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Purpose of Review: Our escalating reliance on disposable products in the operating room has generated a large amount of waste, cost, and environmental pollution. Heath damages from the pollution caused by the US healthcare industry cause as much harm, as measured by disability-adjusted life years, as total medical errors. Our response to our own environmental impact should be proportional to that harm. Understanding the waste streams we create and the factors that contribute to our large waste generation in the operating room can help us target solutions to our most harmful practices., Recent Findings: Recent studies within the field of medical waste in ObGyn have included a systematic review analyzing most effective practices for waste reduction and environmental life cycle analyses of specific medical procedures., Summary: Operating room waste includes regulated medical waste, pathologic waste/chemotherapy, sharps, general municipal waste, recycling, linens, and anesthetic gases. The most effective way to reduce the environmental impact from medical waste is to reduce our use of disposable supplies in favor of durable reusable materials. Other important interventions include eliminating 'overage' of unused supplies, optimizing use of anesthetic gas, custom pack scale backs, and proper waste segregation. This review of operative waste is intended to aid healthcare facilities in understanding and addressing their own environmental impact., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The escalating generation of household medical waste, a byproduct of industrialization and global population growth, has rendered its transportation and logistics management a critical societal concern. This study delves into the optimization of routes for vehicles within the household medical waste logistics network, a response to the imperative of managing this waste effectively. The potential for environmental and public health hazards due to improper waste disposal is acknowledged, prompting the incorporation of contamination risk, influenced by transport duration, waste volume, and wind velocity, into the analysis. To enhance the realism of the simulation, traffic congestion is integrated into the vehicle speed function, reflecting the urban roads' variability. Subsequently, a Bi-objective mixed-integer programming model is formulated to concurrently minimize total operational costs and environmental pollution risks. The complexity inherent in the optimization problem has motivated the development of the Adaptive Hybrid Artificial Fish Swarming Algorithm with Non-Dominated Sorting (AH-NSAFSA). This algorithm employs a sophisticated approach, amalgamating congestion distance and individual ranking to discern optimal solutions from the population. It incorporates a decay function to facilitate an adaptive iterative process, enhancing the algorithm's convergence properties. Furthermore, it leverages the concept of crossover-induced elimination to preserve the genetic diversity and overall robustness of the solution set. The empirical evaluation of AH-NSAFSA is conducted using a test set derived from the Solomon dataset, demonstrating the algorithm's capability to generate feasible non-dominated solutions for household medical waste recycling path planning. Comparative analysis with the Non-dominated Sorted Artificial Fish Swarm Algorithm (NSAFSA) and Non-dominated Sorted Genetic Algorithm II (NSGA-II) across metrics such as MID, SM, NOS, and CT reveals that AH-NSAFSA excels in MID, SM, and NOS, and surpasses NSAFSA in CT, albeit slightly underperforming relative to NSGA-II. The study's holistic approach to waste recycling route planning, which integrates cost-effectiveness with pollution risk and traffic congestion considerations, offers substantial support for enterprises in formulating sustainable green development strategies. AH-NSAFSA offers an eco-efficient, holistic approach to medical waste recycling, advancing sustainable management practices., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Hu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Purpose of Review: This review aims to provide an update on the results of studies published in the last two years involving the development of sustainable practices in hospital and operating theaters (OT)., Recent Findings: Recently, many studies evaluated various initiatives to better understand the environmental impact of the OT but also to minimize its environmental impact. Many trials evidenced the positive impact of the instrument's reuse using an appropriate reprocessing procedure. Better waste segregation is associated with a reduction of produced waste and contributes to a significant reduction in CO 2 equivalent emissions. Regarding anaesthetic gas, Desflurane is known to have the worst environmental impact and the majority of the study evidenced that its reduction permits to drastically reduce greenhouse gas emission of the OT., Summary: Greening the OT necessitates climate-smart actions such as waste reduction, the improvement of reusable instruments, recycling of our waste and better anaesthetic gas management. Within the last two years, many efforts have been made to reduce and better segregate waste produced in the OT and also to better understand the environmental impact of disposable and reusable devices., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: The healthcare sector has a substantial environmental footprint, and the delivery of anesthesia contributes significantly. Inhaled anesthetics themselves are potent greenhouse gases, unused intravenous medication exert toxic effects on the environment, and the increasing reliance on single-use devices has led to an ever-growing amount of solid waste produced in operating rooms. This review discusses many of these environmental impacts and suggests practices to mitigate the environmental footprint of anesthetic practice., Recent Findings: The choice of anesthesia maintenance has significant environmental implications, with nitrous oxide and desflurane having the highest carbon footprint of all anesthetic agents. Using low fresh gas flows and supplementing or replacing inhalational agents with propofol leads to a significant reduction in emissions. Many intravenous anesthetic agents pose a risk of environmental toxicity, and efforts should be made to decrease medication waste and ensure appropriate disposal of unused medications to minimize their environmental impacts. Additionally, consideration should be given to replacing single-use devices in the operating rooms with reusable alternatives that are often both environmentally and economically superior. And solid waste generated in the operating room should be segregated thoughtfully, as processing regulated medical waste is a highly energy-intensive process., Summary: Significant opportunities exist to improve the environmental footprint of anesthesia practice, and with the rapidly worsening climate crisis, the importance of implementing changes is greater than ever., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Climate change has immediate impacts on women's health. Hospitals and operating rooms are large contributors to greenhouse gas (GHG) emissions and waste. This article will review current green initiatives designed to minimize environmental impact in the operating room and highlight areas for future improvement., Recent Findings: From a materials perspective, reusable goods result in less GHG emissions while being just as efficacious, well tolerated, and easy to use. Materials should be opened judiciously, only as necessary. Processing regulated medical waste produces greater GHG emissions, so waste should be properly sorted, and items which are not biohazard waste should be processed separately. Choosing appropriate anesthesia and utilizing an 'off' setting, in which operating rooms are shut down when not in use, can also drastically decrease the environmental impact of surgery. Further research is needed to determine effective implementation in hospitals., Summary: This article summarizes current attempts to make operating rooms more sustainable. Many practices result in a decreased carbon footprint and cost savings without adversely affecting patient outcomes. Gynecologic surgeons and the hospitals in which they practice need to focus on implementing these changes in a timely fashion., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role., Design: In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO 2e ) and 1 kg of RMW to 3kgCO 2e was assumed. Paired samples t-tests for comparisons., Results: From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO 2e by 31.6% (138.8kgCO 2e ) was found (mean kgCO 2e 109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO 2e . All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel., Conclusion: In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs., Study Design: A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework., Results: A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste)., Conclusions: Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The inefficiency of conventional biological processes to remove pharmaceutical compounds (PhCs) in wastewater is leading to their accumulation in aquatic environments. These compounds are characterized by high toxicity, high antibiotic activity and low biodegradability, and their presence is causing serious environmental risks. Because much of the PhCs consumed by humans are excreted in the urine, hospital effluents have been considered one of the main routes of entry of PhCs into the environment. In this work, a critical review of the technologies employed for the removal of PhCs in hospital wastewater was carried out. This review provides an overview of the current state of the developed technologies for decreasing the chemical risks associated with the presence of PhCs in hospital wastewater or urine in the last years, including conventional treatments (filtration, adsorption, or biological processes), advanced oxidation processes (AOPs) and electrochemical advanced oxidation processes (EAOPs).

Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G275).

Background: Pharmacological treatments for critical processes in patients need to be initiated as rapidly as possible; for this reason, it is a standard of care to prepare the main anesthesia and emergency drugs in advance. As a result, 20%-50% of the prepared drugs remain unused and are then discarded. Decreasing waste by optimizing drug use is an attractive strategy for meeting both cost containment and environmental sustainability. The primary end point of this study was to measure the actual amount of drug wastage in the operating rooms (ORs) and intensive care units (ICUs) of a Regional Health Service (RHS). The secondary end point was to analyze and estimate the economic implications of this waste for the Health Service and to suggest possible measures to reduce it., Methods: This prospective observational multicenter study was conducted across 12 hospitals, all of which belong to the same RHS in the north-east of Italy. Data collection took place in March 2018 and included patients admitted to ICUs, emergency areas, and ORs of the participating hospitals. Data concerning drug preparation and administration were collected for all consecutive patients, independent of case types and of whether operations were scheduled or unscheduled. Drug wastage was defined as follows: drugs prepared in ready-to-use syringes but not administered at all and discarded untouched. We then estimated the costs of wasted drugs for a 1-year period using the data from this study and the yearly regional pharmacy orders of drugs provided to the ORs and ICUs. We also performed a sensitivity analysis to validate the robustness of our assumptions and qualitative conclusions., Results: We collected data for a total of 13,078 prepared drug syringes. Drug wastage varied from 7.8% (Urapidil, an alpha-1 antagonist antihypertensive) to 85.7% (epinephrine) of prepared syringes, with an overall mean wastage rate of 38%. The estimated yearly waste was 139,531 syringes, for a total estimated financial cost of €78,060 ($92,569), and an additional quantity of medical waste amounting to 4968 kg per year. The total provider time dedicated to the preparation of unused drugs was predicted to be 1512 working hours per year., Conclusions: The overall extent of drug wastage in ORs and ICUs is concerning. Interventions aimed at minimizing waste-related costs and improving the environmental sustainability of our practice are paramount. Effort should be put into designing a more efficient workflow that reduces this waste while providing for the emergency availability of these medications in the OR and ICU., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Background: Balanced resuscitation strategies have led to increased utilization of plasma. Fresh frozen plasma that is thawed and never used is a large source of blood component wastage. Thawed plasma (TP) and can only be stored for 5 days. Liquid plasma (LP) has never been frozen and can be stored for 26 days. Due to longer storage duration, we hypothesized that using LP would result in decreased waste and cost savings compared with TP., Methods: We performed a retrospective review of all trauma patients at our Level I trauma center in the years 2015 to 2016. We compared 2015 when only TP was used to 2016 when both TP and LP were used. All plasma units ordered for trauma patients were tracked until the time of transfusion or wastage. Wastage rates were compared between years and plasma type., Results: There were 5,789 trauma patients admitted to our institution from 2015 to 2016. There were 4,107 plasma units ordered with 487 (11.9%) units wasted. During 2015, 2,021 total units of plasma were ordered with 273 (13.5%) units wasted which was a significantly higher rate than 2016 when 2,086 total units of plasma were ordered and 214 (10.3%) units were wasted (p = 0.0013). During 2016, 1,739 units of TP were ordered and 204 (11.7%) units were wasted which was significantly higher than LP wastage, 347 units ordered and 10 (2.9%) units wasted (p < 0.001). Of the 477 wasted TP units, 76.9% were ordered no more than two times before being wasted and 95.8% were ordered no more than three times before being wasted. Of the 10 LP units wasted, 40% were ordered no more than two times before being wasted, and 50% were ordered no more than three times before being wasted. If TP was wasted at the same rate as LP, 368 fewer units of plasma would have been wasted representing US $39,376 (US $107/unit) of wasted health care expenses., Conclusion: At a Level I trauma center, the addition of LP to the blood bank for trauma resuscitations significantly reduced plasma wastage rates and health care expenses., Level of Evidence: Level III, Economic/Decision.

