Calls for fresh guidance on re-use of disposable surgical equipment

Researchers say recycling of single-use theatre equipment will save cash and reduce environment impact

A report by scientists at the University Hospital of Southampton (UHS) is calling for research into the economic and environmental benefits of re-using disposable stainless steel surgical equipment.

The paper by Dr Nick Enzor1 and colleagues appears to support the findings of an earlier investigation by Shelton et al2 which found 41% of anaesthetic waste to be recyclable, including single-use stainless steel laryngoscope blades and intubating forceps.

Many single-use devices are reused without adequate evaluation of the increased risks to patients

Now the research at Southampton has found additional environmental benefits through the reduction in clinical waste costs and carbon emissions, and claims NHS trusts could save thousands of pounds a year at a time when public services are being charged with making widespread cutbacks.

As a result, Dr Enzor is calling for more indepth research and the publication of clearer guidance on the legalities of re-using equipment manufactured and marketed as single-use only.

The paper claims that, if steel was sterilised before scrapping, in order to minimise the risk to handlers, it could be recycled within the current UK regulations and generate an income of £1,000 per tonne. Moreover, since it is no longer discarded into either clinical waste at a cost of £450 per tonne or sharps bins at £750 per tonne, the used metal is worth closer to £1,500 per tonne.

It found that commonly-used size 4 Macintosh pattern laryngoscope blades weighed 106g, and a pair of adult Magill’s intubating forceps weighed 72g, with scrap values of 10.6 and 7.2 pence respectively. The maximum number of laryngoscope blades per tray is limited by space and weight to approximately 60, with both washer and steriliser cycles able to process up to five fully-laden trays containing 300 laryngoscope blades (31.8 kg of steel). Assuming each cycle runs to maximum efficiency, the cost is 1.34 pence per blade.

User organisations, professional users and reprocessors who prepare single-use devices for further episodes of use, may be transferring legal liability for the safe performance of the product from the manufacturer to themselves, or the organisation that employs them

Furthermore, the non-urgent nature of decontamination means it can be undertaken at slack operating times without delaying the processing of urgent instruments. No additional staff need be employed to facilitate this process.

Dr Enzor states: “Extrapolating these results to the envisaged use at UHS of 20,000 laryngoscope blades per year, the scrap value is £2,120 and the saving of not disposing of the waste is an additional £1,060, less the processing cost of £268. Our NHS trust stands to save £2,912 per annum.”

But perhaps the biggest opportunity for savings is in carbon emissions, with the new research claiming earlier findings had underestimated the opportunity for the reduction in the environment impact.

Dr Enzor states: “The energy expenditure to produce 1kg of steel from iron ore is over 10 MJ greater than when produced from recycled scrap steel (21.9 MJ vs 11.7MJ) and the carbon footprint associated is 1.97kg compared with 0.7kg of CO2 if that steel comes from scrap3.”

The researchers add: “Almost all single-use laryngoscope blades are manufactured in Pakistan and then transported thousands of miles, to be used once only and for less than a minute. This is reflected in the carbon intensity of disposable items and is currently 600g CO2 per £GB spent4, or approximately 3.0kg per laryngoscope blade.

If we cannot reduce the need for laryngoscopy and reusable laryngoscope blades have all but been removed, then recycling the steel is perhaps the only sustainable option

“We conclude that the process of recycling anaesthetic room steel reduces environmental harm and benefits hospitals economically. Furthermore, we support calls for clearer guidance on recycling anaesthetic room steel. If we cannot reduce the need for laryngoscopy and reusable laryngoscope blades have all but been removed, then recycling the steel is perhaps the only sustainable option. Recycling anaesthetic room steel saves carbon and money.”

However, such a move would call for significant changes to legislation governing the manufacture and use of disposable medical equipment.

In order to reduce the risk of abnormal prion proteins, such as CJD, during surgical procedures, the Department of Health states that ‘devices designated for single episodes of use must not be re-used under any circumstances whatsoever’.

The reasons for this are based on fears that by reprocessing equipment designed only to be used once, patients could be put at risk. This could be through the increased potential for cross contamination, or because the decontamination process has weakened the structure of the device.

The Medicines and Healthcare products Regulatory Agency (MHRA) issued updated guidance at the end of 20115, which states that ‘users often justify the reprocessing of such devices on the basis of economic and environmental benefits. These perceived benefits are questionable as many of the processes required to ensure that the device is safe and fit for its intended purpose cannot be undertaken by the reprocessor. Many single-use devices are also reused without adequate evaluation of the increased risks to patients’.

We conclude that the process of recycling anaesthetic room steel reduces environmental harm and benefits hospitals economically. Furthermore, we support calls for clearer guidance on recycling anaesthetic room steel

It provides examples of where the re-use of equipment has had serious implications for patients. These include a single-use lithotriptor stone retrieval basket which had been reprocessed and appeared to be satisfactory for use. During the procedure, the cable was tightened and snapped, resulting in the basket remaining in the patient. Further surgery was required to retrieve it. In another cause, a single-use bladder pressure transducer cover was not changed between patients, resulting in cross-infection with Pseudomonas aeruginosa . One patient developed septicaemia and died of a sub-arachnoid haemorrhage.

The MHRA guidance states: “User organisations, professional users and reprocessors who prepare single-use devices for further episodes of use, may be transferring legal liability for the safe performance of the product from the manufacturer to themselves, or the organisation that employs them.”

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