Abbreviation list: ACSQHC: Australian Commission on Safety and Quality in Health Care, ACPAN: Australasian College of Perianaesthesia Nurses, BPI: Biodegradable Products Institute, CFP: carbon footprint, CO2: carbon dioxide, GENCA: Gastroenterological Nurses’ College of Australasia, HP: healthcare professional, LCA: life cycle assessment, PACU: post-anaesthesia care units, PEF: product environmental footprint, PPE: personal protective equipment, SPSS: Statistical Package for the Social Sciences, USA: United States of America.

Introduction

Environmental sustainability has emerged as a pressing imperative for healthcare services worldwide, given the industry’s substantial resource consumption and contribution to greenhouse gas emissions. Healthcare facilities are responsible for approximately 4.4% of global greenhouse gas emissions, highlighting the urgent need for sustainability initiatives [1]. Recommendations for environmental sustainability encompass a broad spectrum of strategies aimed at reducing greenhouse gas emissions, including the optimisation of care delivery, supplier selection, and waste management practices [2].

In recent years, the healthcare sector has witnessed a significant surge in the use of single-use items, driven in part by the COVID-19 pandemic. The proliferation of personal protective equipment (PPE) during the pandemic has led to a substantial increase in medical waste generation, with some reports indicating up to a 350% rise [3]. Despite efforts to mitigate waste, a considerable portion of hospital waste remains hazardous, further exacerbating environmental concerns [4]. Notably, Australian health services contribute significantly to the nation’s total carbon dioxide (CO2) emissions, underscoring the urgency of addressing sustainability within this sector [4-6].

The paramount strategy for waste reduction lies in the elimination of low-value care, albeit necessitating significant behavioral shifts among healthcare professionals, policymakers, and consumers, as highlighted by Haddock [7]. In the interim, waste segregation stands as a pivotal measure, offering an immediate and tangible solution to mitigate waste generation. Waste streams in healthcare facilities encompass various materials, including metals, paper, and plastics, all of which possess potential for reuse or recycling. Guidelines advocate for the integration of reduce, reuse, and recycle principles, alongside robust segregation, and processing policies, to minimize the healthcare sector’s carbon footprint [810].

However, the successful implementation of these strategies is contingent upon factors such as available services for waste management and the commitment of healthcare facilities to sustainability principles. The evolution of waste segregation practices and the availability of carbon-neutral alternatives offer promising avenues for enhancing environmental sustainability in healthcare. Suppliers play a crucial role in providing financially viable and environmentally friendly solutions, including biodegradable and compostable products [11,12].

Internationally, certification standards for industrially compostable products exist, allowing suppliers to affix specific logos only upon independent certification. Products meeting compost ability criteria according to European (EN 13432), USA (ASTM D6400 / D6868), or Australian (AS-5810 and AS-4736) standards boast internationally recognized certifications, although with slight variations. For instance, the Seedling logo, owned by European Bioplastics and employed in Europe, Australia, and New Zealand, signifies independent certification, and assures compliance with compost ability criteria [13,14]. Similarly, in the United States of America (USA), the Biodegradable Products Institute (BPI) certifies compostable products against the ASTM D6400 standard and features its own BPI compostable logo [15].

Informed decision-making regarding the selection of consumables and equipment is paramount for reducing the environmental impact of healthcare operations. Assessing the carbon footprint (CFP) of products through life cycle assessments (LCAs) or product environmental footprint (PEF) evaluations enables healthcare facilities to make more sustainable procurement choices [11-13]. Additionally, considerations such as resource usage, recyclability, and transportation logistics should inform supplier selection processes [8,9,16,17].

Despite the availability of resources and guidelines promoting environmental sustainability in healthcare [17,18]. Practical implementation often faces challenges such as space limitations, staff engagement issues, and inadequate waste management infrastructure. Consequently, there is a critical need for ongoing efforts to assess and improve environmental sustainability practices within healthcare facilities.

