarding a CVC insertion kit after but one use intuitively appears wasteful. This study however, found that for hospitals using electricity sourced from brown coal for washing and steam sterilisation the environmental effects (CO2 emissions and water use) are greater if reusable kits are used instead of the single use variants. Efforts to reduce the environmental effects of reusable items should be directed towards the inefficiencies and energy sources of steam sterilisers in particular. Further investigations of different sized medical devices with different sources of electricity are required to clarify uncertainty surrounding the environmental and financial effects of most operating room and intensive care purchases.

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CHAPTER 6: REUSE STEAM STERILISATION’S ENERGY AND WATER FOOTPRINT

6.1 BACKGROUND

Chapters 2 and 5 described life cycle assessment (LCA). LCA or ‘cradle to grave’ analysis provides a method to examine the environmental and financial effects of a process or product(26, 183). LCAs of reusable and single use operating room items are increasingly being performed, including surgical gowns(107), laparoscopic instruments(110), laryngeal masks(111), and drug trays(65). LCAs of whole procedures have also been conducted including: cataract surgery(113), delivering a baby(115), different types of dialysis(81), hysterectomies(35), and laparoscopies and laparotomies (188).

Uncertainty is however, emerging regarding the differing results from healthcare LCAs. As an example, one input-output LCA found that the ‘carbon footprint’ of one cataract operation was approximately 180 kg CO2 (113), similar to burning 80 litres of petrol (114). On the contrary, Woods et al performed a process based LCA, finding that a standard gynaecological laparoscopy had a carbon footprint of only 29 kg CO2 (188). Such marked differences in an operation’s ‘carbon footprint’ indicate different LCA methods a paucity of baseline data and rarity of analyses.

Chapter 5 examined the life cycle of a reusable and a single use central venous catheter (CVC) insertion kit consisting of plastic pots, wrap and simple surgical metalware. Initially planned as part of this PhD were further LCAs of: (i) operating room and intensive care unit (ICU) equipment, (ii) an entire operation, and (iii) an ICU patient stay. It was considered however, that the environmental footprint of CVC insertion kits may have been unrealistic, i.e. an under or over-estimation. Steam sterilisation’s environmental effects were found to be the major contributor to the total carbon footprint and water use required to make a reusable CVC insertion kit patient ready again. The CVC study may have overestimated the true carbon footprint since the hospital steriliser routinely took much heavier loads than a steriliser modelled to be full of relatively light CVC insertion kits. That is, the LCA of CVC insertion kits was modelled with relatively ‘inefficient’ loads that may not represent standard

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hospital practice. On the contrary, the LCA of CVC insertion kits may have underestimated the steriliser’s energy and water use due to inclusion of only steriliser loads and accessory cycles, but omission of the energy consumption when the steriliser was in standby mode.

In place of further life cycle assessments this PhD turned to closer study of hospital steam sterilisers. This chapter studies steam steriliser energy and water use and the following chapter investigates how sterilisers are used by hospital staff over a prolonged period.

‘Steam sterilisation’s energy and water footprint’ by McGain F, Moore G and Black J, of which this chapter is an expansion, has been submitted for consideration of publication. This chapter is based upon the article ‘Steam sterilisation’s energy and water footprint’ by McGain F, Moore G and Black J, Australian Health Review 2016, (in press).

6.2 INTRODUCTION

Worldwide, steam remains the most common form of sterilisation for reusable surgical items (182). A basic input for any life cycle of reusable surgical equipment should include steam sterilisation, yet there are few data for in-situ hospital steam steriliser energy and water usage (189). Prior studies of the electricity requirements of steam per unit of mass sterilised vary from 0.2 to 1.4 kWh/kg for external linen sterilisation facilities (107). Campion et al(115), (and later Thiel et al)(35), calculated from ‘machine specifications’ that to decontaminate and sterilise a caesarean section pack in a USA hospital required approximately 0.5 kWh/kg, but, Campion noted, this does not appear to account for the steam production (115).

Our previous study found that the electricity consumption for hospital sterilisation of central venous catheter (CVC) insertion kits was significantly greater, at 3.6 kWh per kg (189). Those estimates may be imprecise, since it was assumed that a small steriliser load, steriliser cycles were examined for only a few days, and idle (standby) steriliser electricity use was excluded. Prolonged measurements of a steam steriliser’s energy and water use were undertaken to provide data that could serve as estimates

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for LCA of operations and potentially lead to a reduced financial and environmental ‘footprint’ of steam sterilisation.

The features of the sterilisers used by the Central Sterile Supply Department (CSSD) at our hospital were typical of many installations globally. A steriliser is either ‘off’ or ‘on’. When ‘off’ the steriliser is totally off, or in a ‘deep sleep’, using minimal electricity and no water. When ‘on’, hospital steam sterilisers may be performing an active cycle or ‘idle’ (in standby). An idle steriliser still requires electricity and water, primarily to produce steam to keep the steriliser jacket warm. Active steriliser cycles are ‘standard’ 134 °C cycles for sterilisation of items, or ‘accessory cycles’ for quality assurance, in which no items are sterilised. Accessory cycles include Warm Ups (to prepare the steriliser for actual loads), Bowie Dicks (a test using chemical indicators to assure thermal penetration) and the Leak Test (to ensure an adequate vacuum) (142). Batch Monitoring System and Spore Test cycles (chemical and biological indicators of sterility) were deemed Standard 134 °C cycles as they were used to sterilise actual items and labelled secondarily as Standard 134 °C cycles.

There are three points of water use for a steam steriliser: steam production, water for the vacuum ring pump, and cooling water for the chiller/heat exchanger (see Figure 1). Steam produced in the generator will move to the jacket and into the chamber when the steriliser is in an active cycle. After leaving the chamber the steam is condensed to liquid water via a heat exchanger. When the steriliser is idle, steam moves from the generator to the jacket and thus via steam traps to the heat exchanger, thus bypassing the steriliser chamber. For the same time period the amount of steam required for the steriliser jacket is a fraction (approximately 10%) of the steam required for an active cycle for the steam chamber.

The vacuum pump evacuates the steriliser chamber prior the steam’s entrance into the chamber to improve steam penetration. Smaller amounts of mains water are also used to cool steam exiting the steriliser jacket, e.g. during a Warm Up cycle, when the steriliser is idle, and when the steriliser is ‘blown down’ from idle to deep sleep every night (to prevent ‘scale formation’ in the steam generator). As the vacuum pump uses the majority of the mains water this second water stream has been labelled as vacuum pump water.

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A third source of water is required by a heat exchanger to rapidly condense the steam after it has passed through the sterilising chamber during an active cycle (so that it is not hot enough to damage piping) and thus on to sewerage. There is no water transfer between the steriliser steam condensate and the heat exchanger water. Water use is an order of magnitude greater for the vacuum pump and chiller/heat exchanger than steam generation.

The standard 134 °C cycles were mostly mixed (linen, metal, plastic or mixed metal and plastic), although there were single type cycles – linen, metal or plastic. Open steriliser loads (no wrapping) of loan equipment were also performed, which have no sterile theatre wrap and no drying time. Such loan equipment has been used by the hospital theatre staff and is being sterilised prior to their non-sterile return for checking by the external loan company.

A routine day commences with the Warm Up whereby steam is piped into the steriliser jacket at 125 °C and 215 kPa. Although no vacuum is created within the steriliser chamber, water is used to cool the steam exiting the jacket. For a Bowie Dick cycle to test for sterility there are 7 vacuum pulls (with vacuum pump water) to achieve a chamber pressure of minus 85 kPa followed by steam entry into the chamber at 134 °C for 4 minutes. The Leak test detects a vacuum leak of anything beyond 1.3 kPa over 10 minutes. No chamber steam is used, although the background steam production to keep the jacket warm continues. The Leak test cycles are performed once a week to ensure that a vacuum can be ‘held’ without a noticeable steriliser leak. All accessory cycles are of approximately 20 minutes duration. For Standard 134 °C cycles there are also 7 vacuum pulls followed by steam entry at 134 °C for 4 minutes, but thereafter there is also a drying time of between approximately 10-25 minutes to ensure a dry load. These standard 134 °C cycles had a variety of different contents, mostly being mixed (linen, metal and plastic), although there are smaller numbers of single type cycles – linen, metal or plastic.

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Figure 2 Location of instrumentation on the steam steriliser.

The aim of this study was to determine the contribution of steam sterilisation to the energy and water use required to make reusable surgical instruments patient-ready again. It was unclear what the patterns of electricity and water consumption of a standard hospital steriliser were over a prolonged period. After discussion with engineering staff it was considered that the electricity and water consumption of hospital sterilisers would: (i) increase linearly with greater load mass, whilst taking account of the different specific heats of the linen(190), metal and plastic (191), and (ii) also have a fixed component dependent purely upon steam occupying the steriliser chamber. The proportion of steriliser electricity and water use when idle was unknown.

6.3 RESEARCH QUESTIONS

1. What is the total electricity and water consumption of the steriliser over a representative period (up to one year) and what are the masses of items (linen, metal and plastic) sterilised for this period? 2. What are the absolute and relative amounts of steriliser electricity and water use for standard cycles, accessory cycles and idling?

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3. What are the frequency distributions of the: (i) mass of items sterilised in standard cycles, (ii) electricity and water consumption for standard and accessory cycle sterilisations? 4. What are the averages of electricity and water consumption per kilogram of equipment for: (i) standard 134 °C cycles, and (ii) total steriliser use? 5. What is the relationship between the total mass of equipment in mixed steriliser cycles and electricity and water consumption? 6. What is the relationship between the individual masses of linen, metal and plastic in mixed steriliser cycles and electricity and water consumption? 7. What is the relationship between the mass of linen in linen-only steriliser cycles and electricity and water consumption? 8. What is the relationship between the mass of metal in metal-only steriliser loads and electricity and water consumption? 9. What is the relationship between the mass of plastic in plastic-only steriliser loads and electricity and water consumption? 10. What is the marginal cost (i.e. cost/unit= kWh/kg and litres/kg) of electricity and water per mass of items per steriliser run? How does this marginal cost vary with mass?

6.4 METHODS

The activity of one ‘Gorilla’® electric steam steriliser (Atherton, Thornbury, Australia) was examined at the 350-bed Sunshine Hospital, Melbourne, Australia. Only one of four sterilisers was metered since the sterilisers performed very similar numbers of cycles per annum and there were metering costs involved. The steriliser had a metered source of electricity applied (accuracy of +/-0.1 kWh). Three metered sources of water were also applied – steam, vacuum pump water and heat exchanger/chiller (accuracy of +/- 5 litres, Elster V-100, Essen, Germany) (Fig. 1). Sunshine hospital performs most surgery types (excluding cardiothoracic, vascular and neurosurgery) and has a significant obstetric and emergency service requiring 24- hour theatre cover.

Several hundred litres of water for both the heat exchanger and vacuum pump were used per sterilisation cycle. The heat exchanger water for the sterilisers had previously been replaced with continuously recirculating ‘chiller’ (air conditioning) water,

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achieving water savings of greater than one hundred litres per cycle. Since none of this measured chiller water was consumed it was of minimal further interest, although it was warmed by the condensing steam, leading to greater chiller energy cooling requirements. Previously (189) it was found that for a typical 20kWh sterilisation cycle the extra electricity requirements per cycle from the chiller were 7kWh. Those data were not re-examined in this study (i.e. this study is most likely under-estimating steriliser electricity consumption). Some hospitals also recirculate the vacuum pump water to achieve water savings, but this does not occur at Sunshine Hospital.

For quality assurance purposes at the study hospital all sterilised items were ‘scanned in’ to a database with a unique identifying code, using ScanCare software (ScanCare, Varsity Lakes, Queensland, Australia). The details of all sterilisation cycles from ScanCare were obtained. Before commencing data collection all sterilised items were weighed on electronic balance scales (+/- 1gram). An ‘item’ was defined as anything with a unique number, e.g. needle-holder (50g) or a large orthopaedic set (6kg). We neither recorded the volume of items sterilised nor the associated proportion of space occupied by items in the steriliser chamber. The manner in which items were stacked by CSSD staff could significantly alter the number of items occupying a steriliser load. For example, placing the smaller items singly would quickly fill a steriliser rack much more so than if they were placed side-by-side in a ‘toaster rack’ then placed onto the main rack.

‘Loan sets’ (i.e. items loaned to the hospital) varied in their composition even for the same unique identifying label (e.g. ‘Loan Shoulder Tray Set’). An approximation of the mass of these loan sets was made by Central Sterile Supply Department (CSSD) staff weighing and averaging several examples of each tray. There were four categories of items sterilised: linen, metal, plastic, and mixed metal and plastic. Most metal items were sterilised on plastic trays that were separately weighed to distinguish between ‘true’ metal and plastic masses (‘gross’ metal masses included the plastic tray’s mass, but ‘net’ metal masses subtracted the mass of the plastic tray, which was thus added to ‘gross’ plastic mass).

Electricity and water usage data were sampled five minutely to a wireless data logger (SoftLogic, Milnthorpe, Cumbria, UK) and thus to an associated website (http://www.softlogic.com.au). Each 5 minute datum point was correct to the nearest 0.1 kWh (electricity) and 5 litres (water). The utility data were downloaded onto a

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spreadsheet and database. The data were then summed into electricity and water use for each steriliser cycle (all standard 134 °C cycles and accessory cycles) and overall electricity and water usage. Visual Basic programming was used to link the data tallies of electricity and water use to the timing of the steriliser cycles, summing such data into utility use for each steriliser cycle. The meter data were synchronised with datum from the steriliser controller and scanned data of items in each load.

It was planned to obtain one year’s data (April 2013 to April 2014). Since the heat exchanger water was recirculated, and the volume of steam water was less than 30 litres per cycle no statistical analyses of steam water use were made. ‘Open’ and failed steriliser loads were included in the total steriliser electricity and water use, but were excluded from further analyses of electricity and water use per mass sterilised as they had a very different (lower) usage pattern which would not be indicative of making a reusable, sterilised item patient ready again.

SPSS 22 (IBM, Armonk, NY, USA) statistical software was used to perform statistical analyses. Linear regression techniques were used to search for relationships between item mass and types (linen, metal and plastic) sterilised and electricity and water consumption. Common non-linear relationships (‘transformations’) were also searched for between steriliser mass and items – i.e. squared, cubed, square root, reciprocal (inverse), log10. Since the amount of steam water used per cycle was very small and the error rate was up to five litres no statistical analyses of steam water use were performed. Further, since the heat exchanger/chiller water was not actually consumed no statistical analyses of chiller usage were done. Analyses of water use thus focus upon vacuum pump water. A currency converter (152) on the 17/6/2015 was used to convert AUD$1 to USD$0.77.

6.5 RESULTS

Data were available for 304 out of 365 days (with gaps principally due to 6 weeks Wi - Fi outage over January-February 2014). Over the 304 days the hospital steriliser required 54.2 MWh of electricity, 1,576,370 litres of vacuum pump water and 65,430 litres of steam water to sterilise 28,282 kg (Table 1). Of the total mass of 28,282 kg, 11,427 kg (43%) was linen, 10,903 kg (41%) metal, 5,321 kg (14%) plastic and 631 kg (2%) mixed metal and plastic items. Of the 1,343 standard 134 °C cycles, there

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were 1,066 mixed cycles, 248 ‘single type of item’ cycles (196 linen, 30 metal and 22 plastic), 18 ‘open’ loads of loan equipment and 11 failed loads.

Table 10 shows that electricity usage during idling was 40% of the total, although 70% of the vacuum pump water was used during the 134 °C cycles. There is minimal usage of the vacuum pump water during idling time, although there is water used to cool the steam exiting the jacket and for when the steriliser is blown down to deep sleep. The mean (standard deviation) load mass of 134 °C cycles was 21.2 (+/-9.7) kg. The 10th centile was 10.9 kg, the 90th centile 36.0 kg, and 32% of cycles were less than 15kg. For the electricity consumption for 134 °C cycles, the 10th and 90th centiles were 16.4 kWh and 21.0 KWh.

Table 10 Steriliser Electricity and Water use for 134 °C and Accessory Cycles and Idling time.

134 °C Accessory Idling Cycles1 Cycles Number of cycles 1,343 830 N.A. Electricity (kWh) 24,870 (46%) 7,782 (14%) 21,457 (40%) Total (% total) Electricity (kWh) 18.7 +/-1.9 9.4 +/- 4.1 N.A. Mean +/-S.D. Water2 (litres). 1,103,675 (70%) 143,495 (9%) 329,200 (21%) Vacuum Pump – Total (% total) Water (litres) Vacuum 822 +/-135 173 +/- 79 N.A. Pump – Mean, +/-S.D.

1Accessory Cycles are: Warm Up, Bowie Dick and Leak Tests. 2Since steam use is small with a relatively high margin of error and the heat exchanger (chiller) water is recirculated continuously these have been excluded (see text).

Table 11 shows the steriliser energy and water consumption per kg of equipment sterilised and includes 134 °C cycles alone, followed by all usage. Twice as much electricity and almost 50% more water/kg items sterilised were used when including all steriliser use compared with 134 °C cycles alone.

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Table 11 Average masses of items for different types of 134 °C cycles

Cycle Type Number1 Average mass (kg) +/- S.D. (kg)

All cycles 1,332 21.2 +/- 9.7 Linen only 196 36.5 +/- 8.8 Metal only 30 19.6 +/-10.2 Plastic only 22 7.7 +/- 2.6 1The 11 failed cycles were excluded from the total 1,343 cycles.

Figure 2 shows the frequency distribution of the masses of items for all loads with the following centiles of note: 10th centile= 10.9 kg, 75th centile= 26.6 kg and 90th centile= 36.0 kg, whilst 56% of all steriliser cycles had 20kg or less and 32% were 15kg or less.

Figure 3 Frequency distribution of the total mass of steriliser items1

1The 11 failed cycles were excluded from the total 1,343 cycles.

Table 12 is derived from Tables 10 and 11 and shows the amount of electricity and water used per kg of equipment sterilised. Due in particular to the long idling times the total amount of electricity and water used by the steriliser per kg of sterilised

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items is appreciably greater than the amount used per kg when considering only the 134 °C cycles.

Table 12 Average electricity and water usage1 per kg of equipment sterilised for all 134 °C Cycles (n= 1,343) and total steriliser use.

Steriliser Mode Electricity (kWh)/kg Water (litres)/kg

134 °C Cycles 24,870/28,282 1,129,275/28,282 =0.9kWh/kg =40 L/kg Total2 54,190/28,282 1,641,800/28,282 =1.9 kWh/kg =58 L/kg

1Total water use/kg includes steam and vacuum pump water. 2Total electricity and water use includes all cycles and idling time.

For further analyses of 134 °C cycles, the 18 open load cycles were excluded due to their lower consumption patterns, as were the 11 failed cycles, leaving 1,343 – (18 + 11) = 1,314 cycles. Fig. 3 graphs the relationship between total mass and electricity use for 134 °C cycles.

Figure 4 Mass-total versus Electricity for 134 °C cycles.1

1(n=1,314). Note non-zero y-axis.

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The general linear regression model is: y = C + a x, and here: y= electricity (kWh), C= Constant, a= co-efficient of x (mass) and x= mass. Visual inspection of Figure 4 shows that there is a relationship between total steriliser load mass and electricity use, but that any regression line may explain these data only moderately well and that the ‘constant’ (i.e. y-intercept) is likely to be more important than the total load mass for electricity use. Figure 4 explores the linear regression analysis of steriliser load mass with electricity use.

Linear regression of mass versus electricity gives a statistically significant (p<0.01) model of Electricity (kWh) = 15.7 + 0.14 (Mass in kg), though R2= 0.58, indicating that the equation explains the data only moderately well. The major component to the prediction model is the constant (15.7 kWh), with a small mass coefficient (0.14 kWh/kg). Common transformations (see Methods) were used to investigate other relationships, but in all cases R2<0.5, indicating a poor fit with the data.

Relationships between steriliser load mass and vacuum pump water use were also examined. Figure 5 does not show a clear relationship between the steriliser load mass and the vacuum pump water use. A large amount of water is used regardless of the load mass (i.e. a high y-intercept or constant). R= 0.02, indicating that although the relationship between water use and weight was statistically significant (p<0.01), the model did not explain the data at all well. Common transformations did not improve the fit of the model with the data of water use.

There was a weak relationship between the mass of steriliser cycles and water use by the heat exchanger (chiller) (R2<0.01, model summary of the data not shown). Chiller water is used regardless of the load mass, as the chiller water is recirculated constantly. Further, steam water use was not modelled as such use is small (< 30 litres/cycle) compared with vacuum pump water and the limits of water meter accuracy (+/- 5 litres) precluded further modelling.

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Figure 5 Mass-total versus Water-Vacuum Pump for 134 °C steriliser cycles.1

1(n=1,314). Note non-zero y-axis.

The linear regression equation for electricity consumption of 134 °C cycles that takes account of different item composition and mass was: Electricity (kWh) = 15.6 + 0.15(kg of Linen) + 0.10(kg of Metal) + 0.22(kg of Plastic) + 0.28(kg of Mixed Metal and Plastic), p<0.01. Again the mass coefficients (0.10 - 0.28 kWh per kg) are small compared to the constant. The equation fits the data similarly well (R2 = 0.60) to the mass-only model. Models of water use which took account of the types of loads did not explain the data well (R2=0.02), as per models of total mass only. Such models were poor for all common transformations.

Linear regression models were also developed for the 248 ‘single type of item’ cycles (linen, metal or plastic only) comparing mass to electricity and water. Mixed metal and plastic item steriliser loads did not occur. As noted in the Methods, we took account of the masses of plastic trays that held metal ware.

For electricity, these statistically significant (p<0.01) models had R2s of 0.57 for plastic, 0.70 for linen and 0.80 for metal, indicating a moderately good fit with the data for linen and metalware. The actual linear regression equations were: (i) Electricity (kWh) = 13 + 0.2 (kg Linen), (ii) Electricity (kWh) = 14.5 + 0.15 (kg

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metal) and (iii) Electricity (kWh) = 14.6 + 0.34 (kg plastic). As for the analyses of all 134 °C cycles the load mass coefficients were small. The constant for linen only cycles (13 kWh) was lower compared with all other cycles. The mean (+/- S.D.) duration of the linen only cycles was 43 (+/-6) minutes compared with 51 (+/-4) minutes for all other non-linen cycles. Linen only cycles had a 10 minute versus 25 minute drying time, perhaps because the water molecules bound to the linen fibres are released slowly. There were poor (R2<0.25) fits between load mass and vacuum pump water use for all item types.

The constants for all models of mass versus electricity and water were more important than the load mass coefficients. That is, the extra electricity and water used per kilogram of added mass fell as we added more items. The following graphs give the cost/unit (kWh per kg and L per kg) of electricity and water per unit mass of items (Figures 6 and 7). From Fig. 5, the kWh cost/kg of mass for a steriliser cycle load of 5kg was approximately 3 kWh per kg (or 15 kWh total). The kWh cost per kg for a 15 kg load is 1.2 kWh per kg (18 kWh total) – adding another 10 kg to the steriliser load increased the electricity consumption by less than 3 kWh. The electricity consumption of a 50 kg steriliser load (25 kWh) was only 4kWh more than for a 30 kg load (21 kWh). Steriliser electricity use reached a minimum of 0.5 kWh per kg at the greatest load.

The cost curve for water-vacuum pump/mass versus mass (Fig. 6) showed a similar descending curve. The unit cost of vacuum pump water is large for small loads (150 litres per kg for a 5kg load). A steriliser load mass of 15kg was required to achieve <50 litres of vacuum pump water per kg. The extra water use for a 50kg load versus a 30kg load is small.

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Figure 6 Electricity Cost Curve. Electricity divided by Mass versus Mass.1

1(n=1,314).

Figure 7 Water Cost Curve. Water-Vacuum Pump divided by Mass Versus Mass.1

1(n=1,314).

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6.6 DISCUSSION

The electricity and water use of a hospital steam steriliser was measured over 304 days. A large proportion of electricity (40%) and water (20%) use occurred during idle (standby) times; heavier loads were more efficient; almost one in three steriliser loads were ‘light’ (less than 15kg), and thus inefficient; and linear regression analyses provided moderately predictive equations of electricity use/mass, but not water use. Per day the steriliser required approximately 178 kWh of electricity and 5,400 litres of water. The average 4-person household in Melbourne, Australia has a daily usage of 16 kWh of electricity (158) and 600 litres of water (187). One steriliser’s daily electricity and water use was thus equivalent to 10 households, whilst one standard 134 °C cycle used approximately one day’s worth of household electricity and water.

As a proportion of total steriliser electricity use, a surprising 40% of electricity was used when idle. Approximately 1.9 kWh of electricity and 61 litres of water were required per kilogram sterilised. The electricity/kg sterilised was approximately half of that calculated in the prior LCA study detailed in Chapter 5 (3.6 kWh/kg) (189), primarily because in this current study no assumptions were made about steriliser load mass. Prior studies gave more efficient steriliser electricity use (35, 107, 115) which could be due to using manufacturer specifications to calculate efficiency rather than measuring it; differences in steriliser mechanical efficiencies; different measurement methods (not including idle time); and operational differences such as having less idle time or shorter drying times or using large and perhaps more efficient sterilisers external to the hospital for linen sterilisation(107). It is difficult to compare our results with those of a recent LCA study of a much smaller autoclave used to sterilise small dental burs(112). Further, it is unclear in some published LCAs if the energy and water use of steam sterilisation is included. The following factors are important: (i) the large electricity use per kg compared with prior studies, (ii) the over-estimation in our prior study(189) from using small, inefficient steriliser load assumptions, and (iii) idle steriliser energy use can potentially double the total energy use/kg of items sterilised.

The vacuum pump used 96% of the water and only 4% was used to generate steam. There are large opportunities to reduce or recirculate steam steriliser water, though routinely these options incur financial installation costs. Discussions with the steriliser

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manufacturer indicate that vacuum ring pumps are by far the most common type of vacuum pump used in this type of application.

For standard 134 °C cycles, the electricity (kWh) used = 15.7 + 0.14(kg of mass), i.e. even for a 50kg load, less than one quarter of the electricity use is related to the sterilised items. The large constant and small coefficient in the equation indicates that most of the energy is used to heat the chamber, create the steam to fill the chamber volume and thermal losses, while relatively little is used to actually heat the items being sterilised. The majority of steriliser water use was also independent of the load mass for standard 134 °C cycles. Vacuum pump water forms the bulk of steam steriliser water use and appears to be dependent primarily on the sterilisation duration.