Objective: To evaluate the potential role of head and neck oncologic surgeons in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future., Review Methods: This literature review searched for relevant literature about the relevance of waste in surgical head and neck oncology practice and the innovative alternatives to decrease its effect on environment., Conclusions: Head and neck oncologic surgeons have a role in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future. However, there exist only limited data on waste management and other procedures in surgical oncology to promote these practices., Implications for Practice: By increasing awareness of the corresponding issues of waste production within the healthcare environment, head and neck surgeons can have a pioneering role in considering how to reduce, recycle and reuse in a more efficient manner. As research in this field accumulates, healthcare providers can engage both managers and clinicians in this process. It remains imperative to provide these professionals opportunities for their work force to rethink current practices in a manner that prioritizes environmentally sustainable head and neck surgical practices., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Operating rooms contribute between 20% to 70% of hospital waste. This study aimed to evaluate the waste burden of neurointerventional procedures performed in a radiology department, identify areas for waste reduction, and motivate new greening initiatives., Methods: We performed a waste audit of 17 neurointerventional procedures at a tertiary-referral center over a 3-month period. Waste was categorized into five streams: general waste, clinical waste, recyclable plastic, recyclable paper, and sharps. Our radiology department started recycling soft plastics from 13 December 2019. Hence, an additional recyclable soft plastic waste stream was added from this time point. The weight of each waste stream was measured using a digital weighing scale., Results: We measured the waste from seven cerebral digital subtraction angiograms (DSA), six mechanical thrombectomies (MT), two aneurysm-coiling procedures, one coiling with tumour embolization, and one dural arteriovenous fistula embolization procedure. In total, the 17 procedures generated 135.3 kg of waste: 85.5 kg (63.2%) clinical waste, 28.0 kg (20.7%) general waste, 14.7 kg (10.9%) recyclable paper, 3.5 kg (2.6%) recyclable plastic, 2.2 kg (1.6%) recyclable soft plastic, and 1.4 kg (1.0%) of sharps. An average of 8 kg of waste was generated per case. Coiling cases produced the greatest waste burden (13.1 kg), followed by embolization (10.3 kg), MT (8.8 kg), and DSA procedures (5.1 kg)., Conclusion: Neurointerventional procedures generate a substantial amount of waste, an average of 8 kg per case. Targeted initiatives such as engaging with suppliers to revise procedure packs and reduce packaging, digitizing paper instructions, opening devices only when necessary, implementing additional recycling programs, and appropriate waste segregation have the potential to reduce the environmental impact of our specialty., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

