Can Infection Prevention Go Green?

By ALISON McCOOK

Endoscopes are dirty—and not just from the standpoint of infection. They’re dirty because of how much their use and reprocessing contribute to hospitals’ waste and carbon footprints.

Each endoscopy bed generates nearly 7 pounds (3.09 kg) of waste every day, putting it in the top three of all hospital departments (Lancet Gastroenterol Hepatol 2020;5[7]:636-638). It’s easy to see where the waste comes from: disposable tools and protective gear, high-throughput caseloads, and use of large amounts of water and disinfectants during reprocessing.

Some experts fear the waste problem in endoscopy could worsen, as the field moves more toward disposable products to reduce the risk for infection. The trend toward disposables is creating some tension between infection control and environmental protection, where emphasizing one may put the other at risk, said Nitin K. Ahuja, MD, an assistant professor of clinical medicine and the co-director of the program in neurogastroenterology and motility at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia.

“I’m sympathetic to the thinking of people concerned with infection control, but it’s hard for those of us who are concerned about waste,” Dr. Ahuja said. “Is the disposable duodenoscope just another thing that’s going to end up in the ocean?”

Flying Blind

When he first heard about the disposable duodenoscope, Bu’Hussain Hayee, MBBS, PhD, a consultant gastroenterologist at King’s College Hospital London, was very concerned. “A hospital like King’s, where I work, performs 1,000 procedures using duodenoscopes per year. This is a huge demand for disposable equipment, which I just cannot see being realistic,” he said. “I have also yet to hear a convincing argument that this is sustainable at all.”

However, there’s no way of knowing whether the alternative—reusable scopes that need reprocessing—has any less environmental impact because of the lack of data comparing the footprint of reusable and disposable tools, Dr. Hayee said. Cleaning one endoscope uses between 90 and 100 L (22 gallons) of water, filtered using reverse osmosis to ensure purity, which consumes a lot of energy, he said. “Obviously, single-use scopes do not need water to reprocess them, so there is that. But we can only incinerate used scopes; they can’t be recycled, so the impact is high.” The bottom line, Dr. Ahuja said, is there needs to be more research about the environmental impact of the waste associated with endoscopy: disposable materials such as packaging, single-use instruments and personal protective equipment versus the water, detergents and decontamination used during reprocessing of reusable instruments. “Certainly, more could be done to understand what percentage of resources in any given endoscopy is contributing to the global carbon footprint.”

Ideas for Reducing Waste

Dr. Ahuja recommends that providers think deliberately about their use of accessories during procedures, such as using only one for a small and large polyp in the same colon, so there are fewer things to throw away or reprocess. Dr. Hayee’s practice has installed energy-efficient light bulbs and infrared faucets to control water flow in sinks and started emailing reports and digitizing information, instead of using paper. They also are recycling all noncontaminated waste, and using thermal compaction machines to deal with personal protective equipment and aprons that otherwise would be incinerated, creating an inert plastic “flock” that can be sold to plastic manufacturers for reuse.

The biggest step providers can take is to simply cut back on unnecessary procedures, Dr. Ahuja said—a particular problem for practices in which doctors are paid according to the number of procedures they perform. “Substantive change with regard to the carbon footprint of medicine at large would probably entail moving away from productivity as a primary incentive and toward outcomes instead. We would need to include environmental outcomes as part of the shared set of things we all care about as a professional community.” ■

Garbage generated in the reprocessing of one scope.

Image courtesy of Ofstead & Associates Inc.