The Financial and Environmental Costs of Reusable and Single use Anaesthetic Equipment

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Eleanor Preston
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1 The Financial and Environmental Costs of Reusable and Single use Anaesthetic Equipment Forbes McGain, Western Health Melbourne, Victoria Scott McAlister (Life Cycle Assessor)-Ecoquantum, Tony Fung Nien Lim- Western Health, David Story- Uni. Melb.

2 Why study $, CO 2 and water use? Money has always been important! Healthcare has a large environmental footprint Healthcare sustainability is becoming more prominent Health economists can assist in studying $ costs Life cycle assessment (LCA) examines environmental footprints

3 Life Cycle Assessment, From Cradle to Grave

4 Prior Life Cycles in the O.R. Individual equipment drug trays, laryngeal masks, anaesthetic gases Entire operations caesareans, hysteroscopies, cataracts For individual equipment- Attributed environmental costs What are the costs/impacts of using one reusable tray versus one single use tray?

5 Consequential LCA What is more useful to know are consequences How financial and environmental flows change according to decisions made If our theatres changed from reusable drug trays to single use trays what are the costs? Incorporates consequences- e.g. staffing flows, altered electricity demand

6 A Few Definitions and Thoughts Reusable = reused and recleaned for multiple patient care Single use = used once only Disposable = used on multiple patients, though never cleaned by CSSD Applies only to the circuits (changed weekly) Plastic anaesthetic equipment in Anaesthetic washer loads Circuits and face masks Video laryngoscope handles and monitors were reusable

7 Circuits, direct laryngoscope handles and blades, and face masks (also Proseal reusable LMAs) Video laryngoscope handles and blades

8 How is anaesthetic equipment processed/reused? 1. Scenario 1 (baseline)- reusables as used at Footscray Hospital, Melbourne (6 theatres) ( Proseal LMAs reusable) 2. Scenario 2 (main comparator)- mainly single use as used at the Austin Hospital, Melbourne 3. Scenario 3- all single use (Austin + single use direct laryngoscope handles) 4. Scenario 4- reusables + single use face masks 5. Scenario 5- reusables + single use direct laryngocope blades

9 Holding trays for the washer The washer in action A steriliser load. Note the laryngeal masks

10 Methods-$ Costs If we changed from reusable to single use $ from the hospital viewpoint What are the real labour consequences? Alternative to examining the opportunity cost Time and motion studies of cleaning anaesthetic equipment

11 Methods-Environmental Costs If we changed from reusable to single use What are the real environmental consequences? e.g. where will the next kwh of electricity come from? Electricity and water use of hospital washers and sterilisers (steam and H 2 O 2 )

12 Methods-Life Cycle Assessment Industry and databases were used for inputs EcoInvent (database) Modelling with Monte Carlo Analysis used when it is impossible/impractical to obtain all data computational algorithms relies on repeated random sampling

13 Results-Building the Story 1. Purchase $ costs (at hospitals 1 and 2) 2. Non labour $ costs ( ) 3. Labour $ costs ( ) 4. Modelling from Scenario 1 to 5 5. Consequences of changes to washer and steriliser loads 6. Total $ costs 7. Total environmental costs

14 Anaesthetic equipment purchase costs, compositions and masses Anaesthetic Equipment Purchase Cost ($/item) No. of purchases in 2015 Reusable breathing circuit (polypropylene, 665g) $ circuits 52 weeks x 1/0.9 X 6 ORs=350 uses in 2015 Reusable breathing circuit bag (chloropropene, 80g) $ bags 350 uses Reusable breathing circuit polyethylene wrap, 30g $ wraps 350 uses Single use breathing circuit (HDPE, 480g) $ circuits Bag (chloropropene, 60g) Polyethylene wrap, 25g Reusable face mask (silicone, 80g) $ face masks 9,900 uses Single use face mask (polyolefin/polypropylene, 60g) $ 2 9,900 face masks Reusable LMA Proseal (silicone, 70g, stainless steel handle, 35g) Polypropylene/paper wrapping (5g/5g) 630 uses Single use LMA Supreme (PVC, 65g) Polyethylene wrap (10g) $ LMAs $ LMAs

15 Anaesthetic Equipment Reusable laryngoscope- direct-blade (stainless steel, 125g) Polyethylene/paper wrapping (5g/5g) Purchase Cost No. of purchases in ($/item) 2015 $ blades (rarely purchased) Single use laryngoscope- direct-blade (stainless steel, 60g) $ ,490 blades Reusable laryngoscope-direct-handle (stainless steel, 155g) Battery recharger (polypropylene, 110g) $ 1,150 0 handles (rarely purchased) Single use laryngoscope-direct-handle (Acrylonitrile- Butadiene-Styrene = ABS, 70g) Reusable video-laryngoscope- all reusable parts (including screen and handle), (stainless steel, 270g). Polyethylene/paper wrapping (10g/10g) Single use video-laryngoscope blade (polycarbonate, 55g) Polyethylene wrapping (10g) $ ,490 handles $ 15,000-25,000 0 video laryngoscopes (All purchased 3 years prior) $ video laryngoscopes blades