This paper reports a very high capacity and recyclable Mg-Co-Al-layered double hydroxide@ g-C 3 N 4 nanocomposite as the new adsorbent for remediation of radioisotope-containing medical-based solutions. In this work, a convenient solvothermal method was employed to synthesize a new nano-adsorbent, whose features were determined by energy dispersive X-ray (EDS/EDX), XRD, FESEM, TEM, TGA, BET, and FT-IR spectroscopy. The as-prepared nano-adsorbent was applied to capture the radioisotope iodine-131 mainly from the medical-based wastewater under different conditions of main influential parameters, (i.e. adsorbent dose, initial I 2 concentration, sonication time, and temperature). The process was evaluated by three models of RSM, CCD-ANFIS, and CCD-GRNN. Furthermore, comprehensive kinetic, isotherm, thermodynamic, reusability cycles and optimization (by GA and DF) studies were conducted to evaluate the behavior and adsorption mechanism of I 2 on the surface of Mg-Co-Al-LDH@ g-C 3 N 4 nanocomposite. High removal efficiency (95.25%) of 131 I in only 30 min (i.e. during 1/384 its half-life), along with an excellent capacity that has ever been reported (2200.70 mg/g) and recyclability (seven times without breakthrough in the efficiency), turns the nanocomposite to a very promising option in remediation of 131 I-containing solutions. Besides, from the models studied, ANFIS described the process with the highest accuracy and reliability with R 2 > 0.999., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Intravenous immune globulin (IVIG) is a high-cost medication used in a diverse range of settings. At many institutions, IVIG is dosed using total body weight (TBW). Recent evidence suggests that alternative dosing weights reduce waste without compromising clinical outcomes. The objective of this study was to quantify the waste reduction potential generated through the use of alternative IVIG dosing weights., Methods: We performed a retrospective analysis of all IVIG doses administered from January 2011 through January 2016 to adults (≥18 years). TBW and height at the time of administration were used to calculate prescribed dose (g/kg), ideal body weight (IBW), and adjusted body weight (AdjBW). Three dosing methods were analyzed, as follows: use of AdjBW if TBW is >120% IBW (method 1), AdjBW for all doses (method 2), and IBW for all doses (method 3). Outcomes included potential IVIG use averted, direct drug cost savings, and reductions in outpatient infusion times for each method., Results: A total of 9,918 doses were administered to 2,564 patients over 5 years, representing an average usage of 75,994 g/year. If dosing methods 1, 2, and 3 had been used, the annual use of IVIG would have decreased by 21.9% (16,658 g/year, p < 0.001), 24.2% (18,371 g/year, p < 0.001), and 35.9% (27,252 g/year, p < 0.001), respectively. This translates into average annual cost differences of $2.37 million, $2.62 million, and $3.89 million and average annual outpatient infusion time savings of 841 hours, 920 hours, and 1,366 hours, respectively., Conclusion: IVIG dosing optimization through use of alternative dosing weights represents a significant source of waste reduction and cost reduction., (© American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: When pharmaceuticals are administered based on patient characteristics (for example weight or body surface area), an amount of product will be unused and must be disposed of. This wastage represents inefficiency and can distort decision making., Methods: We present a method for the analysis of optimum fill volumes of pharmaceuticals to minimise wastage across a patient population, using publicly available data. Wastage for patients at each 'step' e.g. by kg of bodyweight is calculated, the frequency of each of these steps in the structure of the population is then estimated using the method of moments, with wastage then estimated for each 'step' multiplied by its prevalence. Illustrative examples of pembrolizumab and cabazitaxel show how wastage could be reduced using UK population data, whilst simultaneously reducing administrative burden., Results: Changing the available vial sizes for pembrolizumab (available as 50 mg/100 mg vials) to 70 mg/100 mg, wastage could be cut from 13.3% to 8.7%. For cabazitaxel (only 60 mg vials available), increasing the fill to 70 mg could reduce wastage from 19.4% to 18.8%, or alternatively, adding a 12.5 mg vial reduce this to 6.5%. A secondary finding is that wastage is higher when the larger vial size is perfectly divisible by the smaller vial size., Conclusions: Reductions in wastage have the potential to reduce the cost of manufacturing medicines, which is not necessarily low for novel products. These cost reductions could lead to increased profit (at the same prices), constant profit with a better return rate (at lower prices), or a combination of the two. Most importantly, they would improve the efficiency of the health-care sector, increasing funding available to treat patients.

Objective: Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED., Methods: A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures., Results: Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42)., Conclusion: Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions., (© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objectives: Redispensing by pharmacies of medication unused by another patient could contribute to optimal use of healthcare resources. This study aimed to assess patient willingness to use medication returned by another patient and patient characteristics associated with this willingness., Design: Cross-sectional survey., Setting: A total of 41 community and 5 outpatient pharmacies in the Netherlands., Participants: Total of 2215 pharmacy visitors., Primary and Secondary Outcome Measures: Patients completed a questionnaire regarding their willingness to use medication returned unused to the pharmacy by another patient, assuming quality was guaranteed. Secondary outcome measures included patient sociodemographic characteristics that were associated with patient willingness, analysed using logistic regression analysis and reported as ORs with 95% CIs., Results: Of the 2215 patients (mean (SD) age 50.6(18.0) years; 61.4% female), 61.2% were willing to use medication returned unused to the pharmacy by another patient. Patients who were unwilling mostly found it risky. Men were more willing to use returned medication (OR 1.3 95% CI 1.1 to 1.6), as did patients with a high educational level (OR 1.8 95% CI 1.3 to 2.5), those who regularly use 1-3 medications (OR 1.3 95% CI 1.1 to 1.7), those who returned medication to the pharmacy for disposal (OR 1.5 95% CI 1.0 to 2.3) and those who ever had unused medication themselves (OR 1.3 95% CI 1.1 to 1.6)). Patients with non-Dutch cultural background were less willing to use returned medication (OR 0.395% CI 0.3 to 0.4))., Conclusions: When quality is guaranteed, a substantial proportion of patients are willing to use medication returned unused to the pharmacy by another patient. This suggests that implementation of redispensing may be supported by patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Medical waste is a total waste stream which is generated from the healthcare facilities during the healthcare delivery process. It can contain potentially hazardous substances for the human being and the environment. Waste handlers play a significant role for its proper management and they need to have adequate knowledge, attitude, and practices. The study aimed to evaluate the knowledge, attitude, and practices of waste handlers regarding medical waste management in Debre Markos town healthcare facilities, northwest Ethiopia., Results: A total of 55 medical waste handlers were studied from 12 healthcare facilities. Among this, 25 (45.4%) were diploma and certificate holders. The majority (69.1%) of the study participants were not provided with proper training. There was a lack of personal protective devices and waste management equipment supply. Regarding knowledge, attitude, and practices, 25 (45.5%), 43 (78.2%), and 44 (80%) of the study participants had adequate knowledge, favorable attitude, and adequate practice scores, respectively. There was high (30.9%) prevalence of needlestick and sharps injuries. Healthcare facilities should provide periodic training and adequate supplies for the waste handlers. Further study should be conducted on a large scale by including different levels of health facilities and regions of the country.