Linear regression equations were moderately useful for comparisons between item mass with electricity use, but did not improve with the addition of item type and were weak for water use. The linear regression equations for single type steriliser loads of linen and metal mass vs. electricity had higher R2 values, probably because such cycles did not have a mixture of items with different packing arrangements. However, such single item type loads are relatively infrequent and perhaps of greater use to future calculations of operating room life cycle assessments is the average electricity and water cost/kg over 304 days for all standard 134 °C cycles (i.e. 0.9kWh and 40 L per kg). Further, as more load mass was added the extra cost of electricity and water fell. Almost one third of steriliser loads were less than 15kg, requiring on average 18 kWh, yet doubling these loads to 30kg would have required only 1.5 kWh more electricity per cycle.

It is possible that the five-minutely data were not precise enough to examine steriliser electricity and water use when cycles were close together, although this occurred rarely. The data were sent via Wi-Fi to a website. There was confirmation that the water data received electronically were identical to the water data directly measured by the steriliser meters and the Wi-Fi electricity data conformed closely to that directly measured by a ‘power clamp’: a Hioki 3197 Power Quality Analyzer, (Hioki Corporation, Nagano, Japan). Data were obtained for 304/365 days, and there were lacking data due to Wi-Fi difficulties during most of January/February 2014. Much of January in Australia is a summer holiday period of low elective surgical activity, i.e. this study probably underestimated idle steriliser time.

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Dividing sterilised items into linen, metal, plastic and combined metal and plastic may seem crude, yet the vast majority of sterilised items fit clearly into these subtypes. The hospital’s sterilisers have heat exchanger water cooled by recirculating chiller water, leading to hundreds of litres of water saving per cycle, but there is an energy cost through greater work required by the hospital chiller to cool the warmed heat exchanger water. Thus, a 20 kWh cycle would use approximately 27 kWh in total if the extra 7 kWh from the chiller was incorporated (189), with a corresponding one third increase in the electricity use per kilogram.

Our results may not be totally generalisable to other hospitals because of differences in steriliser design and usage, e.g. our sterilisers do not reuse vacuum pump water, although this occurs in some hospitals, with considerable water savings. Steam sterilisation, however, does not vary markedly between different hospitals in Australia, conforming to local (139) and international standards (22). It is likely that our results are broadly comparable with steriliser utility consumption in other countries. Steriliser idle time could vary significantly between hospitals due to local usage factors, particularly between purely elective and emergency hospitals (the latter requiring continuous steriliser functioning). Idle time could thus be much less for hospitals that cater for purely elective procedures. Greater inter-hospital variability for electricity and water used during idle time is likely than for differences between standard 134 °C cycles, although loading patterns remain important.

Steam sterilisation is nontoxic, inexpensive and rapidly microbicidal and sporicidal(182), thus remaining the most dependable method to sterilise most medical items. There is an increasing use of low temperature sterilisation systems (192), but these are mainly confined to sterilising malleable ‘visual equipment’ (e.g. colonoscopes). Future efforts to improve steriliser energy and water efficiencies could target two main areas: (i) how hospital staff use sterilisers, and (ii) steriliser hardware and software manufacture, although steriliser energy source/s remain important. Although the four sterilisers at our hospital consume less than 2% of the total hospital daily electricity use, their individual electricity usage remains considerable and can easily be reduced by changed work practices. Similar studies of other hospital equipment are now occurring, e.g. a USA study found that the electricity used when the CT scanner was idle was an order of magnitude greater than the energy used for an actual scan received by the patient (83). Further research is required to establish

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the safety of turning CT scanners off during periods of low demand, and the energy requirements to restart the CT scanner compared with leaving the scanner idle.

As a direct result of this study staff at Sunshine hospital have rotated off one of four sterilisers with no change to the number of 134 °C cycles, saving electricity, water, labour and reagent testing. An idle steriliser uses 5 kWh per hour, and routinely all four sterilisers were on for 22 of 24 hours, i.e. 110 kWh is now saved/day. Further, there are no morning accessory cycles (20 kWh) for that fourth (‘off’) steriliser, and the reduced chiller electricity use will be approximately 40 kWh (one third of 130kWh). It follows then that savings of 170 kWh electricity per day with a yearly financial value of $AUD$9,400 (USD$7,240)(152), equal to 10 average Australian houses per day (158) (with associated water savings) are occurring for the same number of sterilization cycles. Increasing steriliser load mass will also contribute similarly in future to environmental and financial savings.

Our study provides a baseline for future life cycle studies of reusable surgical instruments, and indicates the importance of measuring how hospital steam sterilisers are used during both active cycles and when idle. Measurement of how groups of hospital sterilisers are used will contribute further to energy and water efficiencies. Once such data are available, collaboration between CSSD hospital staff, engineers and others to develop novel ways to improve steriliser efficiencies is feasible. Our study indicates the importance of in-situ monitoring of hospital equipment and the integral role of real-time electronic data gathering and distribution. After a century of use the steam steriliser appears here to stay – and the opportunity to improve its significant electricity and water consumption worldwide grows in importance.

6.7 CONCLUSION

This study was performed to clarify whether the energy and water consumption used for steam sterilisation for the life cycle assessment detailed in Chapter 5 were realistic. The electricity and water use required for the steam sterilisation were quantified. A surprising amount of steriliser time was spent idle, consuming appreciable amounts of energy and water. The load mass had minor effects upon steriliser electricity and water use, whilst the type of load (linen, metal, plastic) had much smaller effects on such electricity and water use. The results of this study

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inform future life cycle assessments of operating room and ICU items and procedures. For example, future LCAs of reusable surgical items could use this study’s calculations of electricity and water use/kg load sterilised, whilst load type could be excluded. Further, considerable efficiency gains in steriliser use are possible through reducing idle periods as well as increasing steriliser load masses. Innovations in hospital steriliser usage and will become increasingly important in a financial, energy and carbon constrained society.

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CHAPTER 7: REUSE HOSPITAL STEAM STERILISER USAGE: COULD WE SWITCH OFF TO SAVE ELECTRICITY AND WATER?

7.1 BACKGROUND

Steam sterilisers are integral to the sterilisation of reusable medical equipment. Chapter 6 quantified the energy and water consumption of a hospital steam steriliser over a prolonged period. The results of Chapter 6 inform future life cycle assessments of operating room and ICU items and procedures. Further, it was noted that a surprising amount of steriliser time was spent idle and many steriliser loads were relatively light, consuming appreciable amounts of energy and water. Considerable efficiency gains in steriliser use could be possible at the hospital level through: (i) reducing idle periods, and (ii) increasing steriliser load masses, including changing the load stacking arrangement and stacking the steriliser with another layer of racking. An examination of the steriliser idle periods was thought more likely to lead to greater and more prompt efficiency gains than altering steriliser load masses.

This chapter is based upon the article ‘Hospital Steam Sterilizer Usage: Could we switch off to save electricity and water?’ by McGain F, Moore G and Black, J, Health Services Research and Policy 2016; Jan. (epub ahead of print).

7.2 INTRODUCTION

Steam sterilisation is an energy intensive process, each sterilising load of around 20 kg for a standard, medium to large sized hospital steriliser requiring about 20 kWh of electricity and 500 litres of water(189), equivalent to an Australian four-person household’s electricity and water use for an entire day(158, 187). Despite the advent of new modes of sterilisation(192), steam remains the most common method of sterilising surgical items(182) Accordingly, a method was developed to examine how hospital steam sterilisers are used, to complement studies of steriliser utility consumption(107, 115, 189).

To reiterate Chapter 6.2 Introduction: a steriliser is either ‘off’ (i.e. in a ‘deep sleep’, using minimal electricity and no water) or ‘on’ (i.e. performing an active cycle or

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‘idle’ in standby). Active cycles are ‘standard’ 134 °C cycles for item sterilisation, or ‘accessory cycles’ (such as Warm Ups and Bowie Dick tests for quality assurance) which do not contain items(139).

Efforts have been made to improve hospital steriliser efficiencies though there are few relevant publications. Unnecessary steriliser cycles can be avoided by standardisation of which items actually require sterilisation(193). One study found that steriliser efficiency (hours of active steriliser cycles/hours of available labour) was 63% for a 6-month period, although there were only monthly details of steriliser use(194). The use of hospital steam sterilisers was assessed and opportunities were sought to improve steriliser electricity and water efficiency.

An idle (i.e. in standby) steriliser still requires electricity, primarily to produce steam to keep the steriliser jacket warm, and water to condense the steam upon leaving the steriliser. The environmental ‘break-even point’ is the period at which potential electricity or water savings from switching off are balanced by the extra resources needed to warm up again before use.

In Chapter 6 one hospital steriliser was found to use approximately 25.8 of 63.9 MWh (40%) of its total electricity and 395,000 of 1,572,000 litres (21%) of its total water requirements for the year whilst idle. That is, each hour an idle steriliser used approximately 5.3 kWh of electricity for steam generation and 81 litres of water to cool this steam. Standard practice was for a Warm Up cycle to be performed prior to a

Standard 134 °C cycle whenever the steriliser had been idle or off for two or more hours to avoid failed cycles. A warm up cycle for a steriliser that had been off (and was thus ‘cold’) used an extra 7 kWh and 60 litres of water compared with one that had been idle (‘tepid’). From such prior data the steriliser ‘break-even point’ was found to be less than two hours (a conservative approach to the break-even point).

At our hospital, due to lower demand for sterilisation overnight and labour capacity, it was routine practice to switch off: (i) one steriliser on all days between 10 p.m. and 6 a.m.; and the other three sterilisers (ii) between 4 a.m. and 6 a.m. every weekday, or (iii) between 2 a.m. and 6 a.m. on every weekend day. One could thus determine directly when a steriliser was active and indirectly when it was idle or off.

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7.3 RESEARCH QUESTIONS

1. How were the four hospital sterilisers used during one full year, including details of periods spent in active use, idle or switched off? 2. Based upon data from Chapter 6, how much electricity and water were used by the sterilisers during these different periods (i.e. active, idle or off)? 3. What would have been the consequences for electricity and water use of two alternative usage policies based upon switching sterilisers off when not needed (either whenever idling, or at set times of the day)?

7.4 METHODS

For one year the activity of four ‘Gorilla’® electric steam sterilisers (Atherton, Thornbury, Australia) was studied in the Central Sterile and Supply Department (CSSD) at Sunshine Hospital, Melbourne, Australia. Ethics approval was obtained from the Western Health Low Risk Ethics Panel (approval no. 2012/165). At the end of each steriliser cycle the summary details of that cycle were routinely recorded by CSSD staff into the ScanCare® database (ScanCare, Varsity Lakes, Queensland, Australia).

All steriliser cycles were included in the analyses whether they were classified as

‘pass’, ‘fail’ or ‘maintenance/validation’ (using staff estimates for the duration of the last). Accessory and standard 134 °C cycles take about 20 and 50 minutes respectively. If a steriliser was in an active cycle at any point during a given hour that hour was categorized as ‘active’. With four sterilisers the maximum number of steriliser-hours available per day was 96.

Due to lower demand it was routine practice to switch off sterilisers overnight (see the final paragraph of 7.2 Introduction for precise timings). Exceptions to this practice were looked for by noting active steriliser cycles during these off hours and when two or three sterilisers were off. The steriliser ‘off’ hours could thus be calculated, and finally the idle hours (as total hours less active and off). Data were stored and analysed using Microsoft Excel® and Access® software (Microsoft, Washington, USA).

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Chapter 6 (Steam sterilisation’s energy and water footprint) identified several potential areas for improved steriliser resource efficiency including reducing idle time and increasing the average mass of each steriliser load. This chapter explores reducing the idle steriliser time only. Two potential opportunities to reduce the hours of steriliser use with an unchanged number of active cycles were analysed: turning off sterilisers routinely instead of leaving them idling, and turning off one steriliser for certain periods if very few on-active cycles occurred in those hours. The potential reductions in electricity and water consumption that would result from such switch offs were modelled.

7.5 RESULTS

Data were obtained for 365 days (8,760 unique hours between 15/4/2013 and 14/4/2014) of all hospital sterilisation cycles. The amount and proportions of time spent by the four sterilisers when active, idle and off are given in Table 13. Of note: all four sterilisers were simultaneously active for only 9% of the hours, and two or more sterilisers were idle for 69% of the hours. For the 365 days there were 53 fewer occasions than predicted by CSSD policy when four sterilisers were off, indicating that some were left idle (such hours were not active). On 41 occasions sterilisers were off when policy indicated they would be idle. There were 57 failed cycles, including 14 standard 134 °C cycles, requiring maintenance work on the sterilisers on six occasions for an average (anecdotal) duration of 6 hours. Most failed cycles were due to ‘colourimetric uncertainty’ of Bowie Dick cycles. Validation of the sterilisers occurred for one day for each of the four sterilisers. Two sterilisers were cleaned for 20 minutes each on every Saturday and Sunday.

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Table 13 Hours when the sterilisers were active, idle and off.1

No. active No. idle No. off No. of hours Percentage of (8,760 total) total

0 4 0 522 6.0 % 0 3 1 558 6.3% 0 0 4 897 10.2% 1 3 0 2022 23.1% 1 2 1 447 5.1% 1 0 3 37 0.4% 2 2 0 2546 29.1% 2 1 1 110 1.3% 2 0 2 4 0.0% 3 1 0 864 9.9% 4 0 0 7532 8.6%

1Routinely, 0, 1, or 4 sterilisers were off although there were 41/8,760 hours when either 2 or 3 sterilisers were off. 2726/753 times there were 4 sterilisers on simultaneously during the hours of 6 a.m.-10 a.m. (i.e. 27 times outside these hours in a year).

The frequency distributions of the numbers of sterilisers in active use per hour for the 365 days are given in Figures 8 (week days) and 9 (weekend days). Figures 8 and 9 reveal greatest steriliser activity between 6 a.m. and 10 a.m., and rarely was there more than one active steriliser on from 11 p.m. to 6 a.m. There were four sterilisers active from 10 a.m. onwards on only 27 of 261 week days and on 1 of 104 weekend days. On weekends three sterilisers were active from 10 a.m. onwards on only 27 of 104 days. Finally, there were only 5 of 365 days when more than two sterilisers were active from midnight until the routine steriliser switch off at 4 a.m. on week days and 2 a.m. on weekend days.

For the four sterilisers together, the year 15/4/2013-14/4/2014 had 1,460 steriliser- days or 35,040 steriliser-hours. For these 35,040 steriliser-hours, the sterilisers were active for 13,430 (38%) steriliser-hours, off for 4,822 (14%) and idle for 16,788 (48%) (Table 13).

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Figure 8 Pattern of active steriliser use on week days.

Figure 9 Pattern of active steriliser use on weekend days.

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Figure 10 gives the spread of active steriliser time for 365 days, i.e. the ‘demand’, on a daily basis. In Figure 10 the x-axis represents the active steriliser-hours, whilst the y-axis indicates the number of days on which those hours of use occurred. Given that the four sterilisers have a maximum of 4x24=96 steriliser-hours of active use per day, active steriliser use for all hours for all days would be indicated by vertical lines reaching 365 days for all 96 hours. The maximum steriliser-hours per routine day prior is 80 hours due to routine steriliser switch offs, whilst a potential switch off of one steriliser permanently would reduce the maximum steriliser-hours to 58 (see Fig. 3). A minimum of 18 hours of active use occurred on every day, whilst the maximum usage on any day was 55 hours.

Figure 10 Frequency distribution of steriliser-hours of active use per day for one year for routine practice1 and if one steriliser was to always be switched off.2

1The average sum of available steriliser-hours is <96 hours as there are routine periods when the steriliser is turned off, i.e. (1) one steriliser is off from 10 p.m. on all days, (2) 4 sterilisers are off from 4 a.m.-6 a.m. on weekdays, and (3) 4 sterilisers are of from 2 a.m.-6 a.m. on weekends. Thus, routinely there are a maximum of 80 steriliser-hours available per day averaged over weekdays and weekends. 2If one steriliser is permanently switched off in addition to routine steriliser switch offs the maximum number of steriliser-hours available per day falls to about 58 (80-22) hours, given that the sterilisers will be off for at least 2 hours per night.

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From the observed steriliser usage noted in Figures 8 to 10, calculations were made about how much difference in electricity and water use there would have been if a new policy had been introduced, of switching the steriliser off instead of idling when no loads were waiting. The break-even point occurred at less than two hours of idle time (see 7.2 Introduction).

The sterilisers were idle on 3,343 separate occasions for the total of 16,788 hours. When idle, the number of separate occasions the sterilisers were idle for two hours or less was 1,862 (56%), and greater than two hours on 1,481 (44%). If such a policy had been in place the sterilisers would have to be turned back on again within two hours on more than half the occasions. Since there were four sterilisers and there were 1,862 separate occasions of idle periods less than two hours per day for the year, each steriliser would have to be turned back on again just over once/day (i.e. 1,862/ (365x4 =1.3)).

The sum of idle hours when the sterilisers were idle for two hours or less was 2,207 (13.1%) hours and when idle for more than two hours was 14,596 (86.9%) hours. Figure 11 indicates the sum of idle hours for each idle duration, showing that long idle periods form the majority of the total idle time.

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Figure 11 Sum of hours idle for idle duration for the 4 sterilisers for one year.1

1The y-axis (sum of hours idle) is given in ascending numbers of hours. The x-axis is the idle duration (1-24 hours), NOT hour of the day. Thus, as noted on the x-axis (idle duration), the steriliser is never idle for 21 or 23 hours and is idle for 20 hours for the longest duration (i.e. the greatest sum of idle hours) over the year.

To find the difference in electricity and water use there would have been with the ‘switch off’ policy the sum of hours when the sterilisers were idling more than two hours was deducted. Given that the steriliser electricity and water use per idle hour was 5.3 kWh and 81 litres respectively, the savings from such an approach would be 65,662 kWh and 1,003,509 litres per year. From Chapter 6 it was known that the four sterilisers used approximately 40% of their electricity and 21% of their water whilst idle. Thus, the overall savings for four sterilisers with this switch-off policy as a percentage of total electricity use would have been approximately 65.7/255.6 MWh (26%) and 1,003/7,560 kilolitres (13%).

An alternative approach would be to switch off sterilisers during periods of low demand. From 10 a.m. onwards it was infrequent for all four sterilisers to be simultaneously active. A switch-off policy of one steriliser from 10 a.m. onwards would lead to delaying some loads until later in the day on approximately 1/10 week days and 1/1,000 weekend days, but would save 12 hours of idle steriliser electricity

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and water consumption per day, equating to 23,214 kWh and 354,780 litres per annum.

Another opportunity would be to switch off a second steriliser from midnight. This would have saved 1,252 idle steriliser hours per annum, or 6.6 MWh and 101 kilolitres. These combined switch-offs would thus have saved 29.9 MWh and 456 kilolitres of water. The potential saving for four sterilisers was approximately 29.9/255.6 MWh (12%) and 456/7,560 kilolitres (6%); half as much as the first switch-off strategy.

7.6 DISCUSSION

Analyses of the use of a hospital’s four sterilisers for one year identified potential savings of electricity and water. The sterilisers were idle for almost half of the total hours for the year, longer than they were active, and they were off for only 15% of the time. Steriliser idling for 12 hours or longer accounted for half of the total idle duration, and two or more sterilisers were idle for almost 70% of the total hours.

Opportunities were identified to improve the efficiency of steriliser use, suggesting two switch-off strategies which could lead to large environmental savings. The first strategy to switch off sterilisers when idle, would save 26% of total steriliser electricity use and 13% of the water. An alternative strategy is to always switch off one steriliser off from 10 a.m. and a second one off from midnight leading to electricity and water savings approximately half that of the first strategy. The average 4-person household in Melbourne, Australia has an annual usage of 6.6 MWh of electricity (158) and 220 kilolitres of water (187). The first strategy of switching off when idle is equivalent to an electricity switch off of 10 households and a water switch off of 4 households. These methods examining how hospital staff use sterilisers could be applied to all hospitals.

This observational study has limitations. Steriliser active time was overestimated since if a cycle occurred during any part of an hour it was counted as an active hour, and because all steriliser cycles were less than one hour (i.e. idle time is likely greater). No account was made for failed cycles, cleaning and validation although from hospital records and anecdotally these periods were limited. Other aspects of the switch-off policies other than electricity and water savings were not considered.

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However, switching steam sterilisers on and off up to several times per day depending upon the switch-off strategy is unlikely to impede correct functioning.

Concerns are recognised regarding the timely completion of steriliser cycles caused by switch off strategies. A Bowie Dick cycle is required to be once daily for any steriliser that is active for that day(139). A Warm Up cycle is required prior to a standard 134 °C cycle whenever a steriliser is brought out of deep sleep (switched on) and when a steriliser has been idle for two or more hours. Switch-on requires an extra 15 minutes of pre-Warm Up prior to the Warm Up. Discussions with CSSD staff suggest that they already do a ‘sleeping steriliser’ pre-Warm Up while they wrap items for sterilisation, leading to minimal delays. Other possible concerns about the effects of steriliser switch-off on CSSD staff workflow are beyond the scope of this study.

This study’s specific findings may not be generalisable to all hospitals. For example, hospitals catering only to elective patients may already switch off after hours. By having access to the timing of all hospital steriliser cycles and using relatively straightforward computer software one could identify potential steriliser switch off periods. Any hospital using a similar system of quality assurance could conduct a similar analysis.

Steam will remain as the most common mode to sterilise reusable surgical equipment for the foreseeable future as it is reliably microbicidal and sporicidal, and rapid(182). Yet steam is also highly energy and water consumptive, which can be mitigated both by how a steriliser is constructed and how hospital staff use it. This study provides a method for hospital staff to analyse their steriliser activity and efficiency. Others may find simple opportunities to switch off sterilisers as occurred as a result of this study. Such scenarios do not require any financial outlays and can have considerable immediate financial and environmental returns. These methods could be applied elsewhere within hospitals (e.g. an operating room’s air conditioning and ventilation or a CT scanner). An idle steriliser is, put simply, inefficient, and a switch off could be rewarding.

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7.7 CONCLUSION

This study concludes the thesis section examining ‘Reuse’. Chapter 4 asked why some surgical items (metalware) are labelled single use or reusable in the first place. Chapter 5 was a life cycle assessment comparing reusable with single use central venous catheter insertion kits, finding that steam sterilisation was the major contribution to the ‘carbon footprint’ of the reusable kit.

Chapters 6 and 7 arose out of concern that the foundations to process inputs for steam sterilisation for life cycle assessments of reusable metalware may be imprecise. Chapter 6 measured the electricity and water use of a hospital steam steriliser and identified possible productivity and efficiency improvements. This chapter complements Chapter 6 by examining how hospital staff use a group of steam sterilisers. The sterilisers were idle for more than half of the year and idle periods were often long, indicating that it would be possible to switch off at least one and sometimes two of the sterilisers. As a result of these steam steriliser studies hospital staff have rotated off one steriliser continuously, with further efficiency changes underway. Perhaps more importantly, the methods used in this study could be used in many hospitals to achieve considerable steriliser efficiency gains for minimal outlays.

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CHAPTER 8: RECYCLE A SURVEY OF ANAESTHETISTS’ VIEWS OF RECYCLING

8.1 BACKGROUND

The focus of Chapters 8 and 9 moves from Reuse to Recycle. Within the operating room (OR) and intensive care unit (ICU) there are many items that one could reduce the usage of, or reuse. Chapters 3 to 7 have detailed several examples of such reducing and reusing. There are many other OR and ICU items for which Reduce and Reuse is unfeasible, at least in developed world settings. Just a few examples of non- reusable items include: (i) the plastic wrap that is used to enclose instruments to be sterilised, as the wear and tear from sterilisation leads to deterioration of such plastic, (ii) all cardboard and paper products, and (iii) used plastic intravenous fluid bags. Many non-reusable OR and ICU items could, however be recycled.

In the majority of circumstances it is environmentally beneficial to recycle, i.e. less energy and other resources are required to recycle an item rather than sourcing it from new material(25, 195). If recyclables must be transported long distances this reduces any environmental benefits. Recycling of more ‘energy dense’ items has greater energy (and potentially CO2 emissions) benefits per unit mass. Thus, recycling aluminium and steel has greater environmental benefits per kg than recycling plastics and finally paper and cardboard when compared with using new items made from such materials. There may be other reasons to recycle beyond reducing the environmental footprint, such as conserving resources or imprecise feelings of ‘doing good’, and these factors may have greater sway on an individual’s decision to recycle(97).

Prior to commencing any OR and ICU recycling programs it is integral to examine whether it is feasible to recycle, what can be recycled, and how much could be recycled. Feasibility investigates not only whether it is possible to recycle given busy OR and ICU environments, but whether staff attitudes to recycling are problematic or supportive and what staff see as opportunities and barriers to recycling. This chapter examines behavioural factors that influence the likelihood of successful recycling.

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Chapter 9 examines what could be recycled in the OR and ICU, and waste audits pre- and post-recycling programs in the OR and ICU.

While an interest in the environment in their personal lives has been found to increase the likelihood that individuals would recycle at the hospital, often environmentally sustainable personal behaviours are not carried into the workplace(49, 96). Topf examined staff indifference to unsustainable hospital practices(97), suggesting that hospital environments encourage environmental ‘numbness’, and elicit a range of coping mechanisms including denial that unsustainable behaviour is occurring; overly critical thinking that may prevent change; myths that green practices and buildings are prohibitively expensive; temporal justification (i.e. staff being too busy to plan for long term goals); and the so-called ‘moral offset’ – “I’m doing enough good just being a doctor/nurse”(97).

Group coping mechanisms include diffusion of responsibility (someone else will solve the problem) and ‘groupthink’ (the illusion of unanimity due to the leader’s influence)(97). By supporting employees to make ethical decisions that align with their own values, they are more likely to take action to address these concerns(98). There has been very little research within healthcare about which of these psychological factors are the most important to address in order to encourage sustainable practices and minimal understanding of patients’ views of healthcare sustainability(97).

This chapter examines anaesthetists’ views of OR recycling. An appreciable proportion of hospital waste stems from the OR(95). Further, anaesthetists form a considerable ‘bloc’ of OR doctors who are involved with waste generation and could have a leadership role in recycling. Whilst a survey of all hospital staff in many hospitals would be ideal, such a survey would be challenging to conduct across

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multiple craft groups (medical residents to consultants, nurses, theatre technicians), and consequently could have a lower response rate. A survey of intensive care unit doctors would also be useful, but was precluded by various constraints.

This chapter is based upon the article: ‘A survey of anesthesiologists’ views of operating room recycling’ by McGain F, White S, Mossenson S, Kayak E, Story D, Anaesthesia and Analgesia 2012;114(5):1049-5.