16 Reusables-non labour costs Process Financial Cost ($) Washer and dryer electricity $ kwh at $0.12/kWh Washer natural gas for hot water (from gas boiler) $ MJ at AUD$0.005/MJ Washer water $ litres at AUD$3.50/1,000 litres inclusive of sewage Washer detergents combined cost $ Asepti Multizyme- 0.5 ml, Asepti Citric Rinse- 0.3 ml, - Asepti Sonic- 0.5 ml Total cost for one washer load (including drying) $2.90 Steam steriliser electricity and water use $0.15/kg - at 0.14 kwh/kg and 40 litres water/kg H 2 O 2 steriliser packages =1.8 ml of 58% H 2 O 2 $24/cycle H 2 O 2 steriliser electricity use $0.20/ kwh at $0.12/kWh for 55 minutes cycle Total cost for one H 2 O 2 steriliser load (holds 4 videolaryngoscopes) $24.20 Landfill for disposable/single use items ($0.25/kg general waste) $0.25/kg

17 Item (n= number of times each item was timed being washed +/- sterilised) Anaesthetic circuit sets (1 set= 1 bag and 3 tubings) (n= 39) Total time (minutes) processing these items (measured) Labour Costs Average time (minutes) spent per item (measured) No. items actually processed in 2015 Extrapolated time (hours) spent processing all such items for the year 2015 Financial cost (labour cost =$35/hour) 261 minutes 7 minutes hours $1,274 Face masks (n=155) , $2,888 LMAs ( Proseal ) $1,151 (n=32) Laryngoscope (direct) , $5,475 blades (n=57) Laryngoscope (direct) , $1,313 handles (n=41) Laryngoscope (video) $1,458 blades and handles (n=20) Totals 388 (<11 weeks work) $13,558

18 Labour $ Costs So, if we changed from completely single use items to reusables this would cost $13,558 p.a. from our time and motion study $14,560 p.a. (0.2 EFT) from CSSD staff estimates Good agreement between two approaches

19 Scenarios of anaesthetic equipment use (for 2015) Scenarios for anaesthetic equipment use Washer and dryer loads p.a. Steam steriliser use p.a. 1. Reusable equipment (hospital 1) 550 loads 4,490 blades and 630 LMAs 2. Single use equipment except for reusable direct laryngoscope handles (hospital 2) 0 loads 0 cycles 0 cycles H 2 O 2 steriliser use p.a. Video-laryngoscopes 180 cycles 3. All single use anaesthetic equipment (= Sc.2 + single use direct laryngoscope handles) (USA) (modelled) 4. Replace only reusable face masks with single use face masks (modelled) 5. Replace only direct laryngoscope reusable blades with single use blades (modelled) 0 loads 0 cycles 0 cycles 365 loads 4,490 blades and 630 LMAs 180 cycles 550 loads 630 LMAs 180 cycles

20 Process/Device Financial Costs All Reusable (Scenario 1) All Single use (reusable direct laryngosope handles and video laryngoscopes (Scenario 2) Labour-CSSD $14,560 $0 Washer loads $1,595 $290 Steam sterilisation $815 $0 H 2 O 2 sterilisation cycles $4,356 $0 Circuits and bags $2,292 $3,850 Face masks $2,482 $19,800 LMAs $8,500 $13,230 Direct laryngoscope blades $1,460 $19,350 Direct laryngoscope blades' $180 $0 wrappings Direct laryngoscope handles $470 $470 Video-laryngoscope blades $0 $11,500 Video-laryngoscope handles $0 $0 Video-laryngoscope blades' $250 $250 packaging Waste costs $25 $278 TOTAL $36,985 $69,018

21 Impact (effect) category Units Average Australian s total activities (p.a.) Environmental Costs Scenario 1 (Reusable) Scenario 2 (Mostly Single use) Scenario 3 (All Single use) Scenario 4 (Single use face masks) Scenario 5 (Single use blades) Climate change kg CO 2 eq 22,727 5,575 5,095 5,775 6,556 6,763 Water depletion kilolitres Eutrophication kg P eq Solid waste kg 1, ,222 1, Human toxicity kg 1,4-DB 6, , eq Terrestrial kg 1,4-DB 41,846, ecotoxicity eq Freshwater kg 1,4-DB 10,582, ecotoxicity eq Marine ecotoxicity kg 1,4-DB eq 11,

22 8000 CO2 Emissions (kg CO2 eq) (S.= Scenario) CO2 Emissions (kg CO2 equivalent)

23 Converting from Single Use to Reusable would Reduce $ costs by $32,000 per annum Increase CO 2 emissions by 0.5 tonnes (10%) Increase water use by 50 tonnes (=av. Australian s direct use) If we were in the USA the CO 2 emissions would reduce by 2.5 tonnes (50%) In Europe the CO 2 emissions would reduce by 4.3 tonnes (85%) Europe = NEW ZEALAND!

24 1 kwhr of electricity produces X kg of CO

25 Perhaps the New Zealanders could assist us? New Zealanders and Taswegians should be Reusable!

26 Limitations Life cycle data- some direct, some indirect One year s data Expensive equipment purchased infrequently Video laryngoscope handles/monitors were reusable regardless $ calculations Based upon real world hospital savings Concordance between time and motion studies and estimations

27 Our work was all about Consequences We caution (as for all research) The results may not be generalisable But the methods are $30 grand doesn t seem much But extrapolated to Australia, assuming 50% hospitals used reusables and 50% single use would save $2 million p.a. and add 25 cars Very different story in the U.K. (take 1,000 cars off the road)

28 Acknowledgements Staff at the CSSD at Western Health (Karen Tricker, Carlos Paciocco, Nancy Trujillo et al) ANZCA Grant Funding

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