This manuscript presents the findings of a survey aimed at establishing a baseline of the current state of environmental sustainability practices in gastrointestinal endoscopy and perianaesthesia departments in Australian and New Zealand hospitals as perceived by perianaesthesia and gastrointestinal endoscopy nurses. By identifying key focus areas and challenges, the survey results provide information for future initiatives aimed at advancing environmental sustainability within these healthcare settings.

Materials and Methods

A survey on environmental sustainability was devised jointly by the Australasian College of Perianaesthesia Nurses (ACPAN) and the Gastroenterological Nurses’ College of Australasia (GENCA) to ascertain the status concerning waste management, potential barriers, hospital engagement, and staff involvement. The survey encompassed five demographic inquiries, 38 inquiries about environmental sustainability rated on five-point Likert scales, and one open-ended question for additional comments. It was disseminated among 647 ACPAN members and an estimated 1395 GENCA members functioning within gastrointestinal endoscopy units or peri-anaesthesia environments.

During October 2023, the survey was distributed via email to GENCA and ACPAN members across Australia and New Zealand, with a six-week window for completion. Two subsequent email reminders were dispatched to facilitate participation.

Statistical analysis

Data acquired were processed and analysed employing a specialised statistical software package (IBM^® Statistical Package for the Social Sciences, SPSS^® 27.0, Armonk, New York, USA). Descriptive analysis was employed for categorical data, presented as counts and percentages, while Pearson correlation was utilized to explore any associations between variables. Statistical significance was deemed present when the P value was less than .05.

Results

The survey yielded responses from a total of 98 participants, comprising 41 from GENCA and 57 from ACPAN. These individuals were affiliated with 88 separate departments across 75 hospitals in Australia, 4 in New Zealand, and 2 with undisclosed locations. There were 60 departments with 1-10 operating theatres/procedure rooms, 23 between 11 and 20, and 5 had more than 20. Forty-two departments had 1-10 recovery bays, 32 had between 11-20 bays, and 14 departments had more than 20. Among the respondents, 61 were based in metropolitan areas, 17 in regional areas, and 14 in rural or remote settings. The distribution of respondents across various departments included 36 in post-anaesthesia care units (PACU), 33 in anaesthesia, 29 in endoscopy, 26 in operating theatres, 25 in day surgery, 9 in sterilisation departments, and one in a Catheter Laboratory, with the latter excluded from further analysis due to misalignment with the survey’s focus.

Only 5% of the hospitals were affiliated with the Global Green and Healthy Hospitals Network (Health Care Without Harm), with negligible representation in the GESA/GENCA sustainability network. Additionally, 9% were part of the ANZCA network, and 1% were affiliated with another environmental sustainability network. Over half, 58% of hospitals boasted a “sustainability” or “green” committee and 72% of departments had team members actively participating, with a positive correlation observed between the number of theatres/procedure rooms and the presence of a hospital sustainability committee (p<0.01) and membership thereof (p<0.05) (Table 1 and Table 2).

Regarding environmentally sustainable water utilization, the use of grey and black water was very limited. However, 23% of respondents confirmed the use of environmentally friendly energy resources (e.g., wind, water, sun) in their hospitals and waste segregation took place in some degree in most hospitals (Table 2). Among hospitals that had implemented waste segregation, only 4% received rebates. Waste segregation at the hospital level exhibited a positive correlation with knowledge about different waste segregation options (p<0.01) and waste treatment options (p<0.01) (Table 1).

Apart from mandatory segregation of clinical, cytotoxic, and sharps waste, 91% of departments segregated other waste streams, including paper/cardboard (59%), batteries (34%), hard plastic (32%), PVC (26%), medication/drugs (22%), soft plastics, comingled, and polypropylene wrap (blue or steri wrap) (18%), food (7%), stainless steel and compostable (6%), copper (3%), and other materials (9%). The majority of the departments reported the use of biodegradable items, but compostable items were utilized by less than half of the departments (Table 2). The use of compostable items correlated negatively with the number of theatres/procedure rooms (p<0.01) and recovery bays (p<0.05), as well as with the presence of a hospital “green” committee (p<0.01) and staff membership therein (p<0.05) (Table 1).

