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Seven garbage bags filled with 12 meters of plastic tubing, 108 gloves, 57 compresses, 24 syringes, and 16 isolation gowns. That’s how much one ICU patient a day generates in waste.

The healthcare industry works with many disposable products and sustainability is of great importance. With that in mind, much of the sector recently signed the Green Deal sustainable care 3.0. As with all Green Deals, the agreements are ambitious. By 2026, at least 20 percent of the healthcare industry must be circular. A little further into the future (2030), CO2 emissions must be reduced by 55 percent, and the use of fossil raw materials at least halved.

Fixation on preventing infection risk

A huge task, because if you ask Nicole Hunfeld, Dutch healthcare has gone overboard with the use of disposable products. The hospital pharmacist was appointed 2020 Green ICU project leader at Erasmus MC and chairs the national committee The Green Intensive Care.

“Since the turn of the century, the healthcare sector has become fixated on preventing infection risk. That’s good in principle, but we’ve gone overboard with it. We are scrambling behind the comma,” Hunfeld said. That fixation has led to many instruments becoming single-use. And that’s not just about gloves or tubing. Even scissors and metal saw blades are thrown away after one use.

Nicole Hunfeld

Hunfeld cites a bronchoscope that allows a doctor to look into the lungs as an example. After one time, it ends up in the trash, including wiring, lights and camera. “That doesn’t have to be disposable at all. They used to be just reused too. We have to go back to the old days in terms of method, with today’s technology.” Even disposable scissors and expensive metal saw blades are thrown away after one use, when there are reusable alternatives.

Another example: in the ICU, the protocol was that when a patient leaves, all supplies from that room are also thrown away. Including unused gloves lying in the closet. “So nine pounds of clean items are then thrown away. While there is no evidence that bacteria actually ends up on the unused, packaged items. So we have since changed that; throwing away is no longer necessary.”

Since the turn of the century, the healthcare industry has become fixated on preventing infection risk. That’s good in principle, but we’ve gone overboard with it.

Nicole Hunfeld

Sustainability avant le lettre

Actually, Hunfeld’s sustainability journey began ten years earlier, when she became the first hospital pharmacist in the Netherlands to work in an intensive care unit at Erasmus MC. Based on the idea that a pharmacist can contribute more on the ward than when she is tucked away behind a desk somewhere far away.

Her presence on the ward turned out to be sustainability avant le lettre. “When I walk past a patient who is no longer in pain, I can advise discontinuing this medication. If I were a few hundred meters away in a pharmacy, I wouldn’t see things like that. That is not only more sustainable and better for the patient, but also cheaper.”

Over the past decade, she digitized the entire medication chain in the ICU. Wherever possible, nurse work was replaced by scanning bar codes or pharmacy staff. Hunfeld: “For example, we were able to take a thousand medication checks a day out of the process by checking medication pumps via barcode. So nurses have more time for the patient.”

The Netherlands’ first circular IC

But ICU department head Diederik Gommers wants to make more than just the medication chain sustainable. By 2030, Erasmus MC must be the first fully circular ICU in the Netherlands. It is up to Hunfeld and her team to give hands and feet to that goal.

Together with Metabolic (a company specializing in sustainability), she first mapped out what disposable materials are used in the ICU on a daily basis. Everything is weighed: from needles to textiles to medicines. The result? Seventeen kilograms of waste per ICU patient per lying day.

Repeat, repeat, repeat

Most of the solution to a greener ICU lies with behavioral changes by healthcare personnel. This is also directly the biggest challenge. As an example, Hunfeld mentions that before the doctor arrives, the nurses are already unpacking and readying all the instruments. “A shame, because a lot of equipment ends up not being used and ends up unused in the trash. It would be better if the nurse opened the package at the doctor’s request. But that’s not how they’re used to it.”

So how do you make sure everyone goes along with the changes? “The only answer to that question is: communicate. And repeat, repeat, repeat. Through newsletters, screens, at the coffee machine. Showing that together we can contribute to a better planet.”

The waste generated by one ICU patient per layday.

Small steps, smaller balloons

Hunfeld, along with colleagues from TU Delft, also stepped up to the manufacturers of disposable products, asking what they need. For example, intensivists indicated that the balloon they use to ventilate patients before hooking them up to a machine is 1.5 times too large. “We hope the manufacturer will now want to start producing smaller balloons. And other solution may be for companies to change their business model, where the hospital will rent materials or processes instead of buying them. At Erasmus MC, we already do this when it comes to hospital beds.”

Erasmus MC also initiated a CIRCO track by Blue City, in which all hospitals from South Holland together followed a training program to become more sustainable. That her hospital is setting an example for the region in this, Hunfeld thinks is logical. “We are an academic center. That means we have a social responsibility. Erasmus MC has to set an example; we also have the capacity to do research.”

There is still a long way to go before the ICU is fully circular. For that, behavioral change and more sustainable products from suppliers are not enough. For example, current legislation does not allow recycled materials to be reused. On the shop floor, at least, Hunfeld is doing what she can. “I have very often been told: what are you up to now? By now I know not to care too much about that. I just keep going, every step is one.”