On an August Thursday in 2021, deep into the pandemic, two Massachusetts General Hospital doctors stood gowned, gloved, bootied up and ready in a retrofitted lounge on the 21st floor of Phillips House, a 20-single-room, inpatient area with sweeping views of Boston, the Charles River and neighboring Cambridge.
Just after 3 p.m. cleaning staff, who usually wheeled the floor’s trash to a collection area, instead took their haul to the lounge, where the floors, walls and heavy antique furniture had been cleaned, covered and taped off — a process that in itself took three people roughly two hours.
The 21st floor’s refuse items — every mask, gown, box, glove and empty bottle — were weighed, sorted, and cataloged, as part of a 24-hour waste audit aimed at cutting plastic use and the hospital’s contribution to climate change.
“As they kept coming in, we were like, ‘Oh my God, another, you know, dumpster of waste,’” said Jonathan Eisen, who, with another hospitalist, Christian Mewaldt, proposed and executed the waste audit.
In all, the day produced 168 kilograms (more than 370 pounds) of waste — a majority of it plastic — an amount equal to more than 8 kilograms (almost 18 pounds) per patient, in a single day.
The health care system in the United States is responsible for about 8.5% of the nation’s greenhouse gas emissions, from sources that include energy used to produce and distribute personal protective equipment (PPE) like disposable gowns, gloves, and masks. Some 14,000 tons of waste is generated every day at hospitals and other health care facilities around the country, roughly a quarter of it plastic. Yet 91% of plastic isn’t recycled, and winds up buried in landfills and elsewhere.
Some hospital systems, including Mass General Brigham, are moving to tackle the problem, through direct actions like paring down fossil fuel use, composting food waste, changing anesthesiology practices and recycling the blue wrap used in the sterilization of instruments for the operating room. In April, MGH marked the second anniversary of the creation of the Center for Environment and Health, which spearheads the hospital’s efforts.
When the sorting of trash collected from the hospital rooms at Phillips House was finally done at close to 1 a.m. that Saturday morning, Eisen snapped a photo of the piles of waste. One, made up of 559 disposable polypropylene hospital gowns, stood higher than Mewaldt’s 5-foot-10-inch frame. About 90% of what was collected was regular trash that did not require the specialized disposal mandated for regulated medical waste.
“While we were doing it and feeling like we were making some progress, just more and more and more wagons full of trash came,” Mewaldt said. ”It certainly felt like it was just dumping down on our heads.”
For the two doctors, what began as a pre-pandemic idea to swap small shampoo bottles with in-room dispensers at Phillips House morphed into something more ambitious. Eisen said his interest in climate change and health care was stoked when he joined MGH’s staff as an attending hospitalist in 2018. He’d heard through the grapevine that Mewaldt had helped eliminate styrofoam containers from the cafeteria, which now operates a composting program. The two had a phone call about the shampoo bottles. Then the pandemic hit and they set the idea aside.
“Where it started for us was a shared desire to try to improve the impact on the climate through the delivery of health care, and a recognition that we created a lot of waste in our health care delivery,” Mewaldt said. “And that some of it probably was preventable. It kind of drove both of us crazy.”
Pushing to get rid of the cafeteria’s styrofoam had turned out to be a lot more complicated than Mewaldt first imagined, he said, and the process took months. He and Eisen started talking again in April 2021, during a plateau in the pandemic, about doing a project at Phillips House. Eisen brought up an audit.
“Jon had an important insight — that we were likely to get much farther in our arguments if we were able to show how much we were actually producing in waste and how much of that was potentially unnecessary,” said Mewaldt, now a cardiovascular fellow at nearby Beth Israel Deaconess Medical Center.
The 21st floor of Phillips House seemed an ideal setting, Eisen said, because it has single-patient rooms, about three quarters of which are typically under contact precautions for infectious diseases, including antibiotic-resistant infections and Covid-19. Those precautions include the use of PPE.
In early April, Eisen emailed Jonathan Slutzman, who led the then newly formed environment and health center. Slutzman had conducted an audit in the hospital’s emergency room in 2018 and published the results in a paper titled “Dumpster Diving in the Emergency Department,” in The Western Journal of Emergency Medicine.
Health care audits are an increasingly popular way to gauge exactly what kind of waste hospitals produce, according to a 2022 study of audits led by Slutzman. That study calls for reporting standards so that waste can be compared across different settings to save money and cut the deluge into landfills globally. Slutzman said when Eisen came to him he encouraged him — and was in a position to help coordinate the project.
Eisen and Mewaldt began coordinating with Latoya Brewster, director of environmental services, Jennifer Sargent, head of nursing and Denis Bogere, the hospital’s then-operations manager, to set up the logistics and make sure the day-to-day rhythm of the floor wouldn’t be disrupted.
By August, they were ready.
“It was so eye-opening — just a tremendous amount of waste that’s generated,” Sargent said on a 2022 webinar posted on the hospital’s website.
The audit also found a “surprising” amount of unused supplies in the collected waste, like gloves, Mewaldt notes.
Brewster, who coordinated with other departments and cleaning staff involved to make sure everything ran smoothly, said the audit helped her understand just how much regular trash was being created.
“I knew that there was some contamination, meaning regular trash, that goes in there,” she said. “But I didn’t understand — or visualize — just how much.”
The greenhouse gas emissions, or GHG, emitted to make and dispose of the waste cataloged in the audit was the equivalent of driving 350 miles, charging 65,000 smartphones or burning 269 kilograms of coal, Eisen and Mewaldt found, using Environmental Protection Agency models.
Today, the hospital is pursuing how and when to switch back to the reusable gowns that were once standard, the researchers said.
They pointed to other hospital systems’ success with reusable gowns, including UCLA Medical Center, which began using them in 2012. Over three years, that system saved $1.1 million on purchasing and avoided sending an estimated 297 tons of waste to landfills, a case study led by Stanford researchers found.
The swap at Mass General would likely begin as a pilot program to work out kinks, like the placement of ties on the gowns, as well as careful evaluation of contact precautions. Slutzman said a decision about the swap may come next year.
“There are some challenges. We need to make sure that we find a device that meets everybody’s needs, in that it needs to be wearable, it needs to be comfortable, it needs to be easy to put on and take off, and that it’s covering people adequately,” Slutzman said. “So, we need to satisfy a number of stakeholders.”
Disposable gowns are usually made of synthetic fibers, including polypropylene, polyester, and polyethylene, while reusable gowns tend to be woven polyester. And the National Academy of Medicine recommends the switch.
What’s more, reusable gowns can typically be washed 75 to 100 times, according to the study led by the Stanford researchers. The University of California, Los Angeles successfully used reusable gowns throughout the pandemic, Eisen and Mewaldt noted. They said the audit armed them with information to push for the switch.
Slutzman, who describes waste audits as “the gateway drug for sustainability science,” said while setting one up can mean careful coordination across many hospital groups, actually doing one isn’t difficult. And that gives hospitals tools to make changes.
“The way to reduce what goes out is to control what comes in — and to change your purchasing and acquisition process,” Slutzman said. “Once the horse has left the barn, it’s hard to get it back in. Once the plastic is in the hospital, it’s going to leave. It’s gotta go somewhere.”
The better practice, he said, is, “to work with our vendors, our manufacturers, our regulators to make it so that the easy practice is the right practice.”