Background: Research waste is estimated to be very common, but assessments of its prevalence and scope are rare. As an example, we assessed research waste in clinical research on calcium intake (assessing study design and endpoint type) and vitamin D supplementation (assessing endpoint type)., Methods: We examined 404 randomised controlled trials (RCTs) and observational studies of calcium intake (diet or supplements) and bone mineral density (BMD) or fracture, and 547 RCTs of vitamin D supplements, and assessed the proportion of studies that used surrogate or clinical endpoints. For studies with BMD or fracture as an endpoint, we estimated when the 'tipping' point occurred indicating the need for RCTs with fracture as an endpoint (based on cumulative meta-analyses of BMD RCTs, and chronological review of observational studies), and whether each study published at least 5y after the tipping point was novel, added new clinical knowledge or was research waste., Results: Observational studies of calcium intake and BMD or fracture outnumbered RCTs by 3.3-4.5 times. For both calcium intake and vitamin D supplements, studies using surrogate endpoints outnumbered studies using clinical endpoints by 1.6-3 times. Of 41 RCT publications of calcium intake and BMD or fracture published at least 5y after the tipping point in 1994, we considered that 19 (46%) lacked novelty, another 13 (32%) added no new clinical knowledge, and 30 (73%) were research waste. Of 204 observational study publications of calcium intake and BMD or fracture, 197 (96%) lacked novelty, another 5 (2%) added no new clinical knowledge, and 202 (99%) were research waste. Of 39 RCTs of vitamin D supplementation and BMD or fracture published at least 5y after the tipping point in 1999, 14 (36%) lacked novelty, another 13 (33%) added no new clinical knowledge, and 27 (69%) were research waste., Conclusions: A high proportion of studies of calcium intake since 2000 (95%) and trials of vitamin D supplements since 2005 (69%) on BMD or fracture represent research waste.

Background: Research waste can occur when trials are conducted in the wrong populations. Vitamin D deficient populations are most likely to benefit from vitamin D supplementation. We investigated waste attributable to randomised controlled trials (RCTs) of supplementation in populations that were not vitamin D deficient., Methods: In December 2015, we searched Pubmed, recent systematic reviews, and three trial registries for RCTs of vitamin D with clinical endpoints in adults, and 25-hydroxvitamin D (25OHD) survey data relevant to large (N ≥ 1000) RCTs. We investigated the proportion of RCTs that studied vitamin D deficient populations, temporal trends in baseline 25OHD, and whether investigators in large RCTs considered relevant 25OHD survey data or systematic reviews in their trial justifications., Results: Of 137 RCTs of vitamin D with clinical endpoints, 118 (86%) reported baseline mean/median 25OHD, which was < 25, 25-49, 50-74, and ≥ 75 nmol/L in 12 (10%), 62 (53%), 36 (31%), and 8 (7%) RCTs, respectively. In 70% of RCTs, baseline 25OHD was > 40 nmol/L. Baseline 25OHD increased over time. Before 2006, 38%, 62%, 0% and 0% of RCTs had baseline 25OHD < 25, 25-49, 50-74, and ≥ 75 nmol/L respectively; in 2011-15, the respective proportions were 9%, 49%, 37%, and 6%. Of 12 RCTs with baseline 25OHD < 25 nmol/L, 8 had neutral findings. Of 25 large RCTs (18 completed, 7 ongoing), 1 was undertaken in a vitamin D deficient population, 3 in vitamin D insufficient populations, and 17 had, or probably will have, baseline 25OHD > 40 nmol/L. 44% (8/18) of large completed RCTs cited relevant prior population 25OHD data, and only 3/10 (30%) relevant prior systematic reviews., Conclusions: Up to 70% of RCTs of vitamin D with clinical endpoints, 71% of large completed RCTs, and 100% of ongoing large RCTs could be considered research waste because they studied cohorts that were not vitamin D deficient.

Anesthesiologists request units of plasma in anticipation of transfusion. The amount of plasma transfused intraoperatively is less than that issued (requested, thawed, and sent). We presented institutional-specific data on plasma usage including anesthesiologist-specific ratios of plasma issued-to-transfused. In month-to-month comparisons from the year before the presentation (June-December 2015) to 7 months after (June-December 2016), plasma issued to the operating room was reduced from 434.9 ± 81 to 327.3 ± 65 units, a change of 107.6 units per month (95% confidence interval [CI], 22-193); plasma discarded by the blood bank was reduced from 109.7 ± 48 units to 69.1 ± 9 units, a change of 40.6 units per month (95% CI, 0.2-81); and plasma transfused went from 188.4 ± 42 units to 160.7 ± 52 units, a nonsignificant change of 27.7 units per month (95% CI, -27 to 83).

Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: This study aims to use lean techniques and evaluate the impact of increasing the use of premixed IV solutions and increased IV production frequency on IV waste., Methods: Study was conducted at a tertiary hospital pharmacy department in three phases. Phase I included evaluation of IV waste when IV production occurred three times a day and eight premixed IV products were used. Phase II increased the number of premixed IV products to 16. Phase III then increased IV production to five times a day., Results: During Phase I, an estimate of 2,673 IV doses were wasted monthly, accounting for 6.14% of overall IV doses. This accounted for 688 L that cost $60,135. During Phase II, the average monthly IV wastage reduced significantly to 1,069 doses (2.84%), accounting for 447 L and $34,003. During Phase III, the average monthly IV wastage was further decreased to 675 doses (1.69%), accounting for 78 L and $3,431. Hence, a potential annual saving of $449,208 could result from these changes., Conclusion: IV waste was reduced through the increased use of premixed solutions and increasing IV production frequency.