8.2 INTRODUCTION

Financial and environmental concerns are stimulating interest in hospital waste management and recycling programs(32, 66, 95, 117, 118, 120, 196). Healthcare generates enormous quantities of waste. On any given day of the year, United States hospital staff will add to landfill more than 6,000 tons of rubbish(197). Twenty to thirty percent of all hospital waste has been shown to arise from operating rooms (ORs)(95) with at least 40% of this waste shown to be potentially recyclable(32) and 25% likely to be of anaesthetic origin(119). Clinical (infectious) waste from hospital patients can vary from 0.4 kg/patient/day in Germany to 5.5 kg/patient/day in the UK and correspondingly, hospital recycling amounts are likely to vary greatly within both hospitals and nations, likely due to variable rates of packaging and reusables(96).

There are multiple published studies of operating room recycling in general, including several led by anaesthetists(129, 130, 198) Surveys of hospital staff’s attitudes to medical waste and recycling have found that an interest in recycling and recycling at home predicts a desire to recycle at work(96, 199, 200). Anecdotally, however, many anaesthetists appear to be unaware of OR recycling programs or consider them ineffective.

Anaesthetists’ attitudes to recycling are important to address future improvements in OR recycling programs given their central role within the operating service. We surveyed views of recycling held by anaesthetists in Australia, New Zealand (ANZ) and England in either regional or metropolitan and public or private practice.

8.3 RESEARCH QUESTIONS

1. Is operating room recycling standard practice in Australia, New Zealand and the United Kingdom?

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2. Are anaesthetists willing to increase recycling within the operating suite?

3. In the opinion of anaesthetists what factors enable and impede the introduction of operating room recycling in an operating suite?

8.4 METHODS

Prospective approval for this survey was obtained via the Human Research Ethics Committee at Western Health, Melbourne, Australia (Low Risk Research Panel No: 2009. L11). Written informed consent was waived by the ethics committee as consent was implied if the survey was returned. The survey was piloted with ten anaesthetic staff of the Western and Austin Hospitals in Melbourne, Australia.

In this 11-question survey the attitudes of anaesthetists to operating room waste recycling was examined. The 11-questions are given at the end of Methods. A guide to survey research in anaesthesia was followed(201). Ten questions elicited closed responses, while the final question was an open one allowing free text. Of the closed questions, four related to demographics, a further three elicited a response on an agreement scale of the Likert type and two invited a ‘one of’ response. The Likert Scale had five points, strongly agree-agree-uncertain-disagree-strongly disagree. Anaesthetists defined their type of hospital practice: including metropolitan (large city) or regional. The anaesthetic practice was also divided into predominantly public hospital (covered by government funded universal health care often with academic affiliation) or private (fee paying patients, usually with no academic affiliation).

Respondents were asked what were the barriers to recycling in operating rooms, which included ‘staff attitudes’. ‘Staff’ was undefined, although in a pilot study anaesthetists understood this to mean potentially all people working within the OR. Anaesthetists were asked if they themselves were willing to provide their own money and time to increase OR waste recycling. In none of the jurisdictions included in the survey was OR waste recycling mandatory.

A web survey was then developed using Survey Monkey (Portland, Oregon, USA). The survey was emailed to 500 randomly selected Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) in late 2009 via the ANZCA Trials Group. This sample size was calculated by ANZCA staff and was based on the following assumptions: the acceptable margin of error (amount of error that is

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inherent from random sampling or the anticipated precision of the estimate given the sample size) is +/- 5% for a proportion, ANZCA has 4,500 Fellows(202), the response rate is 60% and the response distribution (the proportion that agree: disagree) is 50:50(203).

Unlike ANZCA, the Royal College of Anaesthetists (RCoA) in England does not have an organized service that can send surveys to a sample of College Fellows. Therefore requests to complete the survey were also emailed out to administration staff at all 168 Anaesthetic Departments of English National Health Service (NHS) hospitals (but not to private hospitals) asking that the email be sent on to all consultant anaesthetists in each department (approximately 5,000 consultants)(204) to complete the web survey. Reminder emails were sent to all Fellows in Australia and New Zealand (but not England) four and ten weeks later in late 2009. Overall demographic survey data on the Fellows of ANZCA(202) and the RCoA(204) were obtained.

Data are expressed as absolute values and proportions with 95% confidence intervals for the proportions. Statistical analysis was performed with access to Vassar Stats- Website for Statistical Computation using Wilson’s method to calculate the 95% confidence intervals for the proportions (Vassar College, New York, U.S.A.)(205) and two statistical source papers noted on this website.(206, 207). Data are reported as the absolute number, then percentage and 95% CI as recommended by the American College of Physicians(208).

Survey Questionnaire

Question One I am: 1. Female, <45 years of age 2. Female, >45 years of age 3. Male, <45 years of age 4. Male, >45 years of age

Question Two I work most often in (SELECT ONE): 1. Australia/New Zealand 2.The United Kingdom

Question Three I work most often in a (SELECT ONE): 1. Metropolitan area. 2. Regional area.

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Question Four I work most often in a (SELECT ONE): 1. Public hospital 2. Private hospital

Question Five I recycle at home. Strongly disagree-disagree-uncertain-agree-strongly agree

Question Six Anaesthesia waste is recycled in the operating rooms I usually work in Strongly disagree-disagree-uncertain-agree-strongly agree

Question Seven I would like to recycle anaesthesia waste. Strongly disagree-disagree-uncertain-agree-strongly agree

Question Eight Which ONE or MORE are barriers to recycling in operating rooms (select AS MANY as applicable): 1. Staff attitudes 2. Cost 3. Inadequate information 4. Safety 5. Time 6. Lack of space 7. Lack of recycling facilities 8. None of these (Go to Q. Ten)

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Question Nine Which ONE of the following is the greatest barrier to recycling? (select ONE only) 1. Staff attitudes 2. Cost 3. Inadequate information 4. Safety 5. Time 6. Lack of space 7. Lack of recycling facilities

Question Ten To increase recycling in operating rooms I am willing to provide the following (select ONE or MORE): 1. Time to educate others 2. Time to educate myself 3. Funds to educate others 4. Funds to educate myself 5. None of the above

Question Eleven Do you have any additional comments about recycling in operating rooms or this survey?

8.5 RESULTS

This survey was completed by 780 anaesthetists. Of 500 ANZCA Fellows surveyed, 210 (41%) responded. In England 570 Fellows responded from the 168 Anaesthetic Departments. The response rate in England is unclear because the survey was sent to Departmental administrators and the number of consultants who then received the survey is unknown. In the unlikely event, however, that every consultant in England received the survey the response rate would be 11%. The confidence interval (CI) was +/- 3.2%, the CI was +/- 6.6% for ANZ, and the English CI was +/- 3.8%(203). Thus, for example, if this survey was performed a very large number of times, on 95% of occasions the results for the overall group would fall within 3.2% of the results of the survey. Respondent age and gender were similar in ANZ and England (Table 14) and similar to the age and gender profiles for the two Colleges (ANZCA and RCoA). There were, however, no available data of the overall proportion of Anaesthesia consultants in England in private or regional practice.

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Table 14 Demographics of Survey Respondents and Entire Workforce for Australia and New Zealand, and England.

Demographic ANZ Respondents ANZCA English RCOA n = 210 Survey(202) Respondents Survey(204) N = 4509 n = 570 N=5044 Male, n (%) 144 (68%) 3287 (73%) 360 (63%) 3589 (71%) 95% CI: 62 to 74% 95% CI: 60 to 68% Age >45 107 (51%) 2416 (54%) 286 (50%) 2715 (54%) years, n (%) 95% CI: 44 to 57% 95% CI: 47 to 54%)

Regional 51 (24%) 1,195/4,437 295 (52%) Unknown Practice, n 95% CI: 19 to 30% Respondents 95% CI: 48 to 56% (%) (27%)

Private 93 (44%) 679/1,519 Survey of public Unknown Practice, n 95% CI: 38 to 51% Respondents practice only (%) (45%)

Of the 780 survey respondents, the first 10 questions (see Methods above) were each answered by at least 98% of respondents. There was a strong agreement in the responses overall and across different countries and place of practice on questions on recycling practice. For anaesthetists overall and across England, Australia and New Zealand, in regional and metropolitan areas and in both public and private hospitals: 1. more than 90% recycled at home, 2. more than 90% wished to recycle at work, but 3. only 11% agreed or strongly agreed that OR recycling of anaesthetic waste occurred (Table 15).

When asked what was the greatest barrier to recycling the overall responses in descending order were: 1. inadequate recycling facilities 381 (49%), 2. staff attitudes 133 (17%), and 3. inadequate information on how to recycle 121 (16%). These three barriers were the greatest impediments to recycling across all countries and workplaces. Time, safety, inadequate recycling space and cost were each thought by less than 5% of respondents to be the greatest barrier to recycling. The majority of anaesthetists practicing in all areas were willing to provide time to learn 571 (73%)

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and time to educate others 435 (56%), (but would not contribute their own money) to increase recycling practices within operating rooms.

Table 15 Recycling at home and in the operating suite.

Question No. Response-overall, by country, region and workplace Overall England ANZ Regional Private N=780 N=570 N=210 N=340 N=95 Q. 5 “I recycle at home” 744 (95%) 541(95%) 198 326 90 (95%) Agreed or Strongly Agreed. 94 to 97% 93 to 97% (94%) (96%) 88 to 98% N, (Proportion), 95% CI 90 to 97% 93 to 98% Q. 6 “Operating suite waste 87 (11%) 66 (12%) 21 (10%) 36 (11%) 9 (10%) is recycled in the operating 9 to 14% 9 to 15% 7 to 15% 8 to 14% 5 to 17% suites I work in most often” Agreed or Strongly Agreed. N, (Proportion), 95% CI Q. 7 “I would like to recycle 725 (93%) 530 193 314 88 (93%) operating suite waste” 91 to 95% (93%) (92%) (92%) 87 to 97% Agreed or Strongly Agreed. 91 to 87 to 95% 88 to 94% N, (Proportion), 95% CI 95%

The final question (Q. 11) was answered by 215 (28%) and was open-ended: “Do you have any additional comments regarding operating room recycling?” The most common themes to emerge from answers to the last question were:

• 47 wrote that recycling needed to be routine, • 47 were concerned by recycling safety issues such as inappropriate disposal / mixing of items (i.e. contamination of landfill waste with infectious waste), • 40 felt that the hospital administration was unconcerned by the non-existance of OR recycling, • 28 considered that the environmental effects of single-use devices were more important than recycling, • 24 noted that recycling needed to be driven by the ‘top down’ hospital hierarchy, and 16 wrote that waste minimization was more meaningful than recycling.

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8.6 DISCUSSION

Most anaesthetists who responded to this survey consider operating room recycling to be important, regardless of country (England, or Australia and New Zealand), location (regional or metropolitan) or practice (public or private). Only one in nine respondents, however, agreed or strongly agreed that recycling occurred in their operating rooms A significant majority of anaesthetists would be prepared to commit time, to OR recycling and the education of others to do so, but few would commit their own money.

Survey respondents felt that there were three major barriers preventing OR recycling from becoming more widespread: (1) inadequate recycling facilities, (2) inadequate information on how to recycle, and (3) staff attitudes. In contrast cost, lack of time, lack of space, and safety issues were thought to be relatively insignificant barriers to recycling. In free text responses many felt that greater support for OR recycling was needed from hospital administration and that recycling should be routine, although safety and infection control issues needed to be addressed.

There are several limitations to this email survey, which had a response rate of 41% for Australia and New Zealand, but unknown for England (possibly as low as 11%). The question arises as to whether those who did not respond differ from those who did. Since the enthusiasm for waste recycling was very high (about 95%) it is possible that anaesthetists keen on recycling responded while those less enthused did not respond. Both the ANZ and English samples have similar age and gender profile to their respective Colleges(202, 204). There are no data for the proportion of the total English workforce employed in private or regional practice, but for ANZ such proportions for the entire workforce were similar to those for the respondents to our surveys(201). Despite the response rates and possible non-response bias, because 780 anaesthetists responded the 95% confidence intervals for the proportions are narrow: +/- 3.2%. The overall number of respondents gives fairly precise proportions(203).

Previous studies have examined hospital staff’s attitudes to waste management and recycling(199, 200). Tudor et al used the theory of planned behaviour(209) to link intended behaviour and actions of staff in healthcare waste management in the Cornwall National Health Service (NHS), United Kingdom (UK)(96). The more staff believed waste to be a major work issue and were encouraged to conserve materials

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the greater the potential for them to perform sustainable waste management actions(200). Tudor et al also found, however, that the actual waste management actions of employees in healthcare often bears little resemblance to their stated intentions due to perceived attitudes and the behaviour of others (particularly their superiors) and lack of behavioural control(200). Staff need to understand the relevant environmental and financial benefits from waste recycling if they are to engage in the process.

While many anaesthetists may have the intent to recycle, and despite the work of groups to improve recycling rates such as the UK National Health Service Sustainable Development Unit (SDU) and the U.S. based Healthcare Without Harm, the volume of healthcare waste, including operating room waste, continues to rise unabated. We highlight the view held by some anaesthetists in the free text (Q.11) of our survey that while recycling is important the more important point is minimizing the amount of waste produced through actions such as reducing packaging and single use devices. The UK’s SDU has found large opportunities to improve the financial and environmental sustainability of healthcare by reducing packaging(16).

Few anaesthetists would commit their own money to OR recycling, probably because they would never get such money back. It is possible that if recycling led to financial savings, such savings could be shared amongst those who committed. Normalisation of financial commitment to sustainability activities within healthcare such as recycling, could lead to collective behaviour change.

This is a focused and therefore limited survey of OR waste recycling only. OR recycling can often save rather than cost money and can significantly reduce the environmental effects of waste(197). Future surveys of operating room recycling could include the types of recycling available (electronics and metals, different plastics), clarifying why some staff are resistant to recycling, identifying which staff would be most influential in improving recycling rates, and examining the effects of improving recycling facilities and staff education. Examples of further surveys of the umbrella topic of operating room sustainability include: 1. what and why certain items are single use versus reusable (laryngoscopes, laryngeal masks, anaesthetic circuits), 2. exploring why there is such variation by different medical craft groups in the use single use or reusable equipment such as gowns and drapes, and 3. an understanding

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of the environmental effects of anaesthetic agents, and indeed all drugs and devices used by anaesthetists.

These findings suggest that anaesthetists’ views may not be a barrier and efforts to improve operating room recycling should be aimed elsewhere, for example at improved recycling facilities. Importantly, providing evidence that increasing recycling facilities in operating rooms can be financially and environmentally successful (before-after audits) will be integral to ongoing recycling. Excellent examples and case studies of operating rooms that are transitioning to improved sustainability are available at such websites as ‘Greening the OR’(32). A combination of education, encouragement and leadership from senior anaesthetists and hospital staff could lead to significant operating room recycling becoming the norm.

8.7 CONCLUSION

This chapter has surveyed anaesthetists’ views of recycling in order to explore whether it was feasible to recycle within the OR. That is, would the majority of a significant group of OR doctors consider that OR recycling was useful and pragmatic, and would they assist in recycling? Recycling was occurring in few ORs, but a significant majority of anaesthetists would be prepared to recycle. The major barriers to recycling were felt to be inadequate recycling facilities and information on how to recycle, and resistant staff attitudes. Interestingly cost, time, space and safety were thought to be relatively insignificant barriers to recycling. Such information proved useful in the next phase of this PhD – introducing recycling programs to the OR and ICU and subsequently auditing such programs, detailed in Chapter 9. A focus was placed upon staff education on how to recycle, overcoming negative staff attitudes to recycling and providing adequate recycling facilities.

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CHAPTER 9: RECYCLE AUDITING OR AND ICU RECYCLING PROGRAMS

9.1 BACKGROUND

Chapters 8 and 9 explore recycling within the operating room (OR) and intensive care unit (ICU). Chapter 8 appraised the feasibility of recycling, i.e. whether hospital staff attitudes to recycling are problematic or supportive and what staff see as opportunities and barriers to recycling. Anaesthetists are an important cohort of doctors based in the operating room. A survey was performed of anaesthetists based in Australia, New Zealand and England, finding that: (i) recycling was occurring in few ORs, (ii) more than 90% of anaesthetists were prepared to recycle, and (iii) the major barriers were thought to be inadequate recycling facilities, information on how to recycle, and resistant staff attitudes.

After discussions with other staff about OR and ICU recycling that were predominantly supportive, recycling programs were begun in the OR and ICU. As a result of the survey in Chapter 8 a focus was placed upon staff education on how to recycle, overcoming negative staff attitudes to recycling, and providing adequate recycling facilities.

Chapter 9 examines what can be recycled, and how much could be recycled within the OR and ICU. The focus of this chapter is upon waste audits post-recycling programs in the OR and ICU. Prior to enrolment in this PhD the candidate undertook and published several audits of OR and ICU waste pre-recycling and clarified the composition of medical items that could potentially be recycled. These studies are summarised in the following paragraphs as they provide a useful background to the final post-recycling audits and the successes/failures of OR and ICU recycling:

1. McGain F, Clark M, Williams T, Wardlaw T. Recycling plastics from the operating suite. Anaesthesia and Intensive Care. 2008;36(6):913-4.

2. McGain F, Story D, Hendel SA. An audit of Intensive Care Unit recyclable waste. Anaesthesia 2009; 64 (12): 1299-1302.

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3. McGain F, Hendel SA, Story D. An audit of potentially recyclable waste from anaesthetic practice. Anaesthesia and Intensive Care 2009; 37(5):820-823.

Prior to starting recycling within the OR and ICU there were several other concerns to address. Hospital infection control staff were involved from the beginning of the recycling programs. Only non-infectious items would be recycled, i.e. there would be diversion of non-infectious hospital waste to recycling. Clarification of the composition of medical items was achieved early with an associated pilot recycling program(130). Recycling of aluminium, steel, paper and cardboard was straightforward as these were readily identified as such by hospital staff. Unlike household plastics however, many medical plastic products are not identified with the international plastics coding classification number and triangle(210). Further, the national Australian advisory body on plastics, the Plastic and Chemical Industry Association, did not hold an inventory of medical plastics.

Anecdotally in Australia, general awareness of kerbside council recycling was thought to be poor. Perhaps potentially low rates of correct recycling could be due to the large number of different types of recyclables. Most recyclable items from the OR and ICU, however, were cardboard and paper, or varieties of plastics, potentially improving the likelihood of successful recycling.

Clarification of the different plastics used in common medical items was achieved by contacting the manufacturers and suppliers. Polypropylene, polyethylene and polyvinyl chloride (PVC) comprised the majority of the plastic types of items used(130). Knowledge of different plastic types is important for recyclers, particularly PVC, as this cannot be recycled with other plastics due to its markedly different melting temperature and physical characteristics (approximately 50% chlorine by mass)(211). As a result of this plastic identification a pilot recycling program was commenced in the OR(130), including novel recycling of medical PVC thereafter(212).

Waste audits were performed prior to recycling within the OR and ICU in 2008. The methods employed in both waste audits were identical to the post-recycling audits and are detailed under Methods (Section 9.4). The initial OR waste audit was focussed upon anaesthesia waste (defined as waste emanating from the anaesthetist’s trolley or the anaesthetic bay). For five days in the six-theatre hospital all OR waste was

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weighed and all anaesthesia waste was examined and categorised. Total OR waste was 357 kg (48% infectious waste and 52% general waste). Anaesthesia waste was 90 of the 357 kg of total OR waste with plastics forming almost half of the total mass. Of the 90 kg, 66kg was general waste of which 38 kg (60%) was recyclable. There was minimal contamination of general waste with infectious waste. Recycling of a significant proportion of anaesthesia waste was thus possible.

The 10-bedded ICU pre-recycling waste audit occurred over seven consecutive days(120). The total ICU waste for the week was 540 kg, representing 5% of total hospital waste. Of the 401 kg of ICU general waste, recyclables were 230 kg, being mainly plastics, cardboard and paper. Almost 60% of ICU general waste could be recycled with appropriate safeguards, education and training. There was minimal infectious waste cross-contamination. Unlike the OR waste audit where infectious waste formed almost half of all waste, only 25% of total ICU waste was infectious, indicating differences in waste makeup, inadequate waste separation by OR staff, or both(120).

Recycling programs were then embarked upon with subsequent auditing of the OR and ICU recycling. The audit of OR recycling examined all OR waste in detail rather than the more limited detailed audit of anaesthesia waste pre-recycling(119).

The remainder of this chapter is an expansion of the following publications:

1. Part A. OR waste post-recycling(213).

McGain F, Jarosz KM, Nguyen M, Bates S, O’Shea K. Auditing Operating Room recycling: a management case report. Anesthesia and Analgesia Case Reports 2015 Aug 1;5(3):47-50.

2. Part B. ICU waste post-recycling(214).

Kubicki M, McGain F, O’Shea K, Bates S. Auditing an ICU recycling program. Critical Care and Resuscitation. 2015 Jun;17(2):135-40.

Since the methods used are very similar in both studies these are truncated in Part B. Discussion of differences in the Results between the OR and ICU waste recycling programs occurs in the Conclusion.

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PART A. OR WASTE POST-RECYCLING

9.2 INTRODUCTION

There is growing awareness of the effects of unsustainable practices within healthcare, including anaesthesia(32, 105, 117). Healthcare consumes large amounts of resources such as oil based products, energy and water and has a ‘carbon footprint’

(i.e. CO2 emissions); e.g. the English National Health Service (NHS) is responsible for over 3% of England’s total CO2 emissions(8). Hospital procurement is the purchase of all goods entering and exiting hospitals. Hospital procurement and waste disposal contributes more to CO2 emissions than direct hospital energy consumption and transport to and from hospitals combined(8). ‘Waste’ forms a subset of procurement and represents 3% of the U.K.’s total CO2 healthcare footprint – similar to food and catering(8).

Approximately 20% of hospital waste stems from the OR(95, 117, 215). Up to a quarter of this waste is generated primarily by anaesthestist.(119). Recycling of metals, plastics and paper and cardboard usually requires less energy than manufacturing new product(25), although this varies with location. Disposal of infectious waste is more expensive (and energy consuming) than general waste as infectious waste requires closer monitoring/regulation, often more distant transport, incineration and/or chemical treatment, and placement into prescribed, special landfill(95, 96). Correct infectious and other waste segregation by hospital staff is cost effective(215). Several studies have examined the recycling potential of hospital waste both generally(95, 96), and in operating rooms specifically(103, 117-119). Further, novel approaches to OR recycling have been reported(130, 216). There is strong support for OR recycling amongst anaesthestists in several countries surveyed to date(217). There is, however, a paucity of data regarding the effectiveness and financial feasibility of OR recycling programs.

In 2008, waste audits were performed in the OR and ICU at our hospital when no recycling was occurring. Recycling of plastics and cardboard/paper commenced thereafter. This study is a follow-up audit of OR and Day Procedure waste post- recycling which occurred over one continuous week.

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9.3 RESEARCH QUESTIONS

1. What are the weights of OR general waste, infectious waste and recyclables and how does this compare with total hospital waste?

2. What is the weight of truly infectious OR waste within all waste and recycling streams?

3. What is the weight of OR recyclables remaining within the general and infectious waste?

4. What is the ratio of achieved OR recycling to the potential for further recycling?

5. What is the financial cost in Australian dollars of OR waste disposal and how does this compare to the pre-recycling audit(119)?

9.4 METHODS

A prospective audit was undertaken of all waste and recycling streams of the 6-theatre OR and Day Procedures Unit (DPU) at the 300-bed Footscray Hospital, a university-associated hospital in Melbourne, Australia. Approval for this study was obtained from the Western Health Low Risk Ethics Committee (HREC/11/WH/109, 13/12/2011). The audit methodology was based upon our previous audits(119, 120). Without notifying staff, the audit was performed for the second week of December 2012, a standard operating week. Only waste and recyclables within the OR and DPU area were examined. Total hospital waste data, the total number of operations and procedures in the week of the audit as well as the calendar years 2009 (pre-recycling) and 2012 were obtained. The number of patients having operations/procedures with infections requiring contact precautions was also noted, as treating such patients requires disposable gowns and gloves. Infectious waste bags from patients with infections requiring contact precautions were identified by the particular type of disposable gowns present in the bags.

Recycling was defined beforehand as: ‘total’, ‘potential’ and ‘achieved’ (actual). Total recycling consisted of all recyclables that were not considered infectious waste. ‘Potential recycling’ was defined as that which was acceptable to hospital staff and the recycling companies and excluded very small plastic pieces and items that recyclers were unable to take – those composed of multiple plastic types (e.g.

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intravenous fluid giving sets) or deemed inappropriate (e.g. dirty suction catheters). The achieved recycling was that measured in the various recycling streams. The achieved to potential recycling was thought to be the ratio most indicative of the OR recycling program’s progress.

In this follow up audit we examined both OR and DPU waste and recycling streams as we wished to examine the results of commencing recycling in two related areas that share the same waste and recycling disposal section of the hospital. Since the OR and DPU waste was processed in one hospital area it was impractical to separate the two sources (OR or DPU). All waste was measured for at least 5 hours each day for seven continuous days, but did not determine the waste from each individual procedure as this was not feasible. In 2009, there was no OR recycling and we audited only anaesthesia OR waste in detail(119). In 2010, a pilot OR recycling program commenced and evolved gradually to involve the DPU and other hospital areas over the years 2010-2011. Meetings and education sessions were held with the recyclers and hospital staff. Pilot ‘OR plastic runs’ were sent to the recyclers for confirmation of appropriateness and adherence to an older guideline(130).

Routine practice, after initiating the recycling program was to place general waste into green waste bags and infectious (clinical) waste into yellow waste bags. Recycling occurred in the following separated streams: 1. paper and cardboard (boxes, paper towels), 2. polypropylene (sterile surgical, ‘blue’ or ‘green’ wrap), 3. mixed plastics (plastic bottles and ampoules, clear wraps), 4. polyvinylchloride – PVC (intravenous fluid bags, oxygen masks and tubing) and 5. commingled items (i.e. unsorted tins, cans, plastic bottles). There was thus some overlap between commingled and mixed plastic recycling.

Recycling of cardboard and paper and surgical wrap was simple as these products were easily identifiable and limited in variability. Recycling of mixed plastics and PVC required greater education and preparation. Some plastics were deemed by the affiliated recycling companies and hospital staff to be non-recyclable: i.e. inappropriate appearance (urine), problematic ‘syringes’ (despite being needleless) or PVC suction tubing (‘sputum’), or too difficult to recycle since they were not the desired plastic (e.g. polystyrene, polyurethane). Nursing staff have been integral to the recycling program since its inception and coordinated new staff’s involvement, remaining vigilant to recycling contamination.