Only 35% of respondents reported using an environmentally friendly solution for medication/drug disposal, with a positive correlation observed with waste segregation at the hospital level (p<0.05) (Table 1). The utilization of inhalational anaesthetics varied, with 5 departments abstaining from their use. Among those using these anaesthetics, sevoflurane was most prevalent (92%), followed by nitrous oxide (84%), desflurane (45%), and isoflurane (15%). Notably, the use of inhalational anaesthetics correlated negatively with knowledge about waste treatment options (p<0.05) (Table 1).

Tables 3 and Table 4 enumerate environmentally sustainable considerations in the decision-making process for selecting new consumables and provide an overview of biodegradable and compostable items used in departments, respectively. Levels of engagement and compliance in waste segregation varied among healthcare professionals but not significantly. PACU nurses had the highest engagement M=3.21(1.18) and compliance scores M=4.05 (1.36) and medical the lowest, respectively M=2.55 (1.04) and M=3.27 (1.34) (Table 5).

The majority of respondents (93%) expressed low confidence in their knowledge regarding waste streams and their treatments, with only a small fraction (7%) claiming full confidence.

Twenty-four percent of respondents were aware that The Australian Commission on Safety and Quality in Health Care (ACSQHC) would publish a Sustainable Healthcare Module in 2024. As the latter will be voluntary as part of hospital accreditation, the researchers asked the participants whether they thought their department would use the ACSQHC module to improve their environmental sustainability in their department, with 31% confirming they would (Table 2).

Awareness of the upcoming Sustainable Healthcare Module by the ACSQHC in 2024 correlated positively with knowledge about different waste segregation options (p<0.01) and treatment options (p<0.05) (Table 1).

^**. Correlation is significant at the 0.01 level (2-tailed) ^*. Correlation is significant at the 0.05 level (2-tailed).

Table 1: Pearson Correlation between variables: number of operating theatres/procedure rooms (rooms), number of recovery bays (bays), usage of inhalation anaesthetics (inhalation agents), waste segregation practice at hospital level (segregation hospital waste), waste segregation at department/ unit level (segregation department waste), use of biodegradable items in the department (use biodegradables), use of compostable items in department (use compostables), segregation of medicine/drug waste (segregation drug waste), Environmental sustainability applied in procurement decisionmaking process (Procurement), hospital has a “green” committee (Green hospital committee), a team member of the department is member of the hospital’s “green” committee (Green committee member), awareness of the ACSQHC sustainability module (Aware ACSQHC module), participants will use the ACSQHC sustainability module to improve knowledge (Use module), Knowledge about different waste segregation options (Knowledge segregation), knowledge about the treatment of the different waste streams (Knowledge treatment).

Table 2: Practices as perceived by the participants.

Table 3: Environmentally sustainable considerations when selecting new consumables.

Table 4: Percentage of departments that use biodegradable or compostable items

Table 5: Engagement and Compliance scores of the different healthcare professional groups (1= poor, 2=fair, 3=average, 4=good, 5=excellent).

Reasons for the limited implementation of waste streams in departments are elaborated in Table 6, while respondents highlighted several factors influencing environmental sustainability, including important disablers and enablers.

Table 6: Reasons for not implementing waste segregation in the unit/department.

Discussion

These survey results provide an initial exploration of the current knowledge and attitudes of perianaesthesia and gastrointestinal endoscopy nurses regarding waste management practices in high-flow, high-waste areas such as theatres, endoscopy units, and recovery rooms-locations notorious for generating substantial waste in healthcare settings.

Assessment of waste segregation compliance levels revealed that the majority of team members exhibited adherence rates of 50% or lower, indicating suboptimal engagement across various healthcare professional roles. Notably, nurses, particularly those in anaesthesia, demonstrated higher levels of engagement compared to physicians, with porters and cleaners exhibiting relatively lower levels of involvement. Similarly, Meyer et al. [19] noted that only 43% of surveyed surgeons recognized immediate opportunities for reducing surgical waste.