Background: Expiry of red blood cell (RBC) units is a significant contributor to wastage of precious voluntary donations. Effective strategies aimed at optimal resource utilization are required to minimize wastage., Study Design and Methods: This retrospective study analyzed the strategic measures implemented to reduce expiry of RBC units in an Australian tertiary regional hospital. The measures, which included inventory rearrangement, effective stock rotation, and the number of emergency courier services required during a 24-month period, were evaluated., Results: There was no wastage of RBC units due to expiry over the 12 months after policy changes. Before these changes, approximately half of RBC wastage (261/511) was due to expiry. The total number of transfusions remained constant in this period and there was no increase in the use of emergency couriers. Policy changes implemented were decreasing the RBC inventory level by one-third and effective stock rotation and using a computerized system to link the transfusion services across the area. Effective stock rotation resulted in a reduction in older blood (>28 days) received in the main laboratory rotated from peripheral hospitals, down from 6%-41% to 0%-2.5%., Conclusion: Age-related expiry of blood products is preventable and can be significantly reduced by improving practices in the pathology service. This study provides proof of principle for "zero tolerance for RBC unit expiry" across a large networked blood banking service., (© 2017 The Authors Transfusion published by Wiley Periodicals, Inc. on behalf of AABB.)

Pharmacopollution is a public health and environmental outcome of some active pharmaceutical ingredients (API) and endocrine-disrupting compounds (EDC) dispersed through water and/or soil. Its most important sources are the pharmaceutical industry, healthcare facilities (e.g., hospitals), livestock, aquaculture, and households (patients' excretion and littering). The last source is the focus of this article. Research questions are "What is the Household Waste Medicine (HWM) phenomenon?", "How HWM and pharmacopollution are related?", and "Why is a reverse logistic system necessary for HWM in Brazil?" This article followed the seven steps proposed by Rother (2007) for a systematic review based on the Cochrane Handbook and the National Health Service (NHS) Center for Reviews Dissemination (CDR) Report. The HWM phenomenon brings many environmental, public health, and, social challenges. The insufficient data is a real challenge to assessing potential human health risks and API concentrations. Therefore, the hazard of long-term exposure to low concentrations of pharmacopollutants and the combined effects of API mixtures is still uncertain. HWM are strongly related to pharmacopollution, as this review shows. The Brazilian HWM case is remarkable because it is the fourth pharmaceutical market (US$ 65,971 billion), with a wide number of private pharmacies and drugstores (3.3: 10,000 pharmacy/inhabitants), self-medication habits, and no national take-back program. The HWM generation is estimated in 56.6 g/per capita, or 10,800 t/year. The absence of a reverse logistics for HWM can lead to serious environmental and public health challenges. The sector agreement for HWM is currently under public consultation.

Background: The objective was to report a successful implementation of a blood cooler insert and tracking technology with educational initiatives and its effect on reducing red blood cell (RBC) wastage., Study Design and Methods: The blood bank database was used to quantify and categorize total RBC units issued in blood coolers from January 2010 to December 2015 with and without the new inserts throughout the hospital. Radiofrequency identification tags were used with special software to monitor blood cooler tracking. An educational policy on how to handle the coolers was initiated. Data were gathered from the software that provided a real-time location monitoring of the blood coolers with inserts throughout the institution., Results: The implementation of the blood cooler with inserts and tracking device reduced mean yearly RBC wastage by fourfold from 0.64% to 0.17% between 2010 and 2015. The conserved RBCs corresponded to a total cost savings of $167,844 during the 3-year postimplementation period., Conclusions: The implementation of new blood cooler inserts, tracking system, and educational initiatives substantially reduced the mean annual total RBC wastage. The cost to implement this initiative may be small if there is an existing institutional infrastructure to monitor and track hospital equipment into which the blood bank intervention can be adapted when compared to the cost of blood wastage., (© 2017 AABB.)

Introduction: Clots may be seen during hematopoietic progenitor cell (HPC) collection or on product arrival to the cell therapy processing laboratory. We have always given one 81 mg acetylsalicylic acid (ASA) when clotting is seen during collection if there is no allergy, but hypothesized that the incidence of clotting would decrease if ASA was given to all autologous collectors with a platelet count of ≥80×10 9 /L prior to collection (pre-emptively)., Methods: Autologous HPC were collected using the Spectra Optia instrument or Cobe Spectra instrument (Terumo BCT ® , Lakewood, CO) with heparinized citrate. A retrospective review was performed to determine the total number of HPC products, including products with clots, collected between September 2010 and August 2013 (group 1). All autologous HPC collectors from September 2013 onwards were given ASA pre-emptively if their platelet count was ≥80×10 9 /L (group 2), and a similar review was performed in this group. We included the cell density and platelet count of the HPC products and the platelet count of the patient in the data collected. We reviewed procedure notes for adverse events or bleeding., Results: A total of 2574 HPC products were collected between September 2010 and August 2013; clotting was observed in 66 HPC products (66/2574; 2.56%). A total of 1906 HPC products were collected between November 2013 and October 2016; clotting was observed in 24 HPC products (24/1906; 1.25%). Thus an overall reduction was seen in incidence of clotting between groups 1 and 2 (2.56% versus 1.25; P =0.002). Since not all collectors in group 2 received pre-emptive ASA, we reviewed the incidence of clotting within this group. A decrease in incidence of clots was noted with preemptive ASA (group 2A) (5/512, 0.97%) versus no ASA (group 2B) (19/1394, 1.36%), but this was not statistically significant. The mean cell density of the HPC products did not differ significantly between these two groups (group 2A and 2B) but a higher platelet count was observed in the pre-emptive ASA group as expected (group 2A) ( P =0.004). Multivariate logistic analysis after adjusting for platelet count of the HPC products showed a trend towards reduced incidence of clotting in the pre-emptive ASA group (group 2A); however no association was seen after adjusting for the cell density of HPC products, nor was an association between patient's platelet count and incidence of clotting seen. None of the collectors who received ASA suffered any adverse events, including bleeding., Conclusion: We observed an overall reduction in the incidence of clotting in our HPC products after initiating pre-emptive ASA usage (2.56% versus 1.25%; P =0.002). A trend towards lower incidence of clotting was noted when further analysis was performed to include pre-emptive ASA usage and platelet count of the HPC products. Although the overall incidence of clotting was very small (<3.0%), giving ASA pre-emptively further reduced the incidence of clotting and thus prevented wastage/cell loss of HPC products., (© 2017 by the Association of Clinical Scientists, Inc.)