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For the recycling of mixed plastics and surgical (blue or green) wrap, in each of the ORs and the DPU, brackets were installed onto which plastic liners (bags) were placed to accommodate different recycling streams. Bins for holding paper and cardboard were also installed. At the completion of each operation the bags containing general and infectious waste, and the plastics and paper and cardboard recycling streams, were emptied into larger bins at the periphery of the operating suite. PVC plastic was removed at the end of each operation with the patient and taken to Recovery, otherwise known as the post anaesthesia care unit (PACU), where it was placed into a large PVC bin. Hospital environmental services staff took the recyclables thereafter to a central region where the recyclables were kept prior to removal by recycling companies.

All plastics were weighed, with identification of all plastics and potential recyclable plastics. Paper (including paper towels) was weighed as it was found, i.e. with varying moisture content. Glass drug ampoules have rubber and aluminum stoppers, which preclude them from currently being recycled. The majority of the cardboard (large boxes) was separated at the OR and DPU front door, was subsequently compacted, and excluded from this study. Since we commenced hospital cardboard recycling after our first OR waste audit and we were interested in the volumes of cardboard recycling, we examined just one day of this cardboard ‘waste’ to give an indication of the extra cardboard that was not entering the OR and DPU area, but which ultimately stemmed from the OR and DPU. Small cardboard boxes and paper that enters the OR and DPU area are recycled together at our hospital. This cardboard and paper is placed into OR and DPU paper and cardboard recycling bins (not compacted, i.e. more expensive to process) and was audited.

Direct and indirect financial costs for disposal of waste/recycling streams were obtained. Neither labour costs nor the purchase costs of bins were measured. Hospital data were examined for the average number of operations and procedures per day and the average operation and procedure time. The financial costs for waste and recycling included, as applicable, disposal cost/kg, the price of bags, compactor costs, collection and transport fees, and bin hire (i.e. bins not owned by the hospital). Only general waste and cardboard were compacted. Paper and cardboard was recycled in reusable bins and PVC recycling was not bagged (i.e. no purchasing of bags was required for

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these recycling streams). All reusable bin weights were subtracted from the reported weights.

The bag cost/kg waste was calculated as the cost per bag divided by the average amount (in kg) found in the bags of an average of 20 bags for each waste stream. Recycling costs differed markedly according to the contracted recycler. Polypropylene, mixed plastics and PVC were collected without charge, the only costs being bags for polypropylene and mixed plastics. Recycling bins for these streams had been purchased or awarded from a previous grant. Paper and cardboard and commingled bin disposal costs included collection and transport fees and bin hire.

Infectious waste included materials contaminated with blood and other infectious body fluids(218). Researchers wore protective gloves, glasses and scrubs. Researchers sorted materials from each respective bin and bag into infectious, general and recyclable waste to assess the compliance of the recycling program. Non-recyclable waste and recyclables were subsequently classified and weighed. A conservative approach was taken to the potential for recycling, rejecting all items that contained body fluids. Any infectious fluids (such as blood products) were not weighed separately, but included as infectious waste. Non-infectious fluids found in the waste (e.g. crystalloids) were poured into buckets and weighed, forming a subcategory of general waste. Plastic bags that contained non-infectious fluids were considered to be ‘potential recycling’ (not achieved).

Waste was weighed on digital scales, correct to the nearest 10 grams and rounded to the nearest kilogram at the end of the week. Sharps bins were not examined. In our hospital most operations and procedures were performed with staff wearing sterile, reusable surgical gowns and drapes. Select operations (particularly orthopaedic) were performed entirely with single use surgical gowns and drapes. Approximating the proportion of total waste due to these single use gowns and drapes was thought useful. These single use items were thus weighed for one weekday only as an approximate proportion of total waste. This study presents purely descriptive data (weights and ratios of waste to recyclables) with no inferential statistical analyses.

A currency converter (152) on the 17/6/2015 was used to convert AUD$1 to USD$0.77.

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9.5 RESULTS

For the one-week audit, the total mass of the six-theatre OR and DPU waste was 1,265 kg from 237 procedures. General waste was 570 kg (45%), infectious waste was 410 kg (32%) and 285 kg (23%) were recyclables (Table 16). Financial costs for the different waste streams are given in Table 17. The proportion of total hospital general and infectious waste arising from the OR and DPU was 10% (1,265 of 12,415 kg). Of the 285 kg of achieved recycling, there was less than 1kg of contamination with general waste and no infectious waste contamination.

Table 16 Waste and recycling stream masses for the one-week audit.

Waste type Mass (kg) (% total) (total = 1,265) (% each stream)

General 570 kg (45% total) General 321 (56%) Infectious 6 (1%) Recyclable 243 (43%)

Infectious 410 kg (32% total) General 76 (19%) Infectious 283 (69%) Recyclable 51 (12%)

Recyclables 285 kg (23% total) Paper and cardboard 66 (23%) Plastic-polypropylene 146 (51%) Plastic-mixed 43 (15%) Plastic-PVC 23 (8%) Commingled 7 (2%)

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Table 17 Costs of waste and recycling disposal in AUD$.

Type of waste or Disposal Bag cost Compaction, Bin hire Total cost recycling charge per per kg collection, and per kg kg transport AUD$

General waste $0.14 $0.03 $0.06 $0.01 $0.24 Infectious waste $0.90 $0.08 Nil Nil $0.98

Paper and Nil Nil $0.53 $0.04 $0.57 cardboard Plastic- Nil $0.10 Nil Nil $0.10 polypropylene Plastic-mixed Nil $0.22 Nil Nil $0.22 Plastic-PVC Nil Nil Nil Nil $0.00 Commingled Nil Nil $0.71 $0.05 $0.76 (plastic, tins)

In the general waste stream, the 243 kg of recyclables consisted of: 97 kg paper and cardboard, 141 kg plastics, 2 kg aluminium and 3 kg glass. The 141 kg plastics were: 55 kg polyethylene, 30 kg polypropylene, 14 kg polypropylene and polyethylene copolymers, 32 kg PVC and 10 kg other (non-recyclable) plastics. Plastics that were inappropriate or too difficult to recycle were then excluded from further analyses, including conservatively half of the PVC, leaving 101 kg of possibly recyclable plastics. On one weekday only the weight of single use surgical gowns and drapes was 4 kg in the general waste stream.

In the infectious waste bags, 31% was not infectious (Table 17), indicating that truly infectious waste was approximately 23% of all waste. Recyclables found in the infectious waste stream were 16 kg paper and cardboard, 34 kg of plastics and 1 kg aluminium and glass. The plastics included 10 kg polyethylene, 5 kg polypropylene, 2 kg polypropylene and polyethylene copolymers, 8 kg PVC and 9 kg of other plastics. Potentially recyclable plastics (conservatively half of the PVC) thus totalled 19 kg. On one weekday only, the weight of single use infectious surgical gowns and drapes was 10 kg.

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The potential plastic recycling amount was thus the sum of the 212 kg achieved in the recycling stream, 101 kg in the general waste and 19 kg in the infectious waste (total of 332 kg), indicating a plastic recycling rate of 212 kg achieved of 332 kg potential (64%). The paper and cardboard recycling rate was 66 kg achieved of 178 kg potential (37%), and there was 7 kg of commingled recycling. The overall achieved to potential recycling rate was: 285/ (332+178+7) = 285/517 kg (55%).

For the week of the audit, 237 procedures were performed (167 in the OR and 70 in the DPU). In 2012, there were 9,868 procedures performed – 6,735 in the OR and 3,133 in the DPU, i.e. 189 per week. The average number of operations and procedures respectively per day were: 27.2 and 12.1 in 2009, and 27.1 and 12.7 in 2012. The average duration per operation and procedure was respectively 89 and 32 minutes in 2009, and 79 and 34 minutes in 2012 (with similar durations for 2010 and 2011).

In the audit week, 10 patients had procedures requiring contact precautions, while 371 patients had procedures requiring contact precautions in 2012 (approximately 7 per week). For one day the weight of cardboard separated at the front of the OR and DPU (not included in this audit) was 49kg. Three sharps needles were found, all located in the infectious waste stream (rather than within the sharps bins). There were 13.1 kg of non-infectious fluids (predominately crystalloids) found in the general (10.7 kg) and infectious (2.4 kg) waste streams, with minimal fluids in the recycling streams.

The overall financial costs per kg of different waste streams are detailed in Table 17. For general and infectious waste the majority of the costs were the fees charged per kg of waste. For recyclables the majority of the costs were for fixed fees such as collection and transport, although for polypropylene, mixed plastics and PVC the recyclers did not charge.

9.6 DISCUSSION

This study was an audit of a hospital’s six-theatre OR and Day Procedure Unit waste for one continuous week in the setting of routine recycling. Of the approximately 1.3 tonnes of waste per week (representing 8% of all hospital waste), almost a quarter was being recycled. Infectious waste was 410 kg (32%) of all waste, although only 283 kg was truly infectious. The achieved recycling had no infectious contamination and less

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than 1% contamination with general waste. The achieved recycling represented more than half (55%) of what was potential (realistic). Overall, recycling was financially cost neutral compared with no recycling.

Factors which have increased the amount of waste examined in this current study compared with the prior study(119) of OR waste alone are the inclusion of day procedure waste (one third of the total number), 5% more procedures, and a greater use of single use drapes and gowns (60 kg of waste per week). The proportion of all OR waste that was infectious in the pre-recycling OR audit was 48%, suggesting that more than 50% of ‘infectious’ waste was not truly infectious. While the above factors make direct comparisons uncertain, it appears that the proportion of non-infectious waste entering the infectious waste stream has reduced by at least 10%.

Through education programs reductions of infectious waste by 75% can occur(103). In our hospital no such directed education occurred aimed specifically at reducing the infectious waste volumes, but there were informal educational activities to encourage safe OR and DPU recycling (e.g. “If in doubt, chuck it out”). Pre-recycling however, staff anecdotally indicated that they were less concerned whether recyclables entered the infectious or general waste streams as such ‘waste’ could not be recycled anyway. The introduction of OR recycling may be an indirect method to reduce non-infectious waste entering the infectious waste stream through education and/or shift in attitudes. Given that disposal of infectious waste is at least 4 times the cost of general waste, a conservative 10% (100 kg) reduction in infectious waste per week in our hospital’s ORs will lead to savings approaching AUD$4,000 (USD$3,080) per annum.

Beyond the reduction in infectious waste the financial benefits of OR recycling were minimal given that hospital general waste costs only AUD$0.24 per kg. Apart from labour, we included all costs for waste disposal and found large variation in costs per kg for recyclables. Our hospital has contracts with smaller recyclers that do not charge for collection and transport. Paper and cardboard as well as commingled bins are expensive to collect and transport, but bin hire costs for all waste streams are not a major contributor. If greater recycling were achieved of paper and cardboard by 100 kg/week the recycling program would become a cost burden of AUD$2,000 (USD$1,540) per annum, unless compacting or an altered fee structure was arranged or an alternative vendor hired.

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This audit did not formally examine the extra time taken to separate recyclables into different streams. Between 2009 and 2012 there was neither a significant change in the number of operations per day, nor the average duration per operation or procedure. Hospital staff also anecdotally noted there were no delays in operating times caused by recycling. Since the recyclables were sorted by OR staff one would not expect that waste disposal staff (beyond the OR) would require greater time to process the recyclables.

This study has limitations. One week may be an inadequate sample of OR and DPU waste, although the number of procedures for the week and the number of patients requiring contact precautions was broadly similar to the average per week for the year 2012. The researchers were conservative in their assessment of the recycling potential for waste – discarding items that were contaminated with body fluids and those which were potentially troublesome to recyclers (including suction tubing and needleless syringes). Small amounts of aluminium are recycled from suture sets, but not complex single use metal and plastic devices. This study of OR and DPU waste was more extensive compared with the prior study of OR waste alone, which focussed upon anaesthesia waste(119), so they are not truly pre- and post- intervention studies.

Reprocessing is a term used for making single use devices (e.g. laparoscopy ports) patient ready again, by repairing and refashioning(132). Reprocessing is a multi- billion dollar industry in the USA and elsewhere(132), but is currently non-existent in Australia and rare in the UK. Reprocessing can reduce OR waste significantly, but it is unclear (and probably unlikely) if waste reduction from reprocessing would be as significant as commencing a recycling program or reverting back to reusable gowns and drapes from disposables. In our hospital there are few reusable, double steel surgical tray sets that would reduce the requirement for expensive surgical (‘blue’ or ‘green’) polypropylene wrap.

As a proportion of all hospital waste, OR waste in this study was less than half of that reported in the USA(215), which may be due to the lower total amounts of single use waste per procedure in Australia or reflect a more mixed medical and surgical throughput in our hospital. There is wide variation in the amount of waste generated per patient per day, even in neighbouring countries (e.g. UK waste is 5.5 kg per patient per day compared with France, at 1.9 kg per patient per day)(96).

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For one day only, the weight of single use surgical gowns and drapes was 10kg, indicative of 60 kg per week or 60kg of 410kg (15%) of all OR and DPU infectious waste. In our hospital, only orthopaedic surgeons routinely wear single use sterile gowns, which are a combination of polypropylene and cotton and cannot be recycled. Further, ‘surgical packs’ (where single use gowns, drapes, cotton etc. are bundled in together) are routinely used only in orthopaedic and some urological procedures. There are few recyclable components to these ‘packs’. Hospitals that have a large orthopaedic surgical presence or entirely use single use theatre packs (e.g. in the USA) will produce considerably more waste/procedure than that found in our study.

Most reusable surgical instruments were sterilised together in large OR trays and wrapped in single use polypropylene covering. Undoubtedly there was redundancy in such an approach, i.e. not all of these instruments were used for all operations, so wastage of plastic wrap occurred to cover these large trays. A potential solution to reduce plastic wrapping would be to wrap more reusable surgical equipment as single items. Wrapping of single items, however, uses more plastic per item, and there could be a resultant increase in required plastic wrap despite the use of fewer instruments.

Almost two thirds of paper and cardboard was not being recycled, the majority by weight comprised of paper hand towels. The high financial cost of paper and cardboard recycling versus general waste indicates that reducing the quantity of paper towel waste is preferable to increasing the recycling rate. Paper towel waste could be reduced by using environmentally friendly hand drying systems (achieving more than 50% reduction in carbon emissions compared to disposable paper towels)(219).

Hospital plastic recycling with local recycling contractors was cost beneficial. There are, however, barriers to recycling including; financial costs for hospitals with different recycling contractors, geographical distance from recyclers, contamination with infectious and general waste, difficulties identifying, separating and segregating waste, adequate space for appropriate recycling bins, and staff knowledge and motivation(217). Resistance to change is a well-documented challenge to hospital waste recycling(96, 97). Local plastic recyclers were recruited who convert the polypropylene, mixed plastics and PVC into furniture and agricultural pipe, revealing to staff the ‘fruits of their labours’.

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Recycling is usually less energy intensive than producing new product, particularly for metals and most plastics, but not always for paper products. Our 11 tonnes/annum of OR polypropylene, mixed plastics and PVC recycling produces 15 tons less

CO2/annum than manufacture of new plastics(25), equivalent to approximately 7,000 litres of petrol(114). Given that burning 1 litre of petrol emits 2.28 kg CO2, the average fuel efficiency of Australian cars is 10 km per L (24 miles to the gallon), and the average distance travelled/car/annum is 14,000km(220) our OR recycling is equivalent to taking 5 cars off the road. Concerns such as peak oil (and therefore more expensive plastics) improve the incentives for plastic recycling.

In Australia and many other countries, the majority of new paper manufacturers use wood pulp biomass from newly felled trees as part of the energy feedstock for paper production. The recycled component of paper cannot make use of this energy source as trees are not being felled. Thus, any CO2 emission reductions from Victorian paper recycling are attenuated by less wood pulp biomass and the reliance upon CO2 emissions-intensive coal-based electricity(114). There are, however, other benefits from recycling paper, such as less water use and fewer chemical pollutants(25).

Both the financial and environmental savings from recycling 11 tonnes of OR plastics per annum may be relatively small. Such considerations however, will become increasingly important as oil and thus plastics become more expensive and steps are made to reduce the considerable carbon emissions stemming from healthcare activity(3). Procurement is the primary contributor to healthcare’s CO2 emissions(8). Increasing hospital waste recycling, together with increasing reprocessing, reusing and reducing packaging could significantly reduce CO2 emissions.

This waste audit has shown that it is feasible to recycle more than half of potentially recyclable OR and DPU waste, this representing almost one quarter of all waste. At our hospital’s OR and DPU more than 13 tonnes of recycling now occurs per annum, 75% of this being plastics. There has been no infectious contamination of recyclables and no cost burden to the hospital. There appears to have been at least a 10% reduction in the amount of waste entering the infectious waste stream as staff have become more engaged in waste management. OR recycling can improve resource use and be both financially and environmentally sustainable and beneficial.

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PART B. ICU WASTE POST-RECYCLING

9.7 INTRODUCTION

In the US over 7000 tonnes of healthcare waste is produced per day(103). Recycling of waste is one strategy to conserve natural resources, reduce landfill and the carbon footprint(103, 221). In our pre-recycling audit of ICU waste it was found that approximately 40% of the waste could potentially be recyclable(120). There is, however a paucity of data regarding the effectiveness of recycling within the ICU.

In our hospital it was shown that a recycling program implemented in the OR was efficacious, with approximately 55% of potentially recyclable waste (almost 25% of all waste) being recycled, without incurring additional cost(213). It was unclear, however, that these findings would also apply to recycling within the ICU, particularly given that there were different ratios of waste in the ICU compared with the OR (less polypropylene sterile wrap) and better ICU compliance with infectious waste containing only infectious waste(120). A follow up audit of ICU waste was thus undertaken.

9.8 RESEARCH QUESTIONS

1. What are the amounts of potentially recyclable materials within the ICU that are actually recycled? 2. What are the amounts of ICU waste incorrectly disposed of, including infectious waste? 3. What are the non-labour financial costs of the ICU recycling program?

9.9 METHODS

A recycling program was commenced in April 2013 at the 11-bed ICU at the Footscray Hospital. The ICU recycling program was based on a program recently implemented in the hospital’s operating suite and was divided into five streams: paper and cardboard, three plastics types (mixed polyethylene/polypropylene, polyvinyl chloride (PVC), and polypropylene surgical wrap), and commingled (a mixture of paper, aluminium, steel, glass and plastics). The remainder of the ICU waste was

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disposed of into general waste bins or infectious bins. Infectious waste was defined as any waste containing human tissue and/or blood(222).

Mixed plastics included a variety of different plastics used within the ICU, e.g. plastic wraps, bottles and ampoules, but some items were deemed unsuitable by the recycler, e.g. polyurethane (not valued), and plastic syringes (concern about infection transmission). Common examples of plastics have been defined previously (Methods 9.4). In commingled recycling all materials (e.g. tins, plastic bottles) are collected together to be sorted later by the recycler. There was thus some overlap between plastic within commingled materials and the mixed plastic stream. Glass drug ampoules and single use metal instruments (scissors etc.) were not routinely recycled.

Pre-recycling, each ICU patient bed area had one each of a general waste and an infectious waste bin, with half this ratio for high dependency unit (HDU) beds. Post- ICU recycling, one additional bin for paper and cardboard, and another for mixed plastics were provided at each bed area, again with half this ratio for HDU beds. Further paper and plastic bins were distributed around the ICU. PVC, polypropylene and commingled items were a minority of the recyclables, and thus only central bins were provided.

Within the ICU staff tea room three recycling bins were provided: paper, plastic and commingled. The recycling program did not extend to other non-clinical areas, such as administration. Staff were encouraged to dispose of paper and plastic in bins specific to one type of recyclable, but it was also appropriate for paper and mixed plastic recyclables to be placed into the commingled bin.

The recycling program was commenced in April 2013 with education provided to clinical and environmental services staff about correct recycling, bin placement and disposal. After allowing for three months for adjustment to the new program we performed an audit of the waste generated in the ICU over a seven-day period from August-October 2013. Due to clinical work responsibilities the seven days were not consecutive, although each day of the week was audited.

All ICU waste generated over the seven day period was removed and audited in a separate non-clinical area. Sharps bins were not examined. Waste from each stream was sorted into general waste, infectious, paper and cardboard, mixed plastic, PVC, polypropylene, commingled, syringes, and sharps. Products which were made of

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recyclable materials, but which recyclers deemed unsuitable (most often since the products were composed of multiple plastics), were classed as general waste (or infectious if contaminated). For example, renal replacement fluid bags were composed primarily of PVC, but also contained other plastics and were thus deemed unsuitable, i.e. general waste. Noticeable (greater than 10ml) non-infectious fluid was emptied into a separate container and weighed. Infectious fluid was not separated from the infectious waste or, if found in non-infectious waste, removed as bagged into the infectious waste. After sorting, waste was weighed (to +/-10 grams). Investigators wore protective gowns, gloves and eyewear whilst sorting the waste. Cardboard boxes delivered to the ICU were collected and weighed.

Aluminium cans and steel tins formed the majority of the commingled material, although some plastics were also present in the commingled bins. For the purpose of the audit, waste designated as commingled not originating from the commingled recycling bin was defined as aluminium and tin cans (other potentially recyclable waste was sorted into the paper, mixed plastic and PVC categories).

Although plastic syringes are not presently accepted for recycling by our recyclers, all non-infectious syringes were weighed separately to determine their contribution to waste.

During the study period, several patients required staff to observe contact precautions when caring for them, e.g. colonisation with vancomycin resistant enterococci (VRE). As per our institution’s policy, contact precautions required staff to wear non-sterile gloves and gowns when interacting with the patient. All waste associated with patients requiring contact precautions was disposed of into the infectious waste.

No inferential statistical analyses of the data were performed. One week’s analysis was chosen as this was feasible and was likely to be more indicative of the average for an entire year than sorting waste for just one day.

9.10 RESULTS

For the seven day period the total ICU waste as found was 502 kg; general waste 268 kg (53%), infectious waste 161 kg (32%), and recyclables 73 kg (15%) (Table 18). Of the 73kg found in the recycling streams, there was 70 kg of correct recycling, i.e. 2.4 kg contamination; 1.9 kg with other recyclables, 0.5 kg with general waste and no

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infectious contamination. The ratio of the correct actual recycling to potential recycling was 70 kg out of 145 kg (47%).

Of the 88 kg of contamination of the general waste, 81.5 kg was all recyclables (including 28 kg of paper & cardboard and 35 kg of plastics), 1.5 kg was infectious waste and 5 kg was glass bottles. Within the infectious bins, the majority of the contamination was general waste (17 kg, 11% of the total infectious bin waste). The 5kg within the PVC stream had 2kg of contaminants, including 1.3kg of mixed plastics on one of the seven days. It is likely that a bedside mixed plastics bin was inadvertently emptied into the PVC bin on that day. There was minimal contamination of the other recycling streams (Table 18).

After sorting through all bins, the amounts and proportions of waste were: 221 kg (44%) of general waste, 137 kg (27%) of infectious waste and 144 kg (29%) of potentially recyclable waste (Table 19). The 221 kg of general waste included 5 kg of glass, 5 kg of syringes (non-infectious) and 14 kg of non-infectious fluid. Of the potentially recyclable waste, 68 kg was paper and cardboard, 51 kg was mixed plastic, 14 kg was PVC, 5 kg was commingled and 6 kg was polypropylene.

In the week audited there was an average of 10 (range 9 – 11) patients in the unit each day with a mean of 5 (range 3 – 8) patients requiring mechanical ventilation and a mean of 1 (range 0 – 2) patient per day requiring haemofiltration. For the year 1/7/2012 to 30/6/2013 there was an average of 9 ICU patients per day and 4.5 patients requiring mechanical ventilation, with an average of 2.5 patients requiring haemofiltration per week. In the audited week there was a total of 15 bed days occupied by patients requiring contact precautions due to VRE, compared to an average of 10 bed days per week for 2012/13.

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Table 18 Waste as found in each bin type for the seven days, and contamination (i.e. incorrect waste found in the bins). Masses of recyclables add to 73kg.

Waste stream Mass1 Contamination with

(Kg) other waste: kg (%)

Total 502 114 (23%)2

General waste 268 88 (33%)

Infectious 161 24 (15%)

Recyclables3, 4 73 2.4 (3%)

Paper (bin) 19 0.1 (0.4%)

Cardboard5 20 0 (0%)

Mixed plastic 22 0.3 (1%)

PVC 5 2 (37%)

Commingled 3 0 (0%)

Polypropylene 4 0 (0%)

1Masses rounded to the nearest kilogram. 2Total amount of waste incorrectly disposed of. 2None of the recycling streams was contaminated with any infectious waste. 30.5kg of the recycling contamination was landfill, the remainder was recyclable waste incorrectly disposed of. 4Cardboard boxes containing consumables.

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Table 19 Total mass of waste within each waste stream (post sorting), and the amount of each disposed of appropriately (i.e. into the correct bin).

Waste stream Total (% total)2 Appropriate (% appropriate)3 mass1 kg kg Total 502 (100) 386 (76)4

General (Landfill) 221 (44) 179 (81)

Infectious 137 (27) 137 (99)

All recyclables 144 (29) 70 (48)

Mixed plastic 51 (10) 22 (43)

Paper, cardboard 68 (14) 39 (57)

PVC 14 (3) 3 (21)

Commingled 5 (1) 2 (40)

Polypropylene wrap 6 (1) 4 (67)

1Masses rounded to the nearest kilogram. 2Total mass of waste stream as a percentage of total ICU waste. 3Mass of waste disposed of correctly as a percentage of the total weight of that waste stream. 4Total amount of waste disposed of correctly.

The financial cost of disposal of waste and recyclables from each of the streams is shown in Table 17 (see above in Part A, Results 9.5). Such costs included bin purchasing, collection and transport of the waste, but not labour. There was considerable variation in the costs of different waste and recycling streams due to different contractual arrangements, and carting and bin hire fees. Recycling of paper and cardboard and commingled waste is more expensive than disposal of landfill, but the recycling of plastics is less expensive as the local plastic recyclers provide free pick up and cartage. Based on the weights of recyclables in our audit, the cost of recycling per annum in our ICU is approximately AUD$1,000 (USD$770).

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9.11 DISCUSSION

An audit was performed of waste disposal in our 11-bed ICU for seven non- consecutive days in the setting of an established recycling program. Half a tonne of ICU waste was generated with approximate proportions being general waste 50%, infectious waste 33% and 14% recyclables. Almost half (70kg /145kg) of material suitable for recycling was actually recycled. There was minor (2.4%) contamination of the recycling streams, with no infectious contamination.

