More evidence is needed to assess the impact of practices to reduce physical waste from healthcare on health outcomes, social outcomes, or healthcare costs, utilization and value.
Few studies examined the impact of these practices on health outcomes, focusing instead on emissions reductions, energy costs and efficiency gains.
The findings below synthesize the results of the studies on practices to reduce the impact of physical waste in healthcare on climate across three domains of measurement:
Climate change poses a significant and growing threat to human health in the United States (U.S.). Rising temperatures, more frequent extreme weather events, shifting disease patterns, and worsening air quality are driving increasing rates of morbidity and mortality, with the heaviest burden falling on historically marginalized communities, including low-income populations, communities of color, and older adults[1]. The healthcare sector is simultaneously impacted by and a significant contributor to the climate crisis[2]. Globally, the sector accounts for an estimated 4.4% of net emissions, a proportion that is growing alongside expanding healthcare demand[3]. In the U.S., healthcare is responsible for approximately 8.5% of national GHG emissions, making it one of the largest sectoral contributors to climate change in the country[4]. A major driver of greenhouse gases is physical waste[5], which impacts climate through emissions related to manufacturing disposable supplies, transporting and incinerating waste, and methane produced from the decomposition of waste in landfills[6],[7]. Incinerating one ton of medical waste can generate the equivalent of one to two tons of CO2, and also releases dioxins, identified by the U.S. Environmental Protection Agency (EPA) as one of the most potent known carcinogens[8]. In addition, wastes have other potential negative impacts on human health, including toxic exposure of materials like plastics into the environment, sharps-inflicted injuries, the spread of antimicrobial resistance through unsafe storage, treatment and disposal of pharmaceutical wastes, and other environmental impacts[4],[9].
The U.S. healthcare system directly generates an estimated 14,000 tons of waste daily, 20 to 25% of which are plastics[10]. One hospital system estimated that each filled hospital bed results in 29 pounds of waste per day[7]. This is in addition to the waste produced as a result of the supply chain for all goods purchased by health systems.
The financial costs of the GHG footprint are substantial and directly relevant to payers and providers. The sector's GHG emissions were estimated to be responsible for the loss of 388,000 disability-adjusted life-years in 2018, representing a quantifiable disease burden generated by the healthcare system itself[4].
For payers serving Medicaid and uninsured populations in particular, the health equity dimensions of climate change are a growing financial concern. Low-income communities and communities of color face disproportionate exposure to climate-related health risks, which drives increased utilization of healthcare services[11]. These populations are also more likely to be enrolled in Medicaid, thus the costs of climate-attributable illness fall disproportionately on public payers and safety net providers[12]. A policy analysis by the Federation of American Scientists noted that extreme heat events alone drive a 10% surge in emergency department visits among low-income populations, with every 10 additional days of extreme heat inflating annual Medicaid transfer payments by nearly 1% ($11.78) per capita[11]. Reducing the healthcare sector's contribution to climate change is therefore not only a matter of operational efficiency but a lever for addressing the structural conditions that widen health disparities among the populations most dependent on public healthcare systems.
Strategies to reduce waste in healthcare, and the resulting greenhouse gases and broader environmental impacts, include improved waste segregation, removing rarely used surgical instruments, reducing plastic use, diverting food waste, and avoiding single-use disposables when possible[13]. While there is currently no direct Medicaid or Medicare reimbursement mechanism tied specifically to institutional healthcare decarbonization or waste reduction, value-based purchasing frameworks and state regulations sometimes tied to licensing may include healthcare system requirements or reporting[14].
To fund macro-level facility upgrades, non-profit and public hospitals continue to leverage Investment Tax Credits under the Inflation Reduction Act, as detailed by the National Academy of Medicine, to offset the upfront capital required to transition to renewable on-site energy[15]. Concurrently, clinical operations are standardizing sustainability through independent quality frameworks that drive institutional investment. Organizations can utilize the Sustainable Healthcare Certification launched by The Joint Commission, which provides hospitals with standard metrics to set carbon reduction priorities, including waste, and build formal sustainability governance outside of federal mandates[16]. According to Practice Greenhealth’s sustainability benchmark report representing 493 healthcare facilities, strategic sustainability initiatives generated more than $203 million in annual savings through targeted interventions like smart energy management, medical device reprocessing, and waste diversion, demonstrating that institutional decarbonization practices could generate strong financial returns[17].
Operating room staff and patients across surgical specialties at a single high-volume, urban hospital (Cedars-Sinai Medical Center, Los Angeles, California).
