Experts outline sustainability efforts in the department of urology at Yale School of Medicine


"We identified that in our site, we were ordering almost 1600 cystoscopy packs. A lot of the materials that were in those packages were unnecessary for an outpatient procedure," says Malissa Williams.

In this video, Marianne Passarelli, MD, MBA; Malissa Williams; Olamide Olawoyin, MD; and Jeffrey Carbonella, MD, discuss sustainability initiatives for the department of urology at Yale School of Medicine in New Haven, Connecticut. Passarelli is an associate professor of urology at Yale School of Medicine, Williams is urology operations coordinator for the department of urology, and Olawoyin and Carbonella are urology residents at Yale School of Medicine.


Could you discuss the sustainability efforts being implemented in the urology department?

Passarelli: I was actually inspired by Dr. Jodi Sherman from anesthesia, because she does a lot about preventing medical waste and sustainability, more on a hospital level. But I don't think it's ever really come down to the department levels, aside from what she's been trying to do in anesthesia. But the department of urology does a lot of outpatient procedures, and we are the largest consumer of products in the outpatient setting within the Yale New Haven Hospital System. So we had to introduce the concept of being more conscious of and considerate of sustainability. We came up with a few goals when we started. One was to use less, to reduce waste, recycle more. One of the end products of that is also to reduce costs. But I don't think we really need to focus on that; I think that's a side benefit that we get from it. The department, before we formed the committee, actually transitioned from reusable cystoscopes, to recyclable cystoscopes. They found that that was actually a big cost savings for our department. And I think that helped to, in addition to decreasing greenhouse gas emissions because of that, I think that that sort of helped the department gain more interest in trying to move forward with more sustainability projects. It's very hard to do this, but we started to try to identify projects, and then look at the research impacts and to research the impacts and the process line changes that they would require. Then we have to go through our approval process through our operations committee to roll those out. Our first project was actually to streamline the use of the outpatient cystoscopy set-up. Malissa basically looked at all the products that we were using; it was very inconsistent between sites, and to try to reduce the waste from that.

Williams: We identified that in our site, we were ordering almost 1600 cystoscopy packs. A lot of the materials that were in those packages were unnecessary for an outpatient procedure. When we looked at what was in that pack and the set-up at that site vs some of our other sites, we were able to identify where we had extra waste material. In that process, we were able to eliminate about 5 products just from that basic set-up, that we would no longer be purchasing and placing in the trash because they weren't anything that was really necessary. In that process, just by that 1 site, we eliminated 8000 pieces of material just by eliminating cystoscopy packs alone. When we moved from that, we also then discovered that the bottles that we use to do the cystoscopy were recyclable. That led to us starting to recycle the water that we use to do the cystoscopies within our clinics. We recycled probably anywhere from 5000 to 8000 bottles between all of our sites, instead of those just going into the regular trash, those are now being recycled. Everything's had a trickle effect, because now we have the awareness. Now that we have the awareness, we contact the appropriate people to see what other materials that we use, that we then can place in recycling receptacles vs placing them in the trash. We've seen a big increase in us being able to recycle.

Passarelli: I will say that 1 of our problems with buy-in from people is there's a lot of doubt that recyclables are actually being recycled...Not that we shouldn't be trying to recycle, but I think we have we decided we needed to really focus also a little bit more on the use-less aspect of our project, because I don't think that people really believe that things are actually being recycled. We have tried to follow things down the line to make sure that was actually the case. And then the other major project that we started off with is really reducing paper waste, because we're a very paper-dependent department. The amount of waste for 1 piece of paper is tremendous. What we're trying to do is transition from all paper product consents and making them all electronic. That's something that we are instituting right now. A lot of institutions have electronic consents. Each physician had each consent printed up for each different procedure in notebooks in each office - just an incredible amount of paper. And then periodically the OR would change the consents, and they'd have to all be thrown out, and they'd have to make these new ones. So the whole idea was really just, we have to stop this, this is nonsense...We've had some difficulty getting the whole system to work in the New Haven delivery network. But Malissa was great about getting signature pads and things for all the accessibility in all of our offices so that could be done. We're aiming just to do outpatient procedure consents and that type of thing, but now we're rolling it into actual operating room consents that are obtained in the office prior to going to the OR. That's really the gist of what our projects are right now. We have other ones that we'd like to do; it's just very intensive to try to get one project on at a time.

Williams: Also, I'm currently working with the company that we do urodynamics with on interfacing our machines. We're almost done with the interfacing, so then we will be able to not have to print out the actual reports because the reports will go automatically into the Epic chart, and the doctors will be able to view them there. I know some providers had 2 copies, and then things were getting scanned and weren't working. So a lot of things that we're moving onto with the equipment, we're trying to make sure we get that interface capability. So then that way, they're available in real time inside the patient's chart, and it won't be required to print them out on pieces of paper that then have to be moved around. So there's a 2-part fold to that. It's real time and accessible without using all the paper waste.

Please describe the scope of the problem of medical waste.

Olawoyin: One thing that Jeffrey and I have noted, since being in the operating room from being medical students, was that often times, we have a lot of plastic materials that are just being disposed into the regular trash bins; even though there's a recycling can in the room, we often don't use it. I think a lot of it is just poor education in terms of what can be recycled and what cannot be recycled, especially with some of the more biohazard-type content.

Carbonella: I think in the specialty of urology, specifically, we have a lot of single-use items, as well. And the single-use items are often mis-disposed of...Part of the efforts that we're trying to make are to educate the staff in the OR on what can and cannot be recycled, so that we can save on those items.

What efforts are you undertaking to mitigate the issue of medical waste?

Carbonella: Part of our project, to start off, we asked the OR staff to record how many bags they're using—both recycle and trash bags—per case. Our idea is that we're going to track how much is being done so far. And then we have an informational infographic that we're going to post into the ORs and educate the staff on and then measure afterwards, after having implemented that intervention and see how much improvement we can make in terms of decreasing the trash bags and increasing the recycle bags.

Olawoyin: The initial part of the project was taking a survey of all of the operative staff that mostly works in our cystoscopy suites, who do a lot of urological procedures. We did a survey and saw what education they had initially gotten, in terms of what they know about recycling and sustainability in general. An overwhelming majority of them felt as though they hadn't gotten enough education. That let us know that this is something that was needed. Our plan is to also send out another survey at the end of the implementation phase, to see if they feel like they've gotten better education on it.

It's still in the implementation phase. [It] hasn't been measured yet, [but] there seems to be more cognizance from the OR staff in terms of at least filling out the notebooks. I've heard them say, "We need to make sure we are completing this data," and I think that kind of forces them to be a little bit more aware of what they need to do in terms of where materials go. But we haven't collected the data yet, and we haven't analyzed the data yet.

Carbonella: I would just second what Dr. Olawoyin said in that, just by implementing this project alone, it's brought more attention to the issue at hand, and all the nursing staff and OR staff have become much more aware of where things should go. And we still haven't even implemented our actual intervention in which we're going to post an infographic of the different materials that should be recycled and see if that can improve it even further.

This transcription was edited for clarity.

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