The estimated financial cost of recycling in our ICU was approximately AUD$20/week or AUD$1000 per annum. This cost was due to the expense of several recycling streams. In particular, paper and cardboard formed half of the actual recycling and was more than twice as expensive as general waste to dispose of. Only 1% of infectious waste was found outside of the infectious bins, but 18% of the waste found in the infectious waste bins was not infectious (compared to 13% in the previous audit). As shown in Table 17 (Part A, Results 9.5), infectious waste disposal was four times the cost of general waste disposal and improving compliance would be financially advantageous. For example, based on the results of this audit, if the amount of contamination of the infectious bins could be halved, this would lead to a saving of nearly $500 per year.

The proportion of potentially recyclable waste that was recycled was less than in the hospital audit of operating room (OR) recycling(213). The OR is a much greater source of sterile instrument wrap (polypropylene) than the ICU. Such polypropylene is readily recycled and is financially attractive to recyclers. In our prior ICU study(120), the total amount of potentially recyclable waste was greater (240kg vs 145kg), there was more paper and cardboard (114kg vs 69kg) and more PVC (47kg vs 14kg). In our prior study syringes were considered potentially recyclable; however the 5kg of syringes found in this study were considered unsuitable. Further, renal replacement fluid bags were thought to be potentially recyclable; however because they were deemed difficult to recycle, they were general waste in this study.

The difference in the amount of recycling between the two audits (OR and ICU waste post-recycling) is predominantly explained by the differing amounts of paper and cardboard and PVC, but the reasons for this difference are not entirely apparent. The volume of cardboard boxes may fluctuate due to variability in the delivery of

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consumables to the unit, although this does not fluctuate more than 50% from week to week (personal communication, Angela Rees, Western Health ICU Equipment Nurse).

This study did not consider the different clinical and non-clinical (e.g. tea room) areas within the ICU separately and did not measure waste from administrative areas. The additional time and labour required for recycling was not measured. Although not directly comparable, it has been previously shown that identifying out of date stock within the operating suite to send to less developed nations (waste sorting similar to single-stream recycling) did not significantly delay operating room turnaround times(223). Such practises raise the question whether expired stock are less effective, although it is likely that use-by dates are conservative.

The impact of this program on the operation of the ICU is unknown. It was not feasible to audit the seven days continuously, but instead each day of the week was audited non-consecutively. All recycling bins were within five metres of each bed area. Sharps bins were not examined, though it was possible that some potentially recyclable waste was disposed of via sharps bins.

All statistics used were descriptive; we did not perform inferential analyses as it is uncertain if a one week audit indicates routine waste and recycling for all weeks. Nevertheless, this audit is likely to give a reasonable indication of management of waste and recycling within our ICU. Finally, although attempts have been made to quantify the volume of recycling achieved, and the financial cost to our institution, no measurement was made of other more intangible benefits such as the financial and environmental benefits of resource recovery of plastics etc., reduction in CO2 emissions related to recycling, and effects upon staff morale (if any). Thus, the overall benefit to society of an ICU recycling program remains unmeasured.

Based on the results of this audit, it is feasible to recycle up to four tonnes from the ICU per year. With a recycling program already established in the hospital’s operating suite(213), setting up a recycling program within the ICU was not difficult. Given that the ICU only contributes approximately 5% of total hospital waste(120) expanding the recycling program to the rest of the hospital could achieve considerable recycling and is progressively under way. The benefit of this recycling is difficult to quantify.

Recycling leads to a reduction in CO2 emissions as less energy is expended in the

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manufacturing of products from recycled materials(25, 195). Recycling also reduces landfill and conserves natural resources(103). Further, exposing staff to recycling may lead to better compliance with recycling outside of work(224), and anecdotally, the majority of our staff were supportive of ICU recycling.

There is scope for improvement of ICU recycling, given that only 50% of potentially recyclable waste was disposed of in recycling bins. There are, however, potential barriers to recycling, including bin space, education, motivation, and financial costs. There is limited ICU space and there are now four different bins in each ICU bed area (landfill, infectious, paper and cardboard and mixed plastic). This adds complexity to waste disposal with a greater likelihood of incorrect disposal, although this appeared rare in our audit. There is only one PVC bin within the ICU (given limited ICU space and the low PVC volume) and staff must leave their bed areas to access it. In an emergency setting it would be difficult to expect staff to separate rubbish into individual components and dispose of them in the correct bins. Some staff suggested leaving all rubbish in a separate pile and sorting it later, although this practice is unlikely to be widely adopted. Anecdotally, ICU tea room recycling could be improved, although the presence of foodstuffs hampers correct waste separation.

Paper and cardboard recycling is more expensive than disposal of landfill, so increasing recycling of paper and cardboard will increase the cost to the hospital. Paper towel is a major component of the paper and cardboard waste stream, so alternatives for hand drying could be considered (hand driers and hand sanitiser rubs)(120). The cost of recycling will vary according to individual hospital contracts and the recycler’s location.

Importantly, the results of this ICU audit differ from the earlier OR waste audit, which showed that it was financially advantageous to recycle in the OR(213). The OR audit showed a higher proportion of recycling (23% total OR waste), greater polypropylene recycling (50% of all OR recycling), and a much higher baseline of infectious waste which was reduced after recycling commenced (48% reduced to 32%). The OR waste had much more polypropylene plastic which is easy to recycle due to its self-evident composition (‘surgical wrap’). Polypropylene is considered valuable to recyclers and is correspondingly less expensive than general waste for the hospital to dispose of. Significant financial savings were achieved in the OR post-recycling by reducing the proportion of infectious waste to similar levels found in this ICU audit. Such financial

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savings were not possible in the ICU as the level of infectious waste contamination with non-infectious waste was already much lower than in the OR and did not improve with the advent of recycling.

Sustainability within the healthcare sector involves a multi-faceted approach, of which recycling is only one component. Recycling is unlikely to save hospitals large financial amounts, whilst reducing and reusing where clinically possible, can have significant environmental and financial effects particularly if studied comprehensively, which includes the use of life cycle assessment if necessary(10). Other avenues that could be considered to improve ICU sustainability would include examining water (e.g. for linen), electricity (e.g. reducing non-essential use at night, switching off vacant isolation rooms) and procurement (e.g. excess packaging). Even more broadly would be a consideration of the unsustainability of ineffective therapies which do not improve patient care within the ICU.

This audit has shown that ICU waste can be safely and effectively recycled. There was minimal contamination of the recycling streams, although actual recycling was only half of the potential. Contrary to the audit of OR waste which could be saving the hospital greater than AUD$5,000 (USD$3,850) per year, our ICU recycling program is costing the hospital approximately AUD$1,000 (USD$770) per year. Reasons for this cost discrepancy include a different composition of recyclables in the ICU versus OR, and less opportunity to reduce the already relatively well sorted expensive infectious waste in the ICU versus the OR prior to commencing recycling. Detailed audits of area specific hospital recycling programs reveal different outcomes. Investigation of why it often remains more financially expensive for hospitals to recycle than to discard such resources as garbage would be welcomed.

9.12 CONCLUSION

These audits of recycling waste conclude the thesis section Recycle. Chapter 8 surveyed anaesthetists’ views of recycling in order to discover if a prominent group of OR doctors supported recycling and thought it to be feasible. The overwhelming majority of anaesthetists indicated that OR recycling was not occurring in their theatres, but supported recycling and indicated that the major barriers to recycling were education to commence recycling, inadequate recycling facilities, and resistant

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staff attitudes. With these factors in mind recycling programs were undertaken in the OR and ICU.

Chapter 9 has explored such recycling programs through detailed audits of OR and ICU waste. Recycling was found to be feasible, with minimal contamination of recycling streams with infectious waste. Recycling reduces the total environmental life cycle cost of most items, and since these studies showed feasible recycling the environmental effects of everyday activities in the OR and ICU have been reduced. Recycling does not greatly reduce the financial burden of hospital waste processing since waste disposal is relatively inexpensive per kilogram. The OR recycling program showed financial cost savings for the hospital as there was a concomitant reduction in infectious waste with the introduction of recycling. On the contrary, since adherence to correct infectious waste disposal was more rigorously adhered to within the ICU, reductions in infectious waste did not eventuate with an ICU recycling program, which thus actually increased the cost of waste disposal due to some expensive recycling streams.

Chapter 10 is a summary of the thesis and a discussion of what lies ahead for research within the domain of hospital environmental sustainability.

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CHAPTER 10: DISCUSSION

This thesis has explored environmental sustainability within the operating room (OR) and intensive care unit (ICU). Environmental sustainability has been partitioned into the themes of reducing, reusing and recycling, with thesis research questions following each theme. This chapter revisits the questions posed and results obtained during the thesis. Thereafter, discussion moves to: (i) the methods used in the thesis and their wider applicability, (ii) the generalisability of the results, (iii) practical outcomes that have changed hospital purchasing, reusing and recycling, and (iv) the future research agenda for hospital sustainability.

10.1 REDUCE

Chapter 3 considered where possibilities exist for reducing the amount of equipment used per patient within the OR and ICU, of which there are many examples. A detailed study was subsequently performed of the reduction in use of one common item: anaesthesia circuits.

10.1.1 The frequency of washing anaesthetic breathing circuits.

Anaesthetic breathing circuits were chosen and their use analysed in such a manner as to not compromise patient care.

1. Was it possible to extend the use of reusable breathing circuits from the standard 24-hour interval between decontamination at our hospital to 7 days without a resultant significant deterioration in the hygienic quality of breathing circuits? 2. What were the equipment, electricity and water cost savings resulting from extended circuit use?

A before-after study of anaesthetic circuits, whereby the duration between decontamination was progressively extended, was chosen so as to not impede patient care or OR workflow patterns. Extending the interval between anaesthetic circuit decontaminations from daily to weekly was associated neither with an increased absolute number of bacterial colonies, nor with an increase in the proportion of positive microbiological results. Due to the unchanged bacterial load it was feasible to reduce the frequency of breathing circuit changes, whilst complying with Australian

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professional standards(142), provided daily emptying of circuit condensate was undertaken. These study findings are generalizable; small financial and environmental savings from reduced anaesthetic circuit changes at one hospital could become larger savings for an entire healthcare system and are relevant to many hospitals, particularly in developed nations.

Two prior studies of increasing the interval between decontaminations of anaesthetic breathing circuits were smaller and did not include statistical analyses(140, 141). These studies were performed in Germany and led to guideline changes in Germany, where it is now accepted practice to change circuits weekly(137). On the contrary, current guidelines require anaesthesia circuit changes for every patient in many countries including the USA(159).

Several questions arise: What cultural and institutional factors may impede improvements in sustainable anaesthesia practice? What is required to change practice? Does the place and country of research influence the likelihood that the research will be adopted? Why is there such a discrepancy between (and perhaps within) different countries’ treatment of anaesthetic breathing circuits and is this indicative of differences in the resource utilisation of many hospital devices? Future research could concentrate on these questions, including using qualitative methods (interviews and focus group discussions) and perhaps include psychologists and anthropologists.

A potential criticism of the study of anaesthetic breathing circuits is its before-after design, i.e. that it was not a randomised controlled trial. Another concern is that the study did not include searching for viruses. Studies of the anaesthetic circuit load of viruses or more fastidious bacteria would be difficult, expensive and unlikely to be pragmatic due to the required study recruitment size and duration needed to show a treatment effect. A randomised, controlled and perhaps blinded trial of prolonging circuit changes was contemplated at our hospital and considered to be impractical by staff. Randomising circuit changes to different durations in separate operating rooms, and changing this duration randomly for each subsequent circuit change, though not impossible, could potentially have impeded workflow patterns and would likely have had poor compliance.

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Rates of ventilator associated pneumonia (VAP) are very low after routine anaesthesia. A large, prospective, randomised, controlled trial examining the effects of reducing the frequency of anaesthetic circuit decontamination on VAP could definitively answer whether less frequent decontamination is detrimental to patients. Such a study would be unlikely to ever be performed due to the infrequent occurrence of VAP and thus the very large trial recruitment size, cost and duration.

In summary, the Chapter 3 study of anaesthetic circuits is the most robust evidence to date to indicate what a safe duration between anaesthetic circuit decontaminations is. The study methods and data are robust enough to change hospital practice, although a conservative approach to change would be to intermittently monitor bacterial contamination counts of anaesthetic breathing circuits as part of quality assurance. Research exploring why there is such variability in the uptake of research findings of hospital environmental sustainability both within and between different countries could be rewarding both financially and environmentally. Limited implementation of evidence is a problem across many aspects of health care, described by the Australian National Health and Medical Research Council (NHMRC) as a ‘valley of death’(225).

Chapter 3 also explores the dilemma originally raised by Daschner et al of ‘protecting the patient’ or ‘protecting the environment’ (66). This dilemma can be false, i.e. with regards to the frequency of washing breathing circuits, the patient remains protected and the environment has benefitted.

10.2 REUSE

Chapters 4 to 7 examined several facets of reusing. Chapter 4 queried what makes something single use in the first place, taking metalware as an example. Chapter 5 introduced the method of life cycle assessment (LCA), examining a common item used in the OR and ICU, the central venous catheter (CVC) insertion kit. Steam sterilisation was found to be a large contributor to the environmental footprint of the CVC insertion kit. Chapters 6 and 7 thus investigated both the electricity and water use of steam sterilisers and how hospital staff use such sterilisers, identifying potential areas to improve environmental efficiencies.

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10.2.1 What makes surgical metal ware single use?

Prior to comparing common reusable and single use medical equipment this thesis questioned the foundation of what makes an item single use. Within hospitals, there is a strong trend towards increase in the replacement of reusable devices with single use variants. Simple, common metalware was chosen as steel items were seen as easily recognisable and robust, and steelmaking is well understood to be energy intensive.

Chapter 4 examined:

1. Why some simple surgical metal devices were labelled as single use and how is their composition different from traditional reusable metalware? 2. What were the broader ecological and social issues that might influence a decision to purchase single use surgical metalware?

Within the past decade there was a 10-fold increase of single use stainless steel surgical metalware in our hospitals driven by losses of the alternative expensive reusable metalware, occurring primarily where instruments were not ‘double counted’ such as in the ICU and emergency department (i.e. outside of the OR).

In Chapter 4 single use metalware was found to have the same chemical composition as reusable metalware, i.e. both were stainless steel. Physically, the single use metalware had a rougher surface leading to rusting when steam sterilised. When this single use metalware underwent simple reprocessing it became physically and visually indistinguishable from reusable metalware despite multiple washings and sterilisations. To reprocess such single use metalware to become reusable is made challenging by Australian regulations and currently would be financially unviable.

National bodies regulating medical devices could contribute to the transition towards improved healthcare sustainability and ask of manufacturers why any stainless steel items are ‘single use’. There are broader ecological and social issues that might influence a decision to purchase single use surgical metalware such as the ‘fair trade for surgical instruments’(176), but these also appear to be subsumed by the financial advantages of using single use metalware.

Chapter 4 explored what makes common surgical metalware single use. Similar investigations could occur for multiple other metal, plastic and even linen items used in the OR, ICU and beyond. Investigation of plastic and linen devices in particular would have to include analyses of how significantly deterioration occurred with

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successive decontaminations and sterilisations. Linen is very energy and water intensive to make(65), but since it is inexpensive and unlikely to be replaced with a reusable variant such research could be ineffective at instituting change. On the other hand, investigation could pragmatically target more financially expensive devices such as single use stapling guns in the OR. If there is found to be minimal difference between reusable and single use devices one could question the validity of such labelling. Perhaps the existence of the reprocessing industry, which makes single use devices patient ready again, indicates that such devices are not single use. In many countries reprocessing of single use devices is well under way, including a multi- billion dollar industry in the USA(132), yet in Australia it is non-existent due to a small market size and regulatory barriers(10). Further life cycle assessments could clarify if there are environmental benefits to reprocessing in lieu of simply using another single use device(10).

10.2.2 The life cycle of reusable and single use CVC insertion kits

The method of life cycle assessment was introduced in Chapter 5. LCA is a ‘cradle- to-grave’ approach for determining the financial and environmental costs of a product over its entire life(9, 21). A process based life cycle comparison was made of the environmental effects of single-use and reusable versions of a device commonly used in the OR and ICU. The chosen item was a central venous catheter (CVC) insertion kit; containing simple surgical metalware, plastic gallipots, and enclosed in plastic wrap. We asked:

1. What were the complete financial and environmental (CO2 emissions, water use, metal use, toxicity) costs of the reusable and single use CVC insertion kits?

2. What effect did the source of electricity have upon CO2 emissions?

The reusable kit was less financially expensive. The reusable kit had greater CO2 emissions and water use, but lower solid waste and mineral use, whilst other environmental effects were similar(189). The CO2 emissions and water use of the reusable CVC insertion kits were respectively three and ten times that of the single use CVC insertion kit. Steam sterilisation contributed the majority of the CO2 emissions for the reusable kit, whilst decontamination (washing) was also important, though less so. A reusable CVC insertion kit made patient ready in a hospital with gas

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co-generation instead of electricity sourced from brown coal would produce similar

CO2 emissions compared with a single use kit.

This LCA was useful for three main reasons: (i) if the electricity source for steam sterilisation and decontamination were brown coal, the CO2 emissions could be much greater for reusable than single use items, (ii) due to steam sterilisation’s unexpectedly large energy and water use, studies were commenced examining the hospital sterilisers in greater detail (thesis chapters 5 and 6) to clarify if the study’s findings were realistic, (iii) the study indicated just how incomplete our knowledge of the environmental effects of even simple hospital devices was and redirected the thesis away from further LCAs and towards greater investigation of a common reusable device input: steam sterilisation.

LCAs could be performed for similar surgical devices with increasing ease and accuracy as the details of the environmental effects of processes such as sterilisation and decontamination are investigated. Such investigations could provide useful data for the life cycles of entire operations (and the treatment of ICU patients) which to date have relied upon manufacturers’ specifications(35) or have not included the effects of such processes as steam sterilisation(188).

In LCA it is particularly important when comparisons are made between different processes (e.g. reusable or single use approaches) to examine carefully the inputs that are different. If inputs are common to both approaches (e.g. a plastic wrap of the final product) generally it is not vital to have the most precise data of such inputs. For example, knowledge of the environmental effects of the plastic wrap coating a sterilised single use device is of lesser use compared with details of steam sterilisation, as reusable devices are comparably wrapped in plastic coating of similar weight and type, but single use devices are not repeatedly steam sterilised.

10.2.3 Steam sterilisation’s energy and water footprint

In Chapter 5 steam sterilisation was found to contribute considerably to the environmental footprint of reusable surgical equipment(189). It was postulated though that the assumptions used for the steam steriliser’s energy and water use in the LCA were inaccurate. The study in Chapter 6 clarified whether the energy and water data used for steam sterilisation for the life cycle assessment detailed in Chapter 5 were realistic. It was unclear what the patterns of electricity and water consumption of a

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standard hospital steriliser were over a prolonged period, including the consumption when the steriliser was idle, so we asked:

1. What was the total electricity and water consumption of the steriliser, and the amounts of steriliser electricity and water use for standard 134 °C cycles, accessory cycles and idling? 2. What were the averages of electricity and water consumption per kilogram of equipment for: (i) standard 134 °C cycles, and (ii) total steriliser use? 3. What were the relationships between the total mass of equipment in mixed and single-type only steriliser cycles and electricity and water consumption? 4. What were the marginal costs (i.e. cost per unit in kWh/kg and litres/kg) of electricity and water per mass of items per steriliser run?

The electricity and water use of a hospital steam steriliser was measured over more than 300 days. A large proportion of electricity (40%) and water (20%) use occurred during idle times; heavier loads were more efficient, almost one in three steriliser loads were light and thus inefficient, and the load type (e.g. linen) was of little importance. Linear regression analyses provided only moderately predictive equations of electricity use/mass, but not water use. One steriliser’s daily electricity and water use was equivalent to 10 households, whilst one standard 134 °C cycle used approximately one day’s worth of household electricity and water.

This study was important for four reasons: (i) generalisability: the methods used to calculate steam steriliser electricity and water use could be emulated in many countries elsewhere for modest capital investment (approximately AUD$5,000 inclusive of software), (ii) steam sterilisation can contribute appreciably to the total

CO2 emissions and water use of making a reusable surgical item patient ready again, (iii) the steriliser load type (e.g. linen) is of minimal importance and could be ignored when calculating the energy and water use of a reusable item, i.e. only load mass is important, and (iv) steam sterilisation’s environmental effects could be mitigated by the manner in which the steriliser is used (idle duration, steriliser stacking and source of electricity).

It is uncertain how important the volume of space occupied by a device in a steam steriliser is and whether it could limit the load mass considerably (e.g. for less dense

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plastic bowls). Research examining the minimum steriliser load mass according to different steriliser stacking regimens could be insightful.

The results of this study should inform future life cycle assessments of operating room and ICU items and procedures. For example, the Chapter 5 study of CVC insertion kits(189) indicated that the reusable insertion kit had thrice the CO2 emissions of the single use kit. The primary reason for the high CO2 emissions of the reusable kit was steam sterilisation’s electricity use of 3.6 kWh per kg items sterilised. The Chapter 5 study of steam sterilisers, however found that the electricity use was 1.9 kWh per kg items sterilised including idle periods and half that again if only including standard steriliser loads.

If the LCA of CVC insertion kits(189) had used the most recent data (1.9 kWh per kg sterilised versus 3.6 kWh per kg) for steam sterilisers, the CO2 emissions for the reusable kits would have been at least one third lower. The CO2 emissions for the reusable kits could be another one third lower again depending upon how efficiently hospital steam sterilisers are used. Thus, the differences found in our original study of

CVC insertion kits between the CO2 emissions from the reusable versus single use CVC insertion kits could be markedly reduced depending upon how steam sterilisers were used. Such differences in the inputs to life cycle assessments can thus have profound effects on whether a reusable item has greater environmental effects than single use variants. Future LCAs of reusable surgical items could use Chapter 6’s study calculations of electricity and water use/kg load sterilised, whilst load type could be excluded. Further, considerable efficiency gains in steriliser use are possible through reducing idle periods as well as increasing steriliser load masses.

10.2.4 Hospital Steam Steriliser Usage: Could we switch off to save electricity and water?

Chapter 6 found that steam sterilisers used a considerable amount of electricity and water when idle. Further investigation of how hospital staff used a bank of such steam sterilisers was undertaken in Chapter 7.

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3. What would have been the consequences for electricity and water use of two alternative usage policies based upon switching sterilisers off when not needed?

The sterilisers were idle for almost half of the total hours for the year, longer than they were active, and they were off for only 15% of the time. Steriliser idling for 12 hours or longer accounted for half of the total idle duration, and two or more sterilisers were idle for almost 70% of the total hours. Opportunities were identified to improve the efficiency of steriliser use. The first strategy to switch off sterilisers when idle would have saved 26% of total steriliser electricity use and 13% of the water. An alternative strategy to always switch off one steriliser off from 10 a.m. and a second one off from midnight would have led to electricity and water savings approximately half that of the first strategy.

As a result of discussions about these steam steriliser studies hospital staff have rotated off one steriliser continuously, saving approximately AUD$10,000, with further efficiency changes underway. More importantly, the methods used in this study are generalisable. By having access to the timing of all hospital steriliser cycles and using relatively straightforward computer software one could identify potential steriliser switch off periods. Any hospital using a similar system of quality assurance could conduct a similar analysis to potentially achieve considerable steriliser efficiency gains for minimal financial outlays. The methods used in Chapters 5 and 6 to identify steam steriliser energy and water use and how sterilisers were used could be applied elsewhere within hospitals, (e.g. an operating room’s air conditioning and ventilation or a CT and MRI scanner).

It is possible to replace steam sterilisation with other rapid sterilisation methods such as hydrogen peroxide or ethylene oxide, although generally such other methods are more financially expensive and from a microbiological viewpoint steam remains the gold standard(182). Chapter 7 identified how staff use a bank of sterilisers, including the duration and timing of idle periods. Similarly useful research could examine steriliser load optimisation – i.e. how to stack a steriliser. Simple queries could be asked such as “How often are all racks used?” “Could another rack be added without compromising sterilisation?” and “How is equipment stacked?”

Collaborative research between hospital staff and engineers to improve steam steriliser energy and water use at the outset of manufacture is another stream of

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enquiry that could have appreciable effects, but would require greater financial investment than in-situ studies of how hospitals use exisiting steam sterilisers.

10.3 RECYCLE

Chapters 8 and 9 examined OR and ICU recycling. For many items within the OR and ICU one cannot reduce their use indefinitely, nor can they feasibly be reused, yet they could be recycled. Prior to commencing any recycling programs it would be useful to examine the feasibility of recycling as well as what could be recycled, and how much could be recycled. Feasibility includes whether it is possible to recycle in the OR and ICU environments, staff attitudes to recycling, and what staff see as opportunities and barriers to recycling. Prior studies at our hospital indicated that approximately one third of all waste in the OR and ICU could be recycled(119, 120). As a result of the survey in Chapter 8 indicating strong support for recycling, programs were begun in the OR and ICU to commence recycling. Audits were undertaken of such recycling programs.

10.3.1 A survey of anaesthetists’ views of recycling

Chapter 8 examined behavioural factors that could influence the likelihood of successful recycling, focussed upon the views of anaesthetists, a large group of OR staff.

1. Is operating room recycling standard practice in Australia, New Zealand and the United Kingdom? 2. Are anaesthetists willing to increase recycling within the operating suite? 3. In the opinion of anaesthetists what factors enable and impede the introduction of operating room recycling in an operating suite?

Most (more than 90%) anaesthetists who responded to this survey consider operating room recycling to be important, regardless of country, location (regional or metropolitan) or practice (public or private). Of the respondents, less than 10% however agreed that recycling occurred in their operating theatres. A significant majority of anaesthetists would be prepared to commit time to OR recycling and the education of others to do so, but few would commit their own money. The three major barriers respondents believed were preventing OR recycling from becoming more widespread were: (1) inadequate recycling facilities, (2) inadequate information on

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how to recycle, and (3) staff attitudes. In contrast, cost, lack of time, lack of space and safety issues were thought to be relatively insignificant barriers to recycling.

This survey indicated that anaesthetists were strongly supportive of OR recycling and that effort to commence such recycling should be focussed not upon convincing them to do so, but in aiding them to achieve successful recycling programs. It is unknown if other medical craft groups such as surgeons and intensive care physicians also are supportive of OR and ICU recycling. There is some evidence that nurses are supportive(49), but this may not apply to the OR and ICU. Nurses appear to undertake the majority of hospital recycling, for they clean up after procedures and operations and are thus the primary hospital staff required for recycling to be successful. Nevertheless, leadership in recycling programs from anaesthetists, surgeons and intensive care physicians could be vital and requires further investigation. It is also unclear whether a culture of OR and ICU recycling leads to other more sustainable behaviours such as reducing and reusing the use of hospital equipment. There is some non-healthcare related evidence that a predisposition to recycle may bear little relationship with a desire to reuse or reduce(131), indicating a role for future qualitative research focussed upon hospital staff.