Quality improvement (QI) project using three Plan-Do-Study-Act (PDSA) cycles to reduce regulated medical waste (RMW) in the operating room (OR). The intervention (Cycle 3) consisted of a specialized educational in-service ("Red2Red") on proper waste sorting per OSHA and state Department of Public Health guidelines, and a process change limiting each OR to one red RMW bag per case. A leadership team of eight members, comprising physicians, nurses, safety officers, and environmental services (EVS) leadership, met bi-weekly throughout the project. Signage was posted, and OR setup was adjusted and maintained throughout the 14-month follow-up period. Intervention costs not reported.
Pre-post analysis. This was a quality improvement study using three PDSA cycles with Mann-Whitney U test for comparison of continuous variables. Data were collected retrospectively for nine months prior to the test of change (July 2021 to March 2022) and prospectively for 14 months following implementation (April 2022 to May 2023). 13 operating rooms on one floor of the hospital were included.
Healthcare Cost, Utilization & Value: Median monthly RMW tonnage decreased significantly from 19.11 tons to 7.44 tons following the test of change (p<0.001). RMW as a percentage of total monthly waste decreased from 39.8% to 16.61% (p<0.001). Median monthly RMW disposal cost dropped from $17,537.52 (77.06% of total waste cost) to $6,401.14 (49.21% of total waste cost) (p<0.001). Median monthly total waste disposal cost decreased from $23,049.33 to $13,354.94 (p<0.001). Reduction in RMW volume decreased reliance on incineration and specialized processing, reducing associated greenhouse gas (GHG) emissions, though the specific reduction in emissions was not quantified.
Staff and providers at a private outpatient dermatology practice in California.
Two concurrent 30-minute educational interventions delivered to all staff at a private outpatient dermatology practice to reduce unnecessary regulated medical waste (RMW) disposal. Sessions provided case-based examples and photographs of proper RMW disposal practices. Minor logistical changes were also implemented, including adjustments to the proximity of RMW and non-RMW containers within examination and treatment rooms. Study duration was 30 days, divided into a 15-day pre-intervention phase and two sequential post-intervention phases.
Pre-post analysis. This study used an unpaired two-sample t-test to compare proper waste segregation before and after interventions, and a regression model to explore the influence of room type and container orientation on proper waste segregation.
Healthcare Cost, Utilization & Value: Following both educational interventions, the percentage of total waste disposed of as RMW decreased by 6.0% (95% Confidence Interval [CI]: 1.2–10.8%). The percentage of waste appropriately placed in RMW containers increased by 56.1% (95% CI: 43.7–68.5%) after both interventions compared to pre-intervention levels of 11%. For a 10-physician practice, the intervention was estimated to reduce carbon emissions by approximately 200 kg per year and costs by approximately $1,000 per year. Rooms with RMW and non-RMW bins placed close together had 11.5% (95% CI: 0.6–22.4%) more waste placed in the appropriate bin. Treatment rooms had 18.6% (95% CI: 6.8–30.3%) more waste placed in the appropriate bins compared to examination rooms.
Healthcare staff across operating rooms (ORs), intensive care units (ICUs), and obstetrics and gynecology (OBGYN) departments at Akron City Hospital (ACH), a single hospital in Akron, Ohio. Monthly waste data were analyzed from January 2022 to June 2024.
Multi-departmental quality improvement (QI) initiative implemented through sequential Plan-Do-Study-Act (PDSA) cycles to reduce regulated medical waste (RMW) volume and disposal costs at ACH. Interventions were initiated in the ORs in October 2022 and expanded to ICUs and OBGYN by February 2024. Strategies included department-specific staff education sessions on proper waste segregation in alignment with Occupational Safety and Health Administration (OSHA) and Ohio Environmental Protection Agency guidelines, placement of laminated flyers on red bag receptacles as visual reminders, and operational adjustments to the number, size, and placement of red bag containers in each department.
Pre-post analysis. This was a quality improvement study using two-tailed heteroscedastic t-tests to compare mean monthly RMW weights and disposal costs before and after interventions, with an autoregressive integrated moving average (ARIMA) model used to forecast monthly weights from July to December 2024.
Healthcare Cost, Utilization & Value: Monthly total RMW weight at ACH decreased from 56,366 lbs in 2022 to 45,148 lbs in 2023 and 37,017 lbs in early 2024 (p<0.001). Variability in monthly RMW weight also declined, with standard deviation [SD] decreasing from 6,177 lbs in 2022 to 4,062 lbs in 2023. Corresponding RMW disposal costs decreased from $175,189.51 in 2022 to $140,321.18 in 2023 and $57,528.17 in the first six months of 2024. ARIMA modeling indicated stabilization of monthly RMW weights from July to December 2024, supporting the long-term sustainability of the reductions. Anomaly detection confirmed no significant anomalies post-intervention, indicating consistency and reliability of waste management improvements. Reduction in RMW volume decreased reliance on incineration, contributing to a reduced ecological footprint, though the specific reduction in GHG emissions was not quantified.