Quality improvement in the health care setting is a complex process, and even more so in the critical care environment. The development of intensive care unit process measures and quality improvement strategies are associated with improved outcomes, but should be individualized to each medical center as structure and culture can differ from institution to institution. The purpose of this report is to describe the structure of quality improvement processes within a large medical intensive care unit while using examples of the study institution's successes and challenges in the areas of stat antibiotic administration, reduction in blood product waste, central line-associated bloodstream infections, and medication errors., (© The Author(s) 2015.)

Objectives: The rate of plasma product wastage for the United States in 2011 was approximately 1.8%. The plasma wastage rate at our institution was higher, mainly due to products returned out of temperature range from procedural areas. A process review and intervention to reduce plasma wastage was undertaken, which included modifications to our transport cooler., Methods: A new cooler system was designed, and this device was implemented alongside an updated protocol for delivering plasma while also enhancing the previous RBC cooler validation time. We audited plasma and RBC product wastage prior to these interventions, from January 2013 to February 2014, vs after the intervention from April 2014 to March 2015., Results: After the intervention, the monthly plasma wastage rate declined 60% (12.6 units/100 units transfused preintervention vs 5.0 units/100 units transfused postintervention; P < .0001). The monthly RBC wastage rate also decreased 28% (3.2 units/100 units transfused preintervention vs 2.3 units/100 units transfused postintervention; P < .01)., Conclusions: Our intervention resulted in significantly decreased plasma and RBC wastage and is broadly applicable, since out-of-temperature product wastage in procedural areas is likely a significant problem at many institutions., (© American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Blood is a valuable resource and blood wastage in a low socio economic country could impose a very serious impact on healthcare. This study therefore analyzes the usage and wastage of blood and blood products at the Georgetown Public Hospital Cooperation (GPHC), Guyana., Methods: A retrospective study was conducted on the data retrieved from laboratory blood banking information system on usage and wastage of blood products during the years 2012-2014 at the public hospital. The data were analyzed in MS Excel and SPSS 20.0., Results: A total of 16,426 units of blood were issued from National Blood Transfusion Services. During the study period the most frequently requested blood component was packed cells followed by fresh frozen plasma (FFP), platelet, cryoprecipitate (CRYO) and whole blood respectively. Data indicated that 4167 units (25 %) of blood were wasted due to various reasons at GPHC., Conclusions: There is a need for intervention through raising awareness among medical staff in reducing blood wastage.

Mercury, one of the most toxic heavy metals, is ubiquitous in environment. The adverse health impact of mercury on living organisms is well known. The health care facilities are one of the important sources of mercury release into the atmosphere as mercury items are extensively used in hospitals. To assess the awareness about mercury toxicity and the knowledge of proper handling and disposal of mercury-containing items in health care set-up, a questionnaire-based survey was carried out amongst doctors (n = 835), nurses (n = 610) and technicians (n = 393) in government hospitals, corporate hospitals and primary health care centres in the Indian states of Delhi, Uttar Pradesh and Haryana. The study was conducted using a tool-containing pretested structured multiple-choice questionnaire. Analysis of the results using STATA 11.1 software highlighted that overall awareness was more in corporate sector. However, percentage range of knowledge of respondents irrespective of health care sector was only between 20 and 40%. Despite the commitment of various hospitals to be mercury free, mercury containing-thermometer/sphygmomanometer are still preferred by health professionals. The likely reasons are availability, affordability, accuracy and convenience in use. There is an urgent need for source reduction, recycling and waste minimization. Emphasis must be laid on mercury alternative products, education and training of health personnel and public at large, about correct handling and proper clean up of spills., (© The Author(s) 2013.)

Objectives: Blood component waste is an important issue at all hospitals. As an initiative of the patient blood management program at a regional health care system, the causes and extent of blood product wastage were identified, and targeted interventions to effect a reduction were implemented., Methods: Multiple low-cost interventions, including educational outreach, print and digital messaging, and improved transportation and component identification modalities, were implemented beginning in January 2013. The impact on reducing RBC, platelet (PLT), and plasma wastage in the 16 months after intervention implementation was compared with the wastage rates in the 16 months before these interventions had been implemented., Results: Overall, the RBC wastage rate as a percentage of the number of units issued decreased from 0.67% to 0.56% (P = .001) after the interventions were implemented, while the PLT wastage rate decreased from 3.71% to 2.81% (P < .001). The plasma wastage rate increased from 1.14% to 1.40% (P < .001). The initial cost of these interventions was approximately $310. The net cost savings of the reduced waste was estimated at $131,520, excluding intervention costs., Conclusions: Relatively inexpensive interventions can have a prompt and dramatic impact on reducing blood wastage with regard to both cost and resource savings., (Copyright© by the American Society for Clinical Pathology.)