10.3.2 OR and ICU recycling programs

Studies of recycling programs focussed upon staff education on how to recycle, overcoming negative staff attitudes to recycling, and providing adequate recycling facilities. Chapter 9 detailed post-recycling program audits of what and how much could be recycled.

1. What were the masses of OR and ICU general waste, infectious waste and recyclables over seven days? 2. What were the masses of actual and potential OR and ICU recyclables remaining within the general and infectious waste? 3. What was the financial cost of OR waste disposal and how does this compare to the pre-recycling audits?

For the audit of the six-theatre OR and Day Procedure Unit waste, of the 1.3 tonnes of waste almost a quarter was being recycled. Infectious waste bins contained one third of all waste, although truly infectious waste was one quarter of all waste. The proportion of non-infectious waste entering the infectious waste stream appeared to

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fall by at least 10% compared to pre-recycling audits. The achieved recycling had no infectious contamination and minimal contamination with general waste. The achieved recycling represented more than half of what was potential (realistic). Overall, recycling was financially cost neutral compared with no recycling, although if the apparent reduction of infectious waste was included savings approached AUD$10,000 (USD$7,700)(152) per annum.

For the audit of waste disposal in the 11-bed ICU, half a tonne of waste was generated with: general waste 53%, infectious waste 32% and 15% recyclables. Infectious waste bins contained 32% of all waste, with truly infectious waste 27% of all waste. Almost half of the material suitable for recycling was actually recycled. There was minor (2.4%) contamination of the recycling streams, with no infectious contamination. The estimated financial cost of recycling for one week in the ICU was approximately AUD$20 per week or AUD$1000 per annum. This cost was due to the expense of several recycling streams. In particular, paper and cardboard formed half of the actual recycling and was more than twice as expensive as general waste to dispose of.

Infectious waste disposal was four times the cost of general waste disposal and improving compliance would be financially advantageous. The OR recycling program showed financial cost savings for the hospital as there was a concomitant reduction in infectious waste with the introduction of recycling. Adherence, however, to correct infectious waste disposal was more rigorously adhered to within the ICU. Thus, reductions in ICU infectious waste did not eventuate with a recycling program, increasing the cost of waste disposal due to some expensive recycling streams.

The recycling audits indicated that: (i) if education and facilities are provided recycling is feasible and relatively straightforward to perform and infectious waste contamination is rare, (ii) recycling can at least be financially cost neutral, or at worst have a minor cost impost, (iii) it is unclear why the financial costs for different recycling streams vary considerably.

There are limits to how much recycling can be performed. Efforts to increase the achieved recycling as a proportion of the potential recycling should perhaps rather be directed to reducing and reusing equipment. Reducing the use of paper products such as hand towels with hand gels and air dryers, and plastic sterile wraps with reusable stainless steel cases, could be both financially and environmentally rewarding,

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although deserving of further study(213). Further, recycling does not save large amounts of money unless there is a reduction in the infectious waste amounts as the costs for recycling many items is similar to the cost for general waste disposal.

The reduction in CO2 emissions from recycling plastics from the OR was 15 tonnes for one year. As Chapter 3 has shown, reducing the use of anaesthetic circuits via less frequent decontaminations saved approximately AUD$10,000 per annum and 3.6 tonnes of CO2 emissions. Circuits are but one example of many items whose use could potentially be reduced and there are likewise many items that could be reused. Similarly, studies of the electricity and water use of hospital steam sterilisers (Chapters 7 and 8) ended with savings of more than AUD$10,000 and 85 tonnes of

CO2 emissions per annum via reductions in steriliser idle periods. This thesis has shown that exploring recycling for all items used in the OR and ICU has appreciable environmental effects, but these are likely to be less than the environmental benefits of feasibly reducing and reusing all OR and ICU items and procedures. Nevertheless, such statements are anecdotal as such research examining and contrasting reducing, reusing and recycling is in its infancy.

FUTURE SUSTAINABILITY RESEARCH

This thesis has highlighted that many aspects of our understanding of hospital sustainability are immature and that there are large research opportunities in the field. This chapter ends by discussing the wider applicability of the methods and results of the thesis and the future research agenda for hospital sustainability.

The methods used in this thesis were straightforward and could be generalised to many other hospital devices and procedures. The study in Chapter 3 of the microbiological loads of anaesthetic circuits could be applied to other hospital equipment such as breathing circuits used in respiratory and sleep medicine and in the ICU. Chapter 4’s study of metal ware required the use of a mass spectrometer and surface roughness meter, though these were relatively inexpensive, and studies of plastics for example could be performed similarly.

Process based life cycle assessment was used in Chapter 5 to measure the environmental effects of central venous catheter insertion kits. Financial costs may

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prohibit the rapid uptake of healthcare LCAs due to labour costs, although these are likely to fall as more medical items and procedures are examined. As the financial and environmental costs of healthcare rise LCA will increase in relevance. Comparisons between input-output LCAs and the more expensive process based LCAs could clarify whether input-output LCAs could suffice for large numbers of devices and procedures. LCAs of medications will also come to the fore.

Chapters 6 and 7 examined the electricity and water consumption and in-situ hospital use of steam sterilisers. Electrical current and water flow meters could be applied to other hospital equipment. Examining the timing of steriliser loads with the aid of software and basic computer programming could be adapted for other hospital devices. Chapters 8 and 9 involved a survey of anaesthetists’ views of OR recycling and audits of waste, both of which are readily achievable. Surveys of various hospital staff groups’ views of recycling could be instructive and guide not just recycling programs, but also efforts to improve procurement, reducing and reusing. All studies completed in this thesis have applicability beyond just a single hospital. The methods used are generalisable to many hospitals in developed and developing nations since methods of decontamination, sterilisation, procurement and waste disposal follow national healthcare standards which are reflected by international standards.

Not all of the studies contained within this thesis have led to financial or environmental savings for hospitals. The studies of why some metal ware is classed as single use, the LCA of CVC insertion kits and recycling ICU waste did not yield any environmental savings. Nevertheless, there was a decision by staff to adopt the findings of several hospital projects that did record financial and environmental improvements. Research examining why the results of this thesis have or have not been adopted by other hospitals is likely to be revealing. Just why some hospital staff behave in environmentally responsive manner and others do not needs further clarification.

Research studies in this thesis that led to financial savings of more than $AUD30,000 (USD$23,000) per annum were: reducing the frequency of anaesthetic circuit decontamination, reducing the steam steriliser idle periods, and recycling OR waste. Although the financial (and perhaps environmental) savings resultant from this thesis may seem insignificant, there are at least three reasons to counter such a view; 1. the methods used herein (e.g. LCA) could apply to examination of any other hospital

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process or equipment anywhere in any hospital, 2. the results could be generalisable to many Australian and overseas hospitals, and 3. the behaviour of hospital staff can be shown to be influenced by sustainability research.

What is the future research agenda for hospital sustainability and what advice could be given to someone interested in this field of research? There is a need to concentrate upon multiple areas; from the macro, i.e. the prevention of unnecessary healthcare events and avoidable diseases, through to improving a nation’s healthcare financial and environmental footprint, and thus to the micro, i.e. examining the effects of individual equipment and procedures.

This thesis has remained focussed upon research that could improve the environmental effects of OR and ICU equipment and activities as the primary aim. There are many other highly important research projects that would have improved environmental outcomes that are beyond the scope of this thesis.

The bigger picture could be thought of thus: that prevention is better than cure, both for the patient that never was and the avoidance of an associated environmental footprint. The role of public health in reducing the environmental (and financial) effects of healthcare will become increasingly important. Studies are required to examine avoiding hospital admission in the first place. For example, it is possible that through encouraging just one smoker to quit, a general practitioner may have a greater effect upon healthcare dollars saved, reduced hospital admissions and environmental benefits than all of the hospital recycling performed in our hospital for a year. Of course, the patient will benefit from smoking cessation also, which remains the primary aim. Life cycle assessment research of the environmental effects of avoiding smoking, alcohol, obesity and diabetes could add to patient centred reasons to avoid such risk factors and diseases.

Systematic research of healthcare’s total environmental footprint for an entire nation is under way in only the UK currently(4). Although a carbon footprint is rarely indicative of the total environmental footprint it serves as a useful framework and one that has been studied in some detail. Healthcare’s carbon footprint could be subdivided in descending importance into: procurement, direct energy use, and travel. For procurement there is much scope for careful analyses of the environmental effects of different models of patient care as well as carbon hotspots for procurement of

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medications and devices(48). Study of the environmental and financial effects of the hospital building fabric is at a more mature stage than other aspects of healthcare sustainability(36). There are collaborative research opportunities with engineers to examine hospital equipment and how they are used by staff, e.g. radiology machines, OR ventilation and air-conditioning. Hospital staff attitudes to more sustainable transport options could be surveyed and trials of more environmentally friendly approaches piloted.

This thesis has aimed to explore the micro of hospital sustainability, i.e. what are the environmental benefits of reducing, reusing and recycling individual equipment and simple processes? Just as prevention is better than cure, so too is it better environmentally in most cases to follow the waste hierarchy and reduce then reuse then finally consider recycling(14).

A large research agenda is immediately apparent within each field of Reduce, Reuse and Recycle. For Reduce, avoidance of unnecessary procedures and superfluous devices, methods to reduce the packaging of drugs and devices, and reduction in idle periods for large equipment could be examined.

For Reuse, the field of life cycle assessment within healthcare is ready to enter a new phase of research. There are opportunities from the macro to examine input-output LCA studies of the environmental footprint of national healthcare systems right down to the micro LCAs of individual devices or drugs. As an example of the current state of play, several authors have recently completed LCAs of entire operations. The CO2 emissions for three different procedures have been estimated at: (i) 180 kg CO2 for an input-output LCA of cataract surgery(113), (ii) an average 240 kg CO2 for a hybrid process based/input-output LCA for hysterectomy (robotic, laparoscopic and laparotomy)(35), and (iii) a range of 22- 40 kg CO2 for a process based LCA of gynaecological cancer staging surgery (robot, laparoscopy and laparotomy)(188).

Such variability in the CO2 emissions for surgery indicates differing methods such as – input-output versus process based LCAs (detailed in Chapter 2.3), anaesthetic gas inclusion(35) or exclusion(188) (which have high direct global warming potentials,(122)) and uncertainties such as whether the electricity and water requirements for decontamination and steam sterilisation of reusable devices were included. Future LCAs could considerably guide device and drug selection and allow clear comparisons between equipment and procedures.

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For Recycle, research opportunities probably have smaller potential than studies of reducing and reusing. For example, there are potentially hundreds of different devices and procedures to research Reuse with LCA for example, but only a few different recycling streams for all of these hundreds of devices. Nevertheless, recycling strategies on different wards, why different recycling streams have markedly different financial costs(214), and surveys of why groups of clinicians recycle would be valuable.

There are considerable differences between equipment used in the OR and ICU. In our hospital the OR has a majority of reusable equipment, linen, metal ware and plastic used, whereas within the ICU there are very few reusable devices. Most single use ICU equipment is inexpensive, thus even if research indicated that a reusable version had a lower environmental footprint, unless the financial savings were at least moderate, there may be no practice change. In the OR there are more expensive devices which would have research priority.

This thesis gives greater understanding to the environmental effects of hospital activities. Examples are given of improvements in OR and ICU sustainability occurring as a result of the thesis research. The methods used in this study are generalisable to many hospitals nationally and internationally. The studies within and future research could guide future policy makers, clinicians, engineers and others to make rational, informed decisions to improve hospital environmental sustainability, improve efficiency and reduce energy, water and pollution in an increasingly resource constrained world.

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laparoscopic cholecystectomy. Surgical Endoscopy And Other Interventional Techniques. 2005;19(2):268-72. 111. Eckelman M, Mosher M, Gonzalez A, Sherman J. Comparative life cycle assessment of disposable and reusable laryngeal mask airways. Anesthesia & Analgesia. 2012;114(5):1067-72. 112. Unger SR, Landis AE. Comparative life cycle assessment of reused versus disposable dental burs. The International Journal of Life Cycle Assessment. 2014;19(9):1623-31. 113. Morris D, Wright T, Somner J, Connor A. The carbon footprint of cataract surgery. Eye. 2013;27:495-501. 114. Australian Government Department of the Environment. National Greenhouse Accounts Factors. 2014. [cited 13 June 2015]. Available from: http://www.environment.gov.au/system/files/resources/b24f8db4-e55a-4deb-a0b3- 32cf763a5dab/files/national-greenhouse-accounts-factors-2014.pdf. 115. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Science of the Total Environment. 2012;425(15):191–8. 116. Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesthesia & Analgesia. 2012;114(5):1086-90. 117. Hutchins DC, White SM. Coming round to recycling. British Medical Journal. 2009;338:b609. 118. Tieszen ME, Gruenberg JC. A quantitative, qualitative, and critical assessment of surgical waste. Journal of the American Medical Association. 1992;267(20):2765- 8. 119. McGain E, Hendel S, Story D. An audit of potentially recyclable waste from anaesthetic practice. Anaesthesia and Intensive Care. 2009;37(5):820-3. 120. McGain F, Story D, Hendel S. An audit of intensive care unit recyclable waste. Anaesthesia. 2009;64(12):1299-302. 121. Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: application to clinical use. Anesthesia & Analgesia. 2010;111(1):92-8. 122. Andersen MPS, Nielsen OJ, Wallington TJ, Karpichev B, Sander SP. Assessing the impact on global climate from general anesthetic gases. Anesthesia and analgesia. 2012;114(5):1081-5. 123. McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesthesia and Intensive Care. 2007;35(5):808-9. 124. Feldman JM. Managing fresh gas flow to reduce environmental contamination. Anesthesia & Analgesia. 2012;114(5):1093-101. 125. Bluezone Anesthetic Collection Service. 2013 [cited 16 June 2015]. Available from: http://www.bluezone.ca. 126. Vanderbilt Magazine. Recycled anesthetic technology saves dollars, environment. Spring 2009. [ 15 June 2015]. Available from: http://www.vanderbilt.edu/magazines/vanderbilt-magazine/2009/03/recycled- anesthetic-technology-saves-dollars-environment/. 127. Chakladar A, White S. Unnecessary electricity consumption by anaesthetic room monitors. Anaesthesia. 2010;65(7):754-5. 128. NSW Government. Environment, Climate Change and Water. Environmental benefits of recycling. June 2010. [cited 15 June 2015]. Available from: http://www.environment.nsw.gov.au/resources/warrlocal/100058-benefits-of- recycling.pdf.

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173. Daufin G. An introduction to the commercially available surface finishes of stainless steels and notes on their corrosion resistance. Bulletin-Federation Internationale de Laiterie (Belgium). 1985;189:3-12. 174. Honess C, Corus R, Harrison A. British Stainless Steel Industry (BSSA). Importance of surface finish in the design of stainless steel. August 2006 [cited 28 June 2015]. Available from: http://www.bssa.org.uk/cms/File/surfacefinishbssaVer2.pdf 175. Stryker. Industry-leading medical device reprocessing and remanufacturing. 2014. [cited 20 June 2015]. Available from: http://sustainability.stryker.com. 176. Bhutta MF. Fair trade for surgical instruments. British Medical Journal. 2006;333(7562):297-9. 177. Nadvi K. Collective efficiency and collective failure: the response of the Sialkot surgical instrument cluster to global quality pressures. World Development. 1999;27(9):1605-26. 178. Millennium Development Goals Indicators. The official United Nations site for the MDG Indicators. Data availability by country - Pakistan. 2014 [cited 21 June 2015]. Available from: http://mdgs.un.org/unsd/mdg/Data.aspx. 179. Schwaitzberg S. The emergence of radiofrequency identification tags: applications in surgery. Surgical Endoscopy and Other Interventional Techniques. 2006;20(8):1315-9. 180. Sustainable Development Unit. Making you a Good Corporate Citizen. 2015 [cited 20 June 2015]. Available from: http://www.sduhealth.org.uk/gcc/. 181. McGain F, Sussex G, O'Toole JE, Story D. What makes metalware single-use? Anaesthesia and Intensive Care. 2011;39(5):972-3. 182. Rutala W, Weber D. Disinfection, sterilization, and control of hospital waste. In: Mandell G, Bennett J, Dolin R, editors. Principles and Practice of Infectious Diseases. 2. Sixth ed. Philadelphia, Pennsylvania: Elsevier, Churchill Livingstone; 2005. p. 3331-43. 183. Weidema BP, Bauer C, Hischier R, Mutel C, Nemecek T, Reinhard J, et al. Ecoinvent Centre. Swiss Centre for Life Cycle Inventories. Overview and methodology. Data quality guideline for the ecoinvent database version 3. 2014 [cited 21 June 2015]. Available from: http://www.ecoinvent.org/files/dataqualityguideline_ecoinvent_3_20130506.pdf. 184. BPI Boedeker. How to identify plastic materials using the burn test. [cited 30 June 2015]. Available from: http://www.boedeker.com/burntest.htm. 185. Life Cycle Strategies Pty Ltd [cited 30 June 2015]. Available from: ww.lifecycles.com.au/web/. 186. National Transport Commission Australia. Carbon Dioxide Emissions from New Australian Vehicles 2012. March 2013 [cited 7 July 2013]. Available from: http://www.ntc.gov.au/Media/Reports/(7D7B720E-DA94-7518-9F26- 2B14367ED1C9).pdf. 187. Melbourne Water. Water Data: Water use for Melbourne 2014 [cited 13 March 2015]. Available from: http://www.melbournewater.com.au/waterdata/wateruse/Pages/default.aspx. 188. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi‐Shin Kuo D, et al. Carbon footprint of robotically‐assisted laparoscopy, laparoscopy and laparotomy: a comparison. The International Journal of Medical Robotics and Computer Assisted Surgery (epub ahead of print) 2015;10.1002/rcs.1640. .

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189. McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single-use central venous catheter insertion kits. Anesthesia and Analgesia. 2012;114(5):1073-80. 190. Levin M. Handbook of fiber chemistry. Third Edition. Boca Raton, Florida, USA: CRC Press; 2006. 191. The Engineering Toolbox. The specific heat of metals [cited 17 Mar 2015]. Available from: http://www.engineeringtoolbox.com/specific-heat-metals- d_152.html. 192. Schneider PM. New technologies and trends in sterilization and disinfection. American Journal of Infection Control. 2013;41(5):S81-S6. 193. Huey D. Decreasing autoclave sterilization in 34 ambulatory clinics: How one health system used a multi-disciplinary team approach to develop standardization. American Journal of Infection Control. 2014;42(6):S9. 194. Chandrasekhar IS. "Estimation of Capacity and Utilization of Sterilization Department in KLE’S Dr. Prabhakar Kore Hospital, MRC Belgaum," M.S. thesis. Belgaum, India: KLE University, Belgaum, Karnataka; 2012. 195. Grant T, James K, Dimova C, Sonneveld K, Lundie S. Report for life cycle assessment of packaging waste management in Victoria. New South Wales Government Department of Environment and Conservation. Unpublished report by the Centre for Design at RMIT, the Centre for Packaging, Transportation and Storage at Victoria University and the CRC for Waste Management and Pollution Control, Melbourne, Australia 1999 [cited 20 Aug 2015]. Available from: http://f.nanafiles.co.il/Upload3/12007/forummessageattachments/forummessagefile_1 413231.pdf. 196. Dettenkofer M, Kuemmerer K, Schuster A, Mueller W, Muehlich M, Daschner FD. Environmental auditing in hospitals: first results in a university hospital. Environmental Management. 2000;25(1):105-13. 197. Practice Greenhealth. Topics. Waste [cited 1st August 2015]. Available from: http://www.practicegreenhealth.org/topics/waste. 198. Goldberg ME, Vekeman D, Torjman MC, Seltzer JL, Kynes T. Medical waste in the environment: do anesthesia personnel have a role to play? Journal of Clinical Anesthesia. 1996;8(6):475-9. 199. Tudor TL, Barr SW, Gilg AW. Strategies for improving recycling behaviour within the Cornwall National Health Service (NHS) in the UK. Waste Management & Research. 2007;25(6):510-6. 200. Tudor T, Barr S, Gilg A. Linking intended behaviour and actions: A case study of healthcare waste management in the Cornwall NHS. Resources, Conservation and Recycling. 2007;51(1):1-23. 201. Jones D, Story D, Clavisi O, Jones R, Peyton P. An introductory guide to survey research in anaesthesia. Anaesthesia and Intensive Care. 2006;34(2):245. 202. Australian and New Zealand College of Anaesthetists (ANZCA). ANZCA/ASA workforce report. Supply and demand for anaesthesia services. ANZCA, 2009. 203. Dillman DA, Smyth JD, Christian LM. Internet, mail, and mixed-mode surveys: the tailored design. 3rd ed. New Jersey, USA: Wiley; 2009. 204. The Royal College of Anaesthetists. Census Report 2010 [cited 2nd May 2011]. Available from: http://www.rcoa.ac.uk/docs/Censusreport-final.pdf 205. Vassar College, New York, U.S.A. Vassar Stats: Website for Statistical Computation. The confidence interval of a proportion. [cited 1 Aug 2015]. Available from: http://faculty.vassar.edu/lowry/VassarStats.html

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206. Newcombe RG. Two‐sided confidence intervals for the single proportion: comparison of seven methods. Statistics in medicine. 1998;17(8):857-72. 207. Wilson EB. Probable inference, the law of succession, and statistical inference. Journal of the American Statistical Association. 1927;22(158):209-12. 208. Lang TA SM. How to report statistics in medicine: annotated guidlines for authors, editors, and reviewers. American College of Physicians, Philadelphia,. 2nd ed. Philadelphia, Pennsylvania, USA. 2006. 209. Ajzen I. The theory of planned behavior. Organizational behavior and human decision processes. 1991;50(2):179-211. 210. SPI. The Plastics Industry Trade Association. Resin Identification Code. 2015 [Cited 8 Aug 2015]. Available from: http://www.plasticsindustry.org/AboutPlastics/content.cfm?ItemNumber=823. 211. Van Dooren AA. PVC as pharmaceutical packaging material. A literature survey with special emphasis on plasticized PVC bags. Pharmaceutisch Weekblad Scientific Edition The official journal of the Royal Dutch Association for the Advancement of Pharmacy (KNMP).1991(13):109-18. 212. The Vinyl Council of Australia. PVC Recovery in Hospitals. 2012 [ cited 7 Aug 2015]. Available from: http://vinyl.org.au/about-pvc/pvc-products/pvc-in- healthcare/pvc-recovery-in-hospitals. 213. McGain F, Jarosz KM, Nguyen MNHH, Bates S, O’Shea CJ. Auditing Operating Room Recycling: A Management Case Report. Anesthesia and Analgesia Case Reports. 2015;5(3):47-50. 214. Kubicki M, McGain F, O'Shea C, Bates S. Auditing an intensive care unit recycling program. Critical Care and Resuscitation. 2015;17(2):135-40. 215. Greenhealth P. Webinars Presenter: Kristian Hayes, Johns Hopkins Medicine [cited Dec 12 2013]. Available from: https://practicegreenhealth.org/webinars/hhi- less-waste-red-bag-waste-reduction. 216. Enzor N, Pierce J. Recycling steel from single‐use laryngoscope blades and Magill forceps. Anaesthesia. 2013;68(1):115-6. 217. McGain F, White S, Mossenson S, Kayak E, Story D. A survey of anesthesiologists' views of operating room recycling. Anesthesia and Analgesia. 2012;114(5):1049-54. 218. Australia and New Zealand Clinical Waste Management Industry Group. Code of Practice for the Management of Clinical and Related Waste, 5th ed. 2007 [cited 20 Jul 2015]. Available from: http://www.epa.sa.gov.au/xstd_files/Waste/Code of practice/Code of Practice 6th Edition.pdf. 219. Material Systems Laboratory, Massachusetts Institute of Technology. Life cycle assessment of hand drying systems. [cited 10 Jan 2014]. Available from: http://msl.mit.edu/publications/HandDryingLCA-ExecutiveSummary.pdf. 220. Australian Bureau of Statistics 2012. 9208.0 Survey of Motor Vehicle Use, Australia, 12 months ended 30 June 2012 [cited 27 July 2015]. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/9208.0. 221. Riedel LM. Environmental and financial impact of a hospital recycling program. Journal of the American Association of Nurse Anesthetists. 2011;79(4 Suppl):S8-S14. 222. Waste Management Association of Australia, Biohazard Waste Industry of Australia and New Zealand. Industry Code of Practice for the Management of Biohazardous Waste (including Clinical & Related wastes) 2014 [cited 8 Aug 2015]. 7:[Available from: http://www.wmaa.asn.au/scripts/cgiip.exe/WService=WMAA/ccms.r?pageid=10345.

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Minerva Access is the Institutional Repository of The University of Melbourne

Author/s: McGain, Forbes

Title: Environmental sustainability in hospitals: an exploration within anaesthetic and intensive care settings

Date: 2015

Persistent Link: http://hdl.handle.net/11343/59540

File Description: Environmental sustainability in hospitals: an exploration within anaesthetic and intensive care settings

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REVIEW ARTICLE A Comparison of Reusable and Disposable Perioperative Textiles: Sustainability State-of-the-Art 2012

Michael Overcash, PhD

Contemporary comparisons of reusable and single-use perioperative textiles (surgical gowns and drapes) reflect major changes in the technologies to produce and reuse these products. Reusable and disposable gowns and drapes meet new standards for medical workers and patient protection, use synthetic lightweight fabrics, and are competitively priced. In multiple science- based life cycle environmental studies, reusable surgical gowns and drapes demonstrate substantial sustainability benefits over the same disposable product in natural resource energy (200%–300%), water (250%–330%), carbon footprint (200%–300%), volatile organics, solid wastes (750%), and instrument recovery. Because all other factors (cost, protection, and comfort) are reasonably similar, the environmental benefits of reusable surgical gowns and drapes to health care sustainability programs are important for this industry. Thus, it is no longer valid to indicate that reusables are better in some environmental impacts and disposables are better in other environmental impacts. It is also important to recognize that large-scale studies of comfort, protection, or economics have not been actively pursued in the last 5 to 10 years, and thus the factors to improve both reusables and disposable systems are difficult to assess. In addition, the comparison related to jobs is not well studied, but may further support reusables. In summary, currently available perioperative textiles are similar in comfort, safety, and cost, but reusable textiles offer substantial opportunities for nurses, physicians, and hospitals to reduce environmental footprints when selected over disposable alternatives. Evidenced-based comparison of environmental factors supports the conclusion that reusable gowns and drapes offer important sustainability improvements. The benefit of reusable systems may be similar for other reusables in anesthesia, such as laryngeal mask airways or suction canisters, but life cycle studies are needed to substantiate these benefits. (Anesth Analg 2012;114:1055–66)

erioperative gowns and drapes are available in reus- American National Standards Institute and the Association able or disposable alternatives. Comparison of the for the Advancement of Medical Instrumentation (AAMI) Preusable and single-use alternatives in the operating issued new testing standards for medical gowns and room (OR) has focused primarily on gowns, even though drapes in 2003.5 This led to the introduction of gowns and these comprise only about 30% of the weight of the surgical drapes that comply with this standard. Experimental textiles used. The criteria for evaluating perioperative studies before 2000 of liquid and bacterial protection and gowns and drapes include1–3 (1) protection of health care infection with either reusable or disposables have limited workers and patients from surgical site or nosocomial relevance to currently available perioperative textiles. infections, (2) comfort, (3) economics, (4) environmental life The early but frequently cited studies6–15 often (1) com- cycle analysis, and (5) jobs. pared materials now considered obsolete (cotton, Literature was completely reviewed with Medline and cotton/polyester, muslin, pulp), (2) used tests that the Web of Science using the descriptors surgical gowns, cost of Food and Drug Administration and independent labora- surgical gowns, and reusable versus disposable surgical tories demonstrated to produce inadequate results, (3) gowns. The main limitation in the current literature com- lacked transparency in whether similar functionality of paring reusables and disposables is the repetition of old, the gowns was being studied, and (4) excluded pub- now inadequate citations, which have coalesced into lished criticisms of the original results. 4 widely held perceptions. The evolution of gowns and It is generally accepted that these older studies do not drapes, driven by new textile technologies and new re- apply to currently available products.2,3,16,17 The removal quired testing standards, means that we must set aside of older studies does not reflect badly on this earlier work, those comparisons of liquid and bacterial protection that do but simply recognizes that these do not apply to currently not reflect these changes. We should only use studies that available products. Older studies also reflect economic, 1,3,5 cover current textile products and standards. The new environmental, and manufacturing conditions that may lack relevance to contemporary products. The following From the Industrial and Manufacturing Engineering and Department of discussions are based primarily on contemporary studies in Mechanical Engineering, Wichita State University, Wichita, Kansas. Accepted for publication January 23, 2012. reusable and disposable perioperative textiles. Unfortu- The author declares no conflicts of interest. nately, there are so few recent homogeneous studies of Reprints will not be available from the author. gown and drape technology that quantitative meta-analysis Address correspondence to Michael Overcash, PhD, Industrial and Manu- was not feasible. Instead, a qualitative comparison of facturing Engineering and Department of Mechanical Engineering, Wichita reusable and disposables was done for categories such as State University, 1845 Fairmount, Wichita, KS 67260-0035. Address e-mail to [email protected]. comfort, protection, and economics, using health care ex- Copyright © 2012 International Anesthesia Research Society perts in these products to capture the central conclusions DOI: 10.1213/ANE.0b013e31824d9cc3 on similarities and differences.

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REVIEW ARTICLE

compared with disposable level 3). This evidence-based Table 1. Recommendation of Gowns for Various 17 Surgical Conditions (Telford and Quebbeman22) comparison is an appropriate basis for selecting perioperative textiles. Informed decisions on single-use versus a Surgical conditions reusable textiles cannot be made for products with different <100 mL of blood >100 mL of blood loss levels of protection. Operative site loss and <2 h duration and >2 h duration Considering the large number of infection factors in the Head and neck Standard gown Reinforced gown OR,1 the actual role of gowns and drapes in surgery, and Chest Reinforced gown Plastic reinforced gown Abdomen Plastic reinforced gown Plastic reinforced gown the ability to meet modern standards for control of penetra- Perineum Reinforced gown Plastic reinforced gown tion, there is little difference between currently available Extremity Reinforced gown Plastic reinforced gown reusable versus disposable gowns.3,16 The Centers for Dis- Skin and Standard gown Plastic reinforced gown ease Control (CDC)29 and others1 concluded that no data subcutaneous suggest important differences in reusable versus disposable Generally, it appears that a standard gown is level 2, a reinforced gown is level gowns and drapes in preventing surgical site infections.3 3, and a plastic reinforced gown is level 4. Furthermore, the general lack of any documented incident of a Applies to surgeon and surgical assistant; other operating room staff should wear protection 1 level below those designated here. bacterial contamination from permeation of a gown barrier reflects the similarity of reusable and disposable textiles in PROTECTION OF HEALTH CARE WORKERS AND protecting health care workers and patients.1,2,30,31 PATIENTS FROM SURGICAL SITE OR Preferences among health care personnel for disposal NOSOCOMIAL INFECTIONS products do not reflect the available scientific information Surgical gowns have a critical role in infection control.3,18 and are often based on qualitative marketing claims. It is a Contemporary uses for and types of gowns and drapes challenge to help decision-makers understand the near have advanced substantially. Laufman et al.1 grouped the equivalency of modern reusable and disposable textiles. large number of published surgical site infection risk There is also misconception related to multiple uses of a factors into 5 categories based on earlier studies16,19,20: (1) reusable gown or drape. For reusables, maintenance of surgical team discipline in aseptic practices, (2) patient permeability protection after each cycle of use2,32,33 directly health status, (3) preventative drugs and antiseptics, (4) addresses the issue of continuing protection. Each gown or design of the OR and procedures, and (5) protective devices drape should be routinely tested by physical inspection and of which gowns and drapes are 1 of 7 devices (sterilization, repellency testing. Greater access to the reusable service gas/vacuum, air-handling, mechanical and electrical de- data showing continued fluid protection can be effective in vices, instrumentation, and gloves) in the OR. reducing the concerns among health care workers. In Thus, the actual outcome of protecting patients and addition, reliable logging systems track the number of uses, health care workers (or the failure of protection as an permitting removal from service at the specified life time. infection) by means of gowns and drapes is only partially due to the properties of these textiles. This contributes to the challenges of actually attributing infection to reusable COMFORT or disposable gowns or drapes. Comfort of gown users must be compared for gowns of the Surgical gown selection should be based on the type of same rating (i.e., level 3). Data on comfort measurements surgery, because this dictates the level of required protec- are not widely available.33 However, heat barrier and tion.3 Lewis and Brown21 and Telford and Quebbeman22 moisture transmission (“breathability”) are quantifiable list the surgical procedures and different levels of protec- comfort-related measurements.21 Other comfort factors tion that are required, as shown in Table 1, a view shared such as improper fit, stiffness, noise, and roughness are by others.16,23 The transition from inpatient to outpatient largely not measured. It is reasonable to assume that these facilities, and the rapid development of minimally invasive other comfort or appearance factors can be designed into surgery23 also affect the comparison between reusable and the gown or drape and thus be indistinguishable for disposable gowns and drapes. Unfortunately, few studies disposables and reusables at the same level of protection. have tested the ability of contemporary gowns and drapes Lewis and Brown,21 using thermal manikins and standard to reduce infection. comfort thermophysiologic models,34,35 showed that 2 re- The AAMI together with the American National Stan- usable and disposable gowns achieved the comfort range dards Institute developed new standards24 for liquid and for operations exceeding 3 hours, typical for the use of level viral protection with medical textiles, based on anticipated 4 gowns. All 7 of the reusable and disposable gowns tested exposure (type of surgery). A 4-level hierarchy for gowns were in the core temperature range of comfortable for and drapes was used. The highest protection, level 4, uses operations less than 1 hour, now a common occurrence. both liquid and viral (hepatitis B, hepatitis C, and human Mittermayer et al.2 examined 16 reusable and 11 dispos- immunodeficiency virus) penetration tests.25,26 Next in able gowns. He found for reusables (11 gowns) that 1-, 2-, decreasing order of liquid protection are levels 3, 2, and 1, and 3-ply woven gowns with laminates were in the accept- which follow standards set by the American Association of able to very good comfort range, based on a moisture vapor Textile Chemists and Colorists.27,28 The level of liquid transmission rate Ͻ8m2 Pa/W. Seven disposable gowns of protection corresponds to resistance to penetration of blood 1- and 2-ply nonwovens with film laminates were in the and other body fluids at increasing liquid pressures. same comfort range (moisture vapor transmission rate Ͻ8 It is necessary that textile comparisons be made at the m2 Pa/W). These quantitative measurements of comfort same level of penetration protection (e.g., reusable level 3 is were comparable for disposable and reusable products.

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Comparison of Reusable and Disposable Perioperative Textiles

Conrady et al.36 used a more rigorous, user-comparative explain the higher reusable use percentages in Europe effectiveness study of reusable and disposable gowns worn (50%) versus the US (10%),41 rather than any fundamental by surgeons and surgical technicians. The surgical teams cost differences. Neither disposable nor reusable systems conducted 119 surgical procedures in 2 hospitals and have eliminated the other product type. This suggests compared both types of gowns by wearing each type in similar costs because significant cost differences would various procedures. This is the only direct evidence-based have driven the market to essentially zero for the expensive study of gown comfort currently reported. The gowns were option. generally level 2 and 3 gowns, based on whether it was Many hospitals undertake economic analyses before minor or major surgery, respectively. Surgeons and techni- product purchase. Unfortunately, there is no independent cians rated the reusable gowns as more comfortable. access to these data. One can only look at the market and For gown comfort, the available field data and anecdotal conclude that because both reusable and disposable surgi- discussions with manufacturers and users suggest that cal gowns and drapes remain on the market, these costs current reusable gowns, at level 2 and 3 as typical of short must remain competitive. Lastly, the ideal mix may not be procedures, are more comfortable than disposable gowns. exclusively reusable versus disposable textile. Laufman et At level 4 or in long procedures, reusable gowns with al.1 anticipated the evolution of hybrid surgical packages, breathable laminates are more comfortable than disposable which are now in the market, in which specific reusable gowns. and disposable items are selected based on economic and environmental factors, creating a more sustainable surgical ECONOMICS package. Economic comparisons of perioperative reusable and disposable textiles often include unspecified factors, making quantitative comparison difficult.1,3,4,7,37,38 Also, laundry ENVIRONMENTAL LIFE CYCLE ANALYSIS and sterilization at many large hospital facilities are now Life cycle inventory is the quantitative measurement of provided by an external vendor, rather than performed energy and emissions (known as a life cycle inventory) that in-house. Approximately 1% of the hospitals with reusable occurs in the manufacture, use, and disposal of surgical perioperative textiles process these in-house (personal com- gowns and drapes. This encompasses all aspects from oil munication, J. Hamilton, SRI Surgical, 2010). This might and ore to the finished gown or drape, the cleaning and make economic comparison easier because purchase and sterilizing of reusable products, and the final end-of-life contracts are distinct costs, but that has not been evident in stage for reusables and disposables. Life cycle impact published studies. assessment is the quantification of each environmental A major difference between reusables and disposables impact, such as carbon footprint, human toxicity, and has been the purchasing systems for these products. Reim- stream eutrophication, based on the life cycle inventory bursements to hospitals for volume of purchases (of which results. gowns and drapes are not a large percentage) are charac- During the use and at the end-of-life stage, surgical teristic of the disposable market. These cash flows are often wastes (blood, tissue, fluid) are produced for both dispos- not transparent, nor do these necessarily accrue to the able and reusable gowns and drapes. The surgical waste departments needing the gowns and drapes. Reusables are and disposable gowns are either sent to landfills, where more often provided on an annual or multiyear service only the surgical waste degrades (modern gowns are contract. Thus, a comprehensive multiyear evaluation of essentially inert), or incinerated, where the majority of disposables versus reusables has not been performed, and carbon is converted to carbon dioxide. Currently, landfill is is unlikely to occur. the dominant route for disposables and is analyzed in these There are only 3 published economic studies of contem- life cycle studies. Reusable gowns are washed to produce porary surgical gowns, all non-United States (US). In laundry wastes that are treated to achieve receiving water conducting a comprehensive purchasing study in Turkey, standards. Reusable gowns at end-of-life are typically Baykasoglu et al.38 found that the cost of reusable gowns transferred to other uses (less developed countries or ($8 per surgical package) was approximately 25% of the alternative applications) and thus only the treatment of the cost of disposable gown costs ($33 per surgical package). surgical waste (blood, tissue, fluid) is included. Lizzi et al.,39 conducting a study in an Argentinean hospi- In 1998, the CDC hypothesized that there were no tal, found that reusables cost $16 per surgical package, differences in life cycle impacts between reusable and whereas disposables cost $9 per surgical package. Martec disposable gowns.29 Since 1993, there have been 5 life cycle Corporation, a Canadian engineering firm, studied the use studies of protective surgical gowns and 1 study of worker of gowns at the National Health Service in the United coveralls in nuclear power plants.11,42–46 These studies do Kingdom.40 They found disposables were 4% lower in cost not support the CDC hypothesis conclusion. These life than reusables, which was within the margin of error of the cycle studies typically compare a fixed number of dispos- study. No detailed multihospital economic study is available gowns (typically 50–75) with a single reusable gown able. The lack of clear data in either direction suggests that used 50 to 75 times. As a result, these studies compare the reusable and disposable surgical gowns and drapes are manufacturing, sterilization, and transport of disposables probably similar in costs with most variations attributable to the manufacture, laundry, sterilization, and transport to local contract negotiations. cycles for reusables. These studies show that the environ- Cost differences between reusables and disposables may mental impact of transport for reusables is modest. For be overshadowed by personnel preferences. This would example, in the Environmental Clarity report,46 transport

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REVIEW ARTICLE accounts for Ͻ2.2% of overall gown life cycle energy at 1000 water required for laundry and sterilization, precluding miles per laundry cycle. comparison with other life cycle studies. As shown in Table Analysis of life cycle data is often limited by the amount 3, subsequent comparisons of water use in the manufactur- of transparent information in the reports. This does not ing of disposable gowns by the Royal Melbourne Institute suggest that the conclusions are flawed, but simply that of Technology (RMIT), the European Textile Service Asso- most published studies lack the quality of life cycle data ciation (ETSA), and Environmental Clarity suggest that reporting required for quantitative analysis of periopera- McDowell underestimated the water use by a factor of 13 to tive textiles. 800. Therefore, McDowell’s water estimates are likely in- Table 2 provides a comparison of the disposable and correct. Any of the corrected factors for water would reusable systems covered by each of the 6 life cycles, indicate more water use by disposables than reusables. whereas Table 3 shows the results of these studies. Table 4 Gown sterilization is discussed as a health risk factor by documents the life cycle factors missing from each study. McDowell, but does not appear to be in the environmental All 6 life cycle studies found that the reusable system life cycle. The report showed that higher energy was provided substantially better environmental profiles than needed for the disposable system (20 megajoule [MJ]/gown single-use systems. Selecting disposables instead of compa- and 42.5 MJ/lap drape) than the reusable system (5.8 rable reusables increased energy use and carbon footprint MJ/gown and 11 MJ/lap drape). by 200% to 300%, increased the water footprint by 250% to 330%, and increased solid waste from 38 kg to 320 kg per THE ETSA STUDY 1000 gown uses (a 750% increase). The ETSA conducted a life cycle study published in 2000.42 The functional unit of comparison was 1 reusable gown THE MCDOWELL STUDY (woven PET and Gore laminate) with disposable primary The oldest life cycle study is the comparison by McDow- packaging versus 1 disposable gown (nonwoven 50 wt% ell11 of a woven polyethylene terephthalate (PET) reusable PET and 50 wt% wood pulp) and a low-density polyethyl- gown and lap drape used over 75 cycles and a single-use ene barrier film plus disposable primary packaging, as disposable spunlace PET (50%)/wood pulp (50%) nonwo- shown in Table 2. No gown protection standard was cited, ven gown and lap drape. This 15-page report was pub- but from the general description, the reusable gown was lished in 1993, but the detailed data remain unavailable. probably level 3 and the disposable gown between levels 2 The study basis was 1 surgical procedure in which 3.7 and 3. The reusable gown was laundered for 75 cycles. gowns and 1.2 lap drapes were used. The report does not Transport for the reusables and disposables was specified. state the protection desired by the gown user, but the This report had a moderate amount of transparency, but gowns appear to be a level 2. The gowns predate the AAMI was often unclear in units (e.g., kg reusable gowns was standards for liquid protection and the advent of modern used, but in some instances appeared to be soiled gown and gowns meeting these standards. The weight of these gowns other places clean gown, a significant difference in weight). and drapes was not provided and so other comparative Few data on manufacturing and process are shown. An calculations were not possible. The report does not provide older reusable gown with cotton and PET was also studied, data on the supply chain and manufacturing processes of but because it is not currently meeting AAMI level 2, 3, and the disposable and reusable gowns. 4 standards, this gown was not included in this review. Despite these limitations, the report by McDowell is The ETSA report was the first to identify that greater frequently cited to support the claim that the manufactur- water use occurs in the manufacture of disposable gowns ing of the reusable gown produces higher volatile organic compared with the water used in laundry and sterilization chemical (VOC) emissions (a part of the photochemical of a reusable gown, as shown in Table 3. The purpose of the ozone impact category) from dyeing and finishing com- water use in the supply chain of either gown was not given. pared with disposables. Because both the disposable and The energy for the supply chain, manufacture, use, and reusable systems use PET, it is unclear why the dyeing and end-of-life of the reusable gown system (75 cycles) was finishing for a given color (such as pink or blue) should be lower (11–15 MJ/gown) than that of the disposable gown substantially different. Because the reusable is dyed only (75 gowns) (29–35 MJ/gown). The reusable gowns re- once per 75 uses, whereas the disposables are dyed 75 times quired 42% less energy and 32% less water than disposable for the same 75 uses, the VOC emission difference is even gowns, as shown in Table 3. less clear. Two later studies evaluated VOC emissions and found that manufacturing of disposable gowns produced 4 THE RMIT STUDY to 5 times larger VOC emissions than the manufacturing of The RMIT University conducted a life cycle inventory reusable gowns.43,44 It would seem that citing the McDow- study published in 2008.43 They used the surgical package ell life cycle study as having greater VOC for reusable as a functional unit, although it was only the most basic gowns and drapes is inconsistent with the mutual use of package (gown and towel). The reusable gown was be- dyeing PET and the entire supply chain aggregation of tween a level 2 and level 3, whereas the disposable was VOC measured as a photochemical ozone impact category. probably a level 3. The reusable gown and towel were McDowell reports the reusable perioperative textile wa- assumed to be usable for 127 cycles. This is significantly ter use as 3.9 gallons per gown and 10.7 gallons per lap higher than the 50 to 75 cycles found in current practices drape, far more than the 0.14 gallons per gown and 0.93 where testing for AAMI compliance standards is used. gallons per lap drape required for disposables. The report Their sensitivity analysis showed that their overall energy does not distinguish water required in manufacturing from differences were still present at 50 cycles, but the 127 cycles

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318 a 2012 May Textiles Perioperative Disposable and Reusable of Comparison

Table 2. Descriptions of Life Cycle Inventory Studies of Reusable and Disposable Textiles

• McDowell11 (1993) ETSA42 (2000) RMIT43 (2008) MnTAP44 (2010) UniTech45 (2010) Environmental Clarity46 (2010) oue114 Volume Reusables 1 surgery, 3.7 gowns, and 1 large gown, woven level 1 surgical package, washed 1 gown washed 50 cycles 1 gown for nuclear power 1000 level 3 gown uses, 1.2 lap drapes, washed 3 or 4, washed 75 127 cycles plant radiological washed 75 cycles 75 cycles cycles protection, 100 cycles 1 large gown, woven PET, 546 g ϭ 389 g PET and 1 gown, woven (94% PET/6% 1 large gown, woven PET Woven nylon, weight not Critical areas, Gore fabric; likely level 2 157 g Gore material cotton) (between a level 2 with polyethylene given noncritical areas, woven PET: • modeled as polyurethane and level 3), 287 g laminate, 407 g, level 3 1 gown 0.49 kg ubr5www.anesthesia-analgesia.org 5 Number 1 lap drape, woven PET Cotton towel, 73.5 g Disposable paper autoclave

indicator tape, 5 g CCDHB Public12December2018-5FORINFORMATION Primary disposable Not defined Polypropylene nonwoven Not defined Not defined Paper CSR wrap and insert, packaging CSR wrap, 12.8 g 22.3 kg Disposable paper and Outer bag, half paper half EMAC outer bag, 12.5 kg LDPE, 58 g HDPE, 14.9 g Secondary disposable LDPE bag, 0.33 kg packaging Tertiary disposable LDPE film, 0.0033 kg packaging Not given Total 604 g (1.33 lb.) Total 393.7 g (0.87 lb.) Total 407 g (0.9 lb.) 411 (0.91 lb.) Total 490 kg (1100 lb.) Disposables 1 large gown, spunlace 1 large gown, nonwoven 1 surgical package 1 large gown, polypropylene 1 gown for nuclear power 1000 level 3 gowns 50% PET, 50% wood level 3 or 4 nonwoven, 137 g, level 3 plant radiological 319 pulp protection, single-use 230 g ϭ 104 g paper 1 gown (approximately level Nonwoven polyvinyl critical areas, polypropylene film; pulp, 104 g PET, 22 g 3), nonwoven alcohol noncritical areas, SMS PET: 1 LDPE film polypropylene, 222 g gown 0.243 kg Paper towel, 13.9 g Primary disposable Not defined Not defined Nonwoven polypropylene Not defined Not defined SSMS PP CSR wrap, packaging CSR wrap, 12.8 g 22.1 kg Inset paper, 3.1 kg Paper and LDPE, 58 g Outer bag, half paper and LDPE outer bag, 13.9 kg half HDPE, 21.9 g Secondary disposable LDPE bag, 3 kg; boxboard 35 packaging kg Tertiary disposable LDPE film, 0.33 kg packaging Not given Total 288 g (0.63 lb.) Total 271 g (0.60 lb.) Total 137 g (0.3 lb.) 266 g (0.59 lb.) Total 243 kg (535 lb.) Allocation Not defined Mass in most places, Mass allocation inferred Mass allocation inferred Literature values, so Mass allocation system expansion for from the databases cited from the databases cited mass allocation is recycle of disposables assumed Transport loop Reusable Not defined Ship to Europe (20, 000 Truck in China (100 km), Truck from manufacture to Not defined Fabric movement in US (3320 km), truck to hospital ship to Melbourne (9617 hospital (2000 km) km) to Mexico and return (3000 km), truck to km), truck to (959 km) to distribution in laundry (200 km) manufacturer (30 km), US (2800 km), all truck truck to laundry (30 km) (Continued) 1059 CCDHB Public 12 December 2018 - 5 FOR INFORMATION

REVIEW ARTICLE ϭ ϭ are used in this review because most of their results are for this functional unit, as shown in Table 3. The RMIT report

(2010) had greater transparency than the previous 2 studies, but it

46 is limited to the discussion of the laundry and sterilization of reusable gowns. The surgical package with 2 items was not separated to provide the reader with specific gown and towel data. This is a particular problem because the gown and towel (for both disposable and reusable) are made central sterile room; LDPE

ϭ from different materials. Most data are in percent of total oxide for sterilization; lost instruments from surgery manufacturing waste, gas capture wastewater treatment of surgical wastes to US (11, 700 km), distribution in US (2200 km) Environmental Clarity energy, but the actual total is never given. In addition, Water for manufacturing; ethylene Water for laundry/sterilization and Landﬁll of gown and surgical detailed information on laundry and sterilization are given per kilogram fabric, but the units of the summary are per surgical package and it is unclear how these transforma-

(2010) tions of data were done.

45 The RMIT study found that reusable textiles, after 127 cycles, required less water (2.9 gallons per gown and towel) than disposable textiles (3.7 gallons per gown and towel), UniTech

spun bond-spunbond-melt blown-spun bond polypropylene; NY giving similar results as ETSA, as shown in Table 3. Using Not deﬁned Truck in China (800 km), ship ϭ their sensitivity analysis, the water use of the reusable and disposables was approximately equal at 75 to 85 cycles, the more typical reuse range for such systems, although the

Minnesota Technical Assistance Program; CSR details of the water use for the disposable supply chain ϭ (2010) were not presented. The energy use could only be quanti-

44 fied by back-calculating from the CO2 (global warming) emissions, a clear example of low transparency. The reus-

MnTAP able surgical package had lower energy requirements (8.5

port (800 km), ship to port (11, 670 km), railhospital to (2870 km) MJ/gown and towel) than the disposable system (16.6 Truck from manufacturer to MJ/gown and towel), as shown in Table 3. RMIT determined the cumulative VOC emissions for these 2 surgical packages, when expressed as photochemical oxidation

spun bond-melt blown-spun bond; SSMS PP impact normalized as ethylene. The disposable surgical

ϭ package was 0.46 g photochemical oxidation per surgical (2008)

43 package, whereas the reusable was 0.16 g photochemical oxidation per surgical package, a substantially different

RMIT result from the early McDowell life cycle study. The soiled

km), ship to Melbourne (18, 757 km), truck to distribution warehouse (30 km), truck to hospital (50 km) gown weight compared with the clean gown was estimated Royal Melbourne Institute of Technology; MnTAP Ship NY to Honduras (3165

ϭ by the authors and was given as 2.6 kg soiled gown/kg clean gown. This is approximately 100% larger than recent direct measurements.46

(2000) THE MINNESOTA TECHNOLOGY ASSISTANCE ethyl methacrylate copolymer; SMS 42 PROGRAM STUDY ϭ Van den Berghe et al.44 at the Minnesota Technology ETSA Assistance Program reported a life cycle study in 2010. The Landfill Packaging and gown landfill Incineration Dissolution, Fig. 2 Landfill Packaging landfill Incinerationcomparative Not defined systems Reuse as gown outside US; were a reusable woven PET gown with low-density polyethylene laminate and a nonwoven polypropylene gown, both level 3, as shown in Table 2. The reusable gown was cycled 50 times. This study is not (1993) European Textile Service Association; RMIT readily available as a report and so only slides from 11 ϭ presentations are available for use. Results are expressed in

CO2eq emissions, thus these were back-calculated to esti- high-density polyethylene; EMAC

ϭ mate energy in MJ. As a result, this study currently has low McDowell recovery recovery transparency and very limited detailed results. The study by the Minnesota Technology Assistance Program cataloged energy for these 2 gowns. The reusable

United States. gown was noticeably lower in life cycle energy (4

ϭ MJ/gown) than the disposable gown (13 MJ/gown). No water evaluations were included. VOC emissions were 5

polyethylene terephthalate; ETSA times higher with disposable gowns than reusable gowns. in life cycle ϭ Disposables Reusables Disposables Incineration with energy Reusables Incineration with energy Disposable Not deﬁned Not deﬁned This supports the RMIT life cycle results and does not Table 2. ( Continued ) Other items included End-of-life PET low-density polyethylene; HDPE New York; US support the McDowell life cycle results.