Stocks of red blood cells (RBC) are held to ideally match supply and demand; hold too great a stock and unnecessary wastage occurs; too low a stock results in delay or lack of blood for the patient. Blood is a precious resource and its supply needs to be managed effectively. The aim was to identify how RBC units are wasted and propose laboratory-based reduction measures that would not compromise the clinical requirements of the patient. Wastage of RBC was investigated using a 'dashboard' query of a laboratory information management system. By employing service improvement tools, proposals were made to reduce unnecessary RBC waste while ensuring an adequate supply to the patient. The efficacy of those proposals was examined using the same dashboard to compare similar periods before and after their introduction. The reduction in RBC wastage for all groups during an eight month period (December to July) was from 6.4% (5.3% non-AB or B RhD-positive) pre-implementation to 4.4% (2.5% non-AB/B RhD-positive) post-implementation. Group O RhD-negative wastage reduced from 10.4% to 4.4% after introduction of waste-saving proposals. However, there was an increase in staff time required to introduce the changes and in associated Group and Screen testing (3.4 to 3.8 per unit issued). RBC wastage was significantly reduced (P<0.0001) by 32.8% (52%, non-AB/B RhD-positive), saving approximately 225 RBC units per annum. Financially, increased associated costs did not negate the savings made by the measures introduced.

Clearance monitor systems are used for gross gamma measurements of waste potentially contaminated with radioactivity. These measurements are to make sure that legal requirements, e.g. clearance criteria according to the german radiation protection ordinance, are met. This means that measurement results may overestimate, but must not underestimate the true values. This paper describes a pragmatic way using a calibrated Cs-137 point source to generate a conservative calibration for the clearance monitor system used in the Medizinische Hochschule Hannover (MHH). The most important nuclides used in nuclear medicine are considered. The measurement result reliably overestimates the true value of the activity present in the waste. The calibration is compliant with the demands for conservativity and traceability to national standards., (Copyright © 2014. Published by Elsevier GmbH.)

Background: The national waste rate for hospital-issued blood products ranges from 0% to 6%, with operating room-responsible waste representing up to 70% of total hospital waste. A common reason for blood product waste is inadequate intraoperative storage., Study Design and Methods: Our transfusion service database was used to quantify and categorize red blood cell (RBC) and fresh-frozen plasma (FFP) units issued for intraoperative transfusion that were wasted over a 27-month period. Two cohorts were created: 1) before implementation of a blood transport and storage initiative (BTSI)-RBC and plasma waste January 1, 2011-May 31, 2012; 2) after implementation of BTSI-RBC and plasma waste June 1, 2012, to March 31, 2013. The BTSI replaced existing storage coolers (8-hr coolant life span with temperature range of 1-10°C) with a cooler that had a coolant life span of 18 hours and a temperature range of 1 to 6°C and included an improved educational cooler placard and an alert mechanism in the electronic health record. Monthly median RBC and plasma waste and its associated cost were the primary outcomes., Results: An intraoperative BTSI significantly reduced median monthly RBC (1.3% vs. 0.07%) and FFP (0.4% vs. 0%) waste and its associated institutional cost. The majority of blood product waste was due to an unacceptable temperature of unused returned blood products., Conclusion: An intraoperative BTSI significantly reduced median monthly RBC and FFP waste. The cost to implement this initiative was small, resulting in a significant estimated return on investment that may be reproducible in institutions other than ours., (© 2013 American Association of Blood Banks.)

The mineralogy, as well as elemental composition, of the incinerated hospital waste (HW) ashes are not well known and need to be investigated for the safe handling and disposal of such ash. A study was conducted to investigate the chemical composition, mineralogy and bioleaching of selected metals from incinerated HW bottom ash using Aspergillus niger under the combined effect ofultrasonic radiation. Different techniques were utilized to determine the elemental composition (Electron Dispersive X-ray Spectroscopy [EDX], atomic absorption spectrophotometry, inductively coupled plasma-optical emission spectroscopy, ultraviolet-visible light spectrophotometer) and mineralogy (X-ray Diffraction) of the raw sample, as well as the bioleached samples. Chemical leaching tests were performed to determine the effect of different organic acids on metals dissolution. Microbes were tested for acid production and leaching capabilities of selected metals from medical waste (MW) bottom ash. Wet chemical and EDX analyses showed that the ash was enriched with metallic elements like Na, K, Ca, Fe and Al with a concentration range of 22-115 (g/kg). Furthermore, the ash contained heavy metals such as Cu, Cr, Ni, Sn and Ti in the range of 0.51-21.74 (mg/kg). Citric and oxalic acids generated by fungi could be important leaching agents acting to dissolve these metals. Under ultrasonic treatment, metals dissolution by the acidic metabolites was at its maximum after just 9 d of leaching. The results showed that the dissolution of metals was much higher in citric and oxalic acid than with other acids. Extraction of metals from incinerated MW ash indicated that this ash may be a potential source of metals in the future.