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320 a 2012 May Textiles Perioperative Disposable and Reusable of Comparison

Table 3. Comparative Results of Life Cycle Inventory Studies of Reusable and Disposable Textiles McDowell11 (1993) ETSA42 (2000) RMIT43 (2008) MnTAP44 (2010) UniTech45 (2010) Environmental Clarity46 (2011)

• Reusables Package, 3.7 PET gowns; Gown: PET/PU (0.546 kg) Package: PET/cotton Gown: PET with PE ﬁlm (0.41 Gown for nuclear power Gown: critical areas Gore fabric, oue114 Volume 1.2 PET lap drapes, 75 cycles; between gown (0.287 kg), kg), 50 cycles; level 3 plant radiological noncritical areas woven PET, 75 cycles (no masses level 3 and 4 cotton towel (0.074 protection, woven 75 cycles; level 3 (0.49 kg) given); likely level 2 kg), 127 cycles; nylon (0.41 kg), 100 between level 2 and 3 cycles Process energy values Process energy values Process energy values, all • based on gown use ubr5www.anesthesia-analgesia.org 5 Number Washer 3.2 MJ natural gas/kg 5.4 MJ natural gas/kg Energy improvement laundry, 1.5 clean gown, 80°C, clean linen, 80°C MJ natural gas/kg clean gown:

Table 4 and Fig. 10 Table 4-6 conventional laundry, 5 MJ CCDHB Public12December2018-5FORINFORMATION natural gas/kg clean gown 0.3 MJ electricity/kg 0.18 MJ electricity/kg Energy improvement laundry, 0.6 clean gown (based on clean linen MJ electricity/kg clean gown: 1.55-lb. soiled linen/lb. conventional laundry, 0.6 MJ clean linen), Table 4 electricity/kg clean gown Washer water use 17.3 kg/clean gown ϭ 1.6 gal./lb. soiled linen 3.4 gal./lb. clean gown 2.36 gal./lb. soiled laundry ϭ 2.5 gal./lb. soiled linen based on 40% recycle 3.6 gal./lb. clean gown (based on 1.55-lb. of 2.7 gal./lb. soiled soiled linen/lb. clean linen, Table 4-6 linen), Table 8 Dryer 6.6 MJ/clean gown ϭ 3.1 MJ natural gas/kg Energy improvement laundry, 10 321 12.0 MJ natural gas/kg clean linen, Table 4-8 MJ natural gas/kg clean gown: clean gown, Table 5 conventional laundry, 10 MJ natural gas/kg clean gown 0.36 MJ electricity/gown, 0.18 MJ electricity/kg Energy improvement laundry, 0.4 0.66 MJ electricity/kg clean linen MJ electricity/kg clean gown: clean gown conventional laundry, 0.4 MJ electricity/kg clean gown Total laundry 15 MJ natural gas/kg 8.5 MJ natural gas/kg 3–4 MJ/kg gown Energy improvement laundry, clean gowns, based on clean linen, 12.6 MJ natural gas/kg clean 1.55-kg soiled/kg clean summation gown: conventional laundry, 15 gown MJ natural gas/kg clean gown 0.85 MJ electricity/kg 0.36 MJ electricity/kg Energy improvement laundry, 1 clean linen clean linen MJ electricity/kg clean gown: conventional laundry, 1 MJ electricity/kg clean gown Steam sterilization 0.54–4.8 MJ natural gas/ 1.8 MJ natural gas/kg Not needed 0.44 MJ natural gas/kg clean kg clean linen clean linen, Table 4-10 gown 0.09 MJ electricity/kg 0.063 MJ electricity/kg clean clean linen, Table 4-10 gown Steam sterilization 1.9 gal. water/lb. clean 0.02 gal. water/kg clean linen water use linen, Table 4-10 Wastewater 0.072 MJ electricity/kg 1.2 MJ electricity/kg soiled treatment soiled linen (0.032 linen MJ/lb. soiled linen), Table 5-15 1061 (Continued) 1062

Table 3. (Continued) ARTICLE REVIEW McDowell11 (1993) ETSA42 (2000) RMIT43 (2008) MnTAP44 (2010) UniTech45 (2010) Environmental Clarity46 (2011)

www.anesthesia-analgesia.org End-of-life of surgical Incineration with energy Incineration Landﬁll Incineration Not included Reused pack or gown recovery Results Natural resource energya Natural resource energya Natural resource energya Natural resource Natural resource energya energya Manufacture, new 180 MJ/kg gown, Fig. 10 1.45 MJ/gown plus towel 78 MJ/gown ϭ 190 MJ/kg gown 86 MJ/gown ϭ 209 240 MJ/kg gown gown 127 cycles ϭ 180 MJ/ MJ/kg gown surgical gown plus towel ϭ 410 MJ/kg surgical gown plus towel, from Table 0-1 CCDHB Public12December2018-5FORINFORMATION and % from Fig. 6-1 Wash 2.3 MJ/surgical pack ϭ Table 2 5.8 MJ/kg surgical pack Dry 1.35 MJ/surgical pack ϭ 3.4 MJ/kg surgical pack Sterilize 1.35 MJ/surgical pack ϭ 3.4 MJ/kg surgical pack Total laundry/ 23.5 MJ/kg gown 12.6 MJ/kg surgical 5.6 MJ/kg gown (no sterilization) Energy improvement, 17.7 MJ/

322 sterilization pack kg clean gown: conventional, 21.9 MJ/kg clean gown Polypropylene CSR 0.78 MJ/surgical pack ϭ 0.67 MJ/clean gown ϭ 1.4 MJ wrap manufacture 2 MJ/kg surgical pack paper CSR/kg clean gown Outer bag, half 0.5 MJ/surgical pack ϭ 0.56 MJ/clean gown ϭ 1.1 MJ paper, half HDPE 1.3 MJ/kg surgical EMAC outer wrap/kg clean pack linen Transportation, new Not included 1.9 MJ/kg gown Incomplete 13.9 MJ/kg gown 14 MJ/kg clean gown gown Energy for functional 5.8 MJ/gown, 16 MJ/ 11.4–14.9 MJ/gown, 8.5 MJ/surgical pack ϭ 4 MJ/gown, 9.8 MJ/kg gown 220 MJ/gown 11.9 MJ/clean gown ϭ 24 MJ/ unit drape 21–27 MJ/kg gown, 22 MJ/kg surgical kg clean gown Table 1 pack, summation Water 11–17 kg/gown ϭ 2.9– 11 kg/gown and towel ϭ 0.38 kg/clean gown ϭ 0.2 4.5 gal./gown ϭ 2.2– 2.9 gal./gown and gal./kg clean gown 3.4 gal./lb. gown, towel ϭ 3.3 gal./lb.

NSHSA&ANALGESIA & ANESTHESIA Table 14 gown and towel Disposables Package, 3.7 50% pulp, Gown: PET/pulp (0.23 kg) Package: PP (0.222 kg)/ Gown: polypropylene nonwoven Gown for nuclear power Gown: critical areas 50% spunlace PET paper towel (0.014 kg) (0.14 kg); level 3 plant radiological polypropylene ﬁlm, noncritical gown, 1.2 50% pulp, protection, polyvinyl areas SMS PET; level 3 50% spunlace PET lap alcohol nonwoven (0.24 kg) drape (0.27 kg) Results Natural resource energy Natural resource energy Natural resource energy Natural resource energy Natural resource energy Manufacture 120–130 MJ/kg gown 15.2 MJ/surgical pack ϭ 57.5 MJ/gown ϭ 430 19.5 MJ/gown ϭ 80 MJ/kg 56 MJ/kg surgical MJ/kg gown clean gown pack, from Table 0-1 and % on Fig. 6-5 (Continued) a 2012 May Textiles Perioperative Disposable and Reusable of Comparison • oue114 Volume

Table 3. (Continued)

• McDowell11 (1993) ETSA42 (2000) RMIT43 (2008) MnTAP44 (2010) UniTech45 (2010) Environmental Clarity46 (2011) ubr5www.anesthesia-analgesia.org 5 Number CSR wrap Polypropylene, 0.9 MJ/ PP SMS, 1.5 MJ/clean gown ϭ surgical pack ϭ 3.3 6 MJ/kg clean gown MJ/kg surgical pack CCDHB Public12December2018-5FORINFORMATION Outer bag Half paper and half LDPE, 0.47 MJ/clean gown ϭ HDPE, 0.52 MJ/ 1.9 MJ/kg clean gown surgical pack ϭ 1.4 MJ/kg surgical pack Transportation Not included 2.6 MJ/kg gown Incomplete 6.8 MJ/kg clean gown Not included 20 MJ/kg clean gown End-of-life of surgical Incineration Landﬁll Incineration Dissolution and Landﬁll package or gown wastewater treatment Energy for functional 20 MJ/gown, 42.5 MJ/ 28–35 MJ/gown, 120– 16.6 MJ/surgical pack ϭ 13 MJ/gown, 95 MJ/kg gown 6050 MJ/gown 22.5 MJ/gown ϭ 92.5 MJ/kg unit drape 150 MJ/kg gown, 61 MJ/kg surgical clean gown Table 1 pack 323 Water 43 kg/gown ϭ 11.5 gal./ 14 kg/gown and towel ϭ 49 gal./lb. clean gown 0.8 kg/gown ϭ 3.3 kg/kg clean gown ϭ 18 gal./lb. 3.7 gal./gown and gown ϭ 0.4 gal./lb. gown gown towel ϭ 6.2 gal./lb. gown and towel, Table 5-1 Environmental 29% gown and 38% lap 42% nre; 32% water 51% nre, 78% water 31% nre 3.6% nre, 7% water 53% nre; 48% water reduction when drape selecting functional unit of reusable system, expressed as % of functional unit of disposable system (based on values per gown or functional unit) PET ϭ polyethylene terephthalate; PE ϭ polyethylene; ETSA ϭ European Textile Service Association; RMIT ϭ Royal Melbourne Institute of Technology; MnTAP ϭ Minnesota Technical Assistance Program; MJ ϭ megajoule; HDPE ϭ high-density polyethylene; CSR ϭ central sterile room; EMAC ϭ ethyl methacrylate copolymer; PP SMS ϭ polypropylene spun bond-melt blown-spun bond; LDPE ϭ low-density polyethylene. a nre ϭ natural resource energy; process energy is converted to nre using factor for delivering fuel to point of use and factor for energy generated per MJ fuel, natural gas factor 1.15, electricity factor 3.44. 1063 CCDHB Public 12 December 2018 - 5 FOR INFORMATION

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Table 4. Listing of Factors that Appear Missing in Life Cycle Studies of Reusable and Disposable Medical Textiles McDowell11 UniTech45 Environmental Missing elements (1993) ETSA42 (2000) RMIT43 (2008) MnTAP44 (2010) (2010) Clarity46 (2011) Manufacture of fabric XX life cycle Cut-sew-trim assembly X X X Transport X X (unclear transport in supply chain of disposables) Sterilization X X (disposables) X X (disposables) End-of-life X X (reusable) X (reusable) Capital equipment X X X X (reusable) X Packaging X (primary and X (secondary and X (primary and secondary) tertiary) secondary) Wastewater treatment X X X X Dyeing and ﬁnishing X X X ETSA ϭ European Textile Service Association; RMIT ϭ Royal Melbourne Institute of Technology; MnTAP ϭ Minnesota Technical Assistance Program.

THE UNITECH CORPORATION STUDY The surgical waste (fluid, tissue, blood) was measured in A fifth life cycle study was completed in 2010 by UniTech.45 the field. For the reusable gowns, the life cycle inventory This study examined worker coveralls in nuclear power includes this organic load (chemical oxygen demand) as plants. These gowns do not require water permeation treated in the aerobic municipal wastewater treatment protection, and are thus more like medical contact precau- plant. This life cycle inventory block included the energy tion garments. The reusable gown is made of woven nylon, and waste to return the nonevaporated water part (97.75%) whereas the disposable gown is of polyvinyl alcohol, 2 very of the laundry/sterilization water to regulatory-permitted different fabrics from surgical gowns. The reusable gown condition and thus was not counted as water consumed. was evaluated for 100 uses. The disposable gown is dis- The reusable gown, after 75 cycles, was routinely trans- solved at end-of-life and managed as a liquid. In addition, ferred to developing countries and used as a surgical gown. no sterilization is required. The same mass of surgical waste per gown or drape was The energy life cycle comparison they completed used in the disposable system and transferred to an anaer- showed 6050 MJ/gown for the disposable and 220 obic landfill, where it undergoes degradation to create MJ/gown for the reusables. The water use for the reusables methane and carbon dioxide. A general US profile of gas was 3.4 gallons/gown whereas the disposables was 49 capture and no gas capture at landfills was used to assess gallons/gown. The details of water use in the supply chain the impact of the degradation of the surgical waste in this were not provided. life cycle inventory. The disposable gown is essentially nondegradable polymer and so only the energy of landfill- THE ENVIRONMENTAL CLARITY STUDY ing a unit weight of gown plus decomposition of surgical Environmental Clarity completed a life cycle study in 2011.46 waste were included. The functional unit was 1000 uses of level 3 gowns, which Medical instruments are routinely lost in the OR after means 13.3 gowns were manufactured and laundered/steam the patient leaves. These were measured in the field. In the sterilized 75 cycles to give a total of 1000 reusable gown case of reusables, these were returned to the health care uses. For the disposable system, 1000 gowns were manu- facilities. However, in the disposables life cycle inventory factured and sterilized using ethylene oxide. The manufac- study, these instruments were manufactured as replace- turing of the reusable gown had in the critical zones of the ments for the instruments that were lost to the landfill. The gown a trilaminate of woven or knitted PET with a center life cycle inventory of these instruments was added to the layer of a breathable barrier film modeled after a breathable disposables case. barrier film involving a 3-layer laminate with an expanded The study also included the transportation of all the polytetrafluoroethylene film. In the noncritical zone, a chemicals in the supply chain as well as the fabric going to woven PET fabric was used. For the disposable level 3 cut, sew, and trim during manufacturing and then to the gown, the critical zone was spun blown-melt bond-spun hospitals as separate items for both reusable and disposable blown PET with a polypropylene film barrier. This same life cycle inventory. material, without the polypropylene film barrier, was used The energy of the full cradle-to-end-of-life analysis of in noncritical zones. the 1000 disposable gown uses (1000 gowns) was 22,500 MJ, A separate laundry and sterilization system was ana- whereas for the 1000 reusable gown uses (13.3 gowns lyzed for the reusable gown. Data were used for an laundered 75 times) of the reusable system, the energy was energy-improved laundry/sterilization system and for a 11,900 MJ. Similarly, the water use (not returned to surface conventional laundry/sterilization because this is the larg- water, known in the water footprint literature as blue est contributor to the reusable gown system. For the water) for the 1000 gown uses was 800 kg for the disposable disposable system, each gown was sterilized with ethylene gowns and 385 kg for the reusable gowns. oxide and the supply chain for ethylene oxide was also Direct life cycle measurement of the manufacture for included. radiofrequency identification (RFID) devices to track the

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Comparison of Reusable and Disposable Perioperative Textiles number of reusable cycles was not made, but a published CONCLUSION literature source for a 32-MB DRAM chip was found.47 The Reusable and disposable gowns and drapes meet new life cycle for the microchip was 40 MJ/chip, which for 1 standards for medical workers and patient protection, use RFID per gown is 40 MJ/reusable gown/drape. Using the synthetic lightweight fabrics, and are competitive in price. transparent Environmental Clarity life cycle analysis, the Reusable surgical textiles offer substantial sustainability basis of 1000 gown uses is 12,530 MJ with RFID (before benefits over the same disposable product in energy accounting for chip recycle) versus 22,500 MJ/1000 dispos- (200%–300%), water (250%–330%), carbon footprint able gown uses. Without the life cycle of the RFID chip, the (200%–300%), volatile organics, solid wastes (750%), and respective energy values are 11,900 MJ and 22,500 MJ, thus instrument recovery. This has now been verified in all 6 indicating that the tracking feature does not substantially available life cycle studies. Other factors including cost, change the life cycle results. In addition, the RFID tracking protection, and comfort are reasonably similar. The large environmental sustainability benefits of reusables allow chips are virtually 100% recycled into new gowns and nurses, physicians, and hospitals to make substantial im- drapes (no observable loss in RFID function over 2 de- provements for this industry. It is no longer valid to indi- cades). Therefore, the greenhouse gas effect of these RFIDs cate that reusables are better in some environmental on the gown or drape carbon footprint or other environ- impacts and disposables are better in other environmental mental impacts is essentially zero. impacts. The uniformity of life cycle results from multiple For the environmental life cycle, the 6 studies on reus- studies over the past decade may reduce the need for future able versus single-use gowns and drapes present a consis- studies of perioperative textiles and shift interest to other tent set of results. There is a significant life cycle difference reusable OR medical products, such as laryngeal mask between these alternatives. First, when comparing reus- airways and suction canisters. ables with disposables, the energy requirement for reusable perioperative textiles is approximately 30% to 50% of the DISCLOSURES energy (expressed as natural resource energy, which is the Name: Michael Overcash, PhD. sum of all fuel energy needed to deliver energy to the point Contribution: This author designed the study, conducted the of use, convert the fuel into usable energy, and consume the study, analyzed the data, and wrote the manuscript. energy in the manufacturing or other processes). Said Attestation: Michael Overcash approved the final manuscript. differently, the disposables are 200% to 300% higher in This manuscript was handled by: Steve L. Shafer, MD. energy usage. When water use needed in manufacturing is added to water required for laundry and sterilization, ACKNOWLEDGMENTS disposable textiles consume 250% to 330% more water than This study was designed with input from a team of firms comparable reusable textiles. Only the earliest life cycle responsible for surgical disposables and reusables (Lac-Mac, Medline, W. L. Gore & Associates, and SRI Surgical). Funding inventory study deviates from these findings,11 but that was from W. L. Gore & Associates and SRI Surgical. This study is compromised by numerous errors that are cor- review was substantially improved by inputs from the Asso- rected by the evidence of the other independent life cycle ciation of the Nonwoven Fabrics Industry (INDA), Textile inventory results. Specifically, the volatile organic carbon Rental Services Association of America (TRSA), and the Ameri- emissions and water consumption are in fact lower with can Reusable Textiles Association (ARTA). The perspective of 11 reusable systems than reported by McDowell for the 1993 both the single-use and the reusable communities has been study. The transparent database of the Environmental committed to scientific, transparent results. Clarity study46 has improved life cycle analyses of single- use and reusable surgical textiles, and will help identify REFERENCES hybrid (reusable and disposables combined) surgical pack- 1. Laufman H, Belkin N, Meyer K. A critical review of a century’s ages to provide the health care market with the best progress in surgical apparel: how far have we come? J Am Coll Surg 2000;191:554–68 alternatives. 2. Mittermayer H. Reusable surgical fabrics, state of the art 2003. CliniCum 2005;Sept:3–11 3. Rutala W, Weber D. A review of single-use and reusable gowns and drapes in health care. Infect Control Hosp Epide- JOBS miol 2001;22:248–57 An interesting comparison of reusable and disposables has 4. Gruendemann B. Taking cover: single-use vs. reusable gowns been the relation to jobs and employment.2,38,48 However, and drapes. Infect Control Today 2002;6:32–4 no comprehensive study of jobs for reusable and disposable 5. ANSI/AAMI. Liquid barrier performance and classification of protective apparel and drapes intended for use in health care alternatives was found at this time. Those studies that facilities, PB70. New York, 2003 included local jobs as a factor in comparing reusable and 6. Moylan J, Kennedy B. The importance of gown and drape disposables identified that reusable laundry, assembly, and barriers in the prevention of wound infection. Surg Gynecol transport steps provided more jobs than the disposable Obstet 1980;151:465–70 2 7. Moylan J, Fitzpatrick K, Davenport K. Reducing wound infec- alternatives. Mittermayer even classified the jobs as local tions. Arch Surg 1987;122:152–7 and hence an attribute to differentiate the gown and drape 8. Tyler D, Lyerly H, Nastala C, Shadduck P, Fitzpatrick K, alternatives. At this time, because there are no comprehen- Anglois A. Barrier protection against the human immunodefi- sive labor studies, this current review only identifies jobs as ciency virus. Curr Surg 1989;46:301–4 9. Shadduck P, Tyler D, Lyerly H, Sebastian M, Farnitano C, a potential dimension for comparisons of reusables and Fitzpatrick K. Commercially available surgical gowns do not disposables. prevent penetration by HIV-1. Surg Forum 1990;41:77–80

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10. McCullough E, Schoenberger L. Liquid barrier properties of 30. Belkin N. A historical review of barrier materials. AORN J nine surgical gown fabrics. INDA J Nonwovens Res 1991;3: 2002;76:648–52 14–20 31. Belkin N. But will it come out in the wash? Text Rent 11. McDowell J. J&J study: an environmental, economic, and 2002;Oct:48–51 health comparison of single-use and reusable drapes and 32. Craig M. Reusable laundry/sterilization procedures, personal gowns. Asepsis 1993;13:1–15 communication. Tampa, FL: SRI Surgical, 2010 12. AAMI. Tech Inform Report: selection of surgical gowns and 33. Apfalter P. Reusable surgical fabrics, consensus statement: drapes in health care facilities, TIR No. 11. Arlington, VA: state of the art 2011. CliniCum 2011;Oct:1–11 AAMI, 1994 34. Umbach K. Physiological tests and evaluation models for the 13. Pissiotis C, Komborozos V, Skrekas G. Factors that influence optimization of the performance of protective clothing. In: the effectiveness of surgical gowns in the operating theatre. Mekjavic L. Environmental Ergonomics: Sustaining Human Eur J Surg 1997;163:597–604 Performance in Harsh Environments. Philadelphia: Taylor & 14. Belkin N. Are “barrier” drapes cost effective? Todays Surg Francis, 1988:131–61 Nurse 1998;20:18–23 35. ISO 11092 (10/93). Textiles, Physiological Effects, Measure- 15. Leonas K. Effect of laundering on the barrier properties of ment of Thermal and Water-Vapor Resistance Under Steady- reusable surgical gown fabrics. Am J Infect Control 1998;26:495–501 State Conditions (Sweating Guarded-Hotplate Test). Geneva: 16. Feltgen M, Schmitt O, Werner H. The human being in the International Organization for Standardization, 1993 spotlight. Hyg Med 2000;25:9–63 36. Conrady J, Hillanbrand M, Myers S, Nussbaum G. Reducing 17. Belkin N. Masks, barriers, laundering, and gloving: where is medical waste. AORN J 2010;91:711–21 the evidence? AORN J 2006;84:655–64 37. Digicomo J, Odom J, Ritota P, Swan K. Cost containment in the 18. Leonas K, Jinkins R. The relationship of selected fabric charac- operating room: use of reusable versus disposable clothing. teristics and the barrier effectiveness of surgical gown fabrics. Am Surg 1992;10:654–6 Am J Infect Control 1997;25:16–23 38. Baykasoglu A, Dereli T, Yilankirkan N. Application of 19. Laufman H. The control of operating room infection, disci- cost/benefit analysis for surgical gown and drape selection: a pline, defense mechanisms, drugs, design, and devices. Bull case study. Am J Infect Control 2009;37:215–26 NY Acad Med 1978;54:465–83 39. Lizzi M, Almada G, Veiga G, Carbone N. Cost-effectiveness of 20. Laufman H. Streamlining environmental safety in the operat- reusable surgical drapes versus disposable non-woven drapes ing room: a common bond between surgeons and hospital in a Latin American Hospital. Am J Infect Control 2008;36: engineers. Healthc Facil Manag Ser 1994;Dec:1–14 122–5 21. 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Standard Test Method for Resistance of Melbourne: Royal Melbourne Institute of Technology Univer- Materials Used in Protective Clothing to Penetration by Syn- sity, 2008 thetic Blood. West Conshohocken, PA: ASTM International, 44. Van den Berghe A, Riegel A, Zimmer C. Comparative Life 2007 Cycle Assessment of Disposable and Reusable Surgical Gowns. 26. ASTM F1671-07. Standard Test Method for Resistance of Materials Used in Protective Clothing to Penetration by Blood- Minneapolis, MN: Minnesota Technical Assistance Program, Borne Pathogens Using Phi-X174 Bacteriophage Penetration as 2010 a Test System. West Conshohocken, PA: ASTM International, 45. UniTech. Life Cycle Inventory Comparisons of Radiological 2007 Protective Garments. Springfield, MA: UniTech Corp., 2010 27. AATCC. Water Resistance: Impact Penetration Test, Test 46. Environmental Clarity. Life Cycle Analysis of Surgical Gowns Method 42-2007. Research Triangle Park, NC: American Asso- and Drapes. Montgomery Village, MD: Environmental Clarity, ciation of Textile Chemists and Colorists, 2007 LLC, 2011 28. AATCC. Water Resistance: Hydrostatic Pressure Test, Test 47. Williams E, Ayres R, Heller M. The 1.7 kg microchip: energy Method 127-2008. Research Triangle Park, NC: American As- and material use in the production of semiconductor devices. sociation of Textile Chemists and Colorists, 2008 Environ Sci Technol 2002;36:5504–10 29. Centers for Disease Control. Guidelines for the prevention of 48. NHS (National Health Service). Surgical Drapes and Gowns in surgical site infection. Infect Control Hosp Epidemiol 1998; Today’s NHS; Independent Multi-Disciplinary Working 204:250–80 Group. London: NHS, May, 2001

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326 CCDHB Public 12 December 2018 - 6 GENERAL BUSINESS

PUBLIC

BOARD DECISION

Date: 3 December 2018

Author Andrew Blair, Capital & Coast District Health Board Chair

Subject RESOLUTION TO EXCLUDE THE PUBLIC

RECOMMENDATION It is recommended that the Board: (a) Agrees that as provided by Clause 32(a), of Schedule 3 of the New Zealand Public Health and Disability Act 2000, the public are excluded from the meeting for the following reasons:

SUBJECT REASON REFERENCE For the reasons set out in the respective public excluded Public Excluded Minutes papers. Public Excluded Matters Arising from For the reasons set out in respective public excluded previous Public Excluded meeting papers. Chair’s report Papers contain information and advice that is likely to 9(2)(b)(i)(j) prejudice or disadvantage commercial activities and/or CEO’s report disadvantage negotiations FRAC Recommendations Proposed licence to occupy for a Coffee Kiosk General Services Procurement Update Health Systems Committee Recommendations Long Term Investment Planning Update Modification of Haumietiketike Update to the Catheter Laboratory Information Systems Business Case Risk Report Workforce and Employment Relations Update Children’s Hospital Programme of Works Status Report * Official Information Act 1982.

Capital & Coast District Health Board October 2018

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