Healthcare systems globally, with a focus on high-income countries. The U.S. was the most frequently discussed country among included empirical studies (27 of 205 included publications, 13.2%), followed by the United Kingdom (21, 10.2%), Australia (17, 8.3%), and Canada (14, 6.8%). Studies addressed healthcare systems at the micro (frontline clinician and facility level), meso (regional or network level), and macro (national or global) levels.
Strategies used by healthcare systems to reduce greenhouse gas (GHG) emissions and carbon footprint. Nine themes were identified through inductive thematic analysis, grouped into overarching strategies and decarbonization tactics: changing clinical and surgical practices (107 publications); enacting policies and governance (97); managing physical waste (83); changing organizational behavior (76); actions of individuals and groups (74); minimizing travel and transportation (70); using tools for measuring GHG emissions (70); reducing emissions related to infrastructure (63); and decarbonizing the supply chain (48).
Systematic review. Eight databases were searched from inception to November 2023. Of 33,737 publications identified, 205 were included following title, abstract, and full text screening. Four quality appraisal tools were applied, and results were reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was prospectively registered on PROSPERO (CRD42022383719). The majority of included studies were appraised as high (54.6%) or moderate (39.0%) quality. 205 publications were included.
Healthcare Cost, Utilization & Value: Across included publications, decarbonization strategies in healthcare systems were associated with GHG emissions reductions spanning all three emission scopes. Changing clinical and surgical practices, particularly replacing high-GHG anesthetic agents and reducing low-value care, was the most frequently discussed decarbonization tactic (107 publications). Managing physical waste was identified in 83 publications as a key avenue for reducing emissions, including waste minimization, reuse, recycling, and improved waste disposal practices. Supply chain decarbonization, including sustainable procurement and food supply, was addressed in 48 publications, though the authors noted this was discussed less frequently than expected given the large contribution of supply chain emissions. Numerous tools and frameworks for measuring GHG emissions were identified; however, the authors noted that implementation and evaluation of the sustainability of decarbonization initiatives were largely missing from the literature.
Surgical patients across multiple specialties in hospital operating room (OR) settings. Included studies spanned otorhinolaryngology, orthopedic surgery, cardiothoracic and vascular surgery, gynecologic surgery, pediatric surgery, plastic surgery, breast surgery, neurosurgery, ophthalmology, and urology. The majority of included studies originated from the U.S. and Canada.
Approaches for surgical instrument tray optimization, defined as the elimination of unnecessary or redundant instruments from reusable surgical trays, and its associated environmental, economic, and efficiency outcomes. Three optimization strategies were identified across included studies: expert analysis (29 studies), including staff review and procedure observation; lean practices (11 studies); and mathematical programming (five studies). Cut-off values for instrument removal ranged from 12.5% to 50% instrument usage rate (IUR), with the most common threshold being instruments used in fewer than 20% of observed procedures.
Systematic review. Searches were conducted in PubMed, Embase, Web of Science, and The Cochrane Library in August 2024 for studies on optimizing surgical trays in human surgeries. Of 4,511 studies identified, 46 met the inclusion criteria following title, abstract, and full text screening. Risk of bias was assessed using the ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool; 22 studies exhibited serious risk of bias, and 24 exhibited moderate risk.
Healthcare Cost, Utilization & Value: Across included studies, tray optimization was associated with instrument reductions of 19% to 89%, with the majority of studies (20 of 46) indicating that over 50% of instruments could be removed from trays. All 32 studies that examined economic outcomes reported cost reductions, ranging from €0.19 to €387.78 per procedure, with relative cost reductions of 32% to 78% reported in seven studies. Tray weight decreased by an average of 43% across 12 studies reporting this outcome, with reductions ranging from 15% to 93%. The environmental impact of tray optimization was described in four studies; optimizing trays can reduce the carbon footprint by 40% to 66%, with the environmental impact of reusable instruments primarily driven by the cleaning and sterilization process. One life cycle assessment (LCA) reported a reduction of 2.22 to 3.70 kg carbon dioxide equivalent (CO2eq) per abdominal radical hysterectomy procedure following a 29% reduction in instrument count, and another reported a reduction of 9.40 kg CO2eq per carpal tunnel release procedure following a 72% reduction in instrument count. Nineteen studies reported improvements in OR efficiency, including reductions in set-up time, instrument counting time, turnover time, and total OR time of 7 to 39 minutes in studies reporting this outcome.
Healthcare providers (HCPs), hospital decision-makers, and surgical staff across operating room (OR) settings globally. North America was among the most represented geographic regions across included studies.
Hospital sustainability initiatives undertaken in the OR setting, with a focus on HCP and decision-maker beliefs and perceptions related to sustainability. Seven categories of sustainability initiatives were identified across included publications: waste segregation and management (57 studies); quantification and reduction of GHG emissions (57 studies); staff training dedicated to sustainable practices (22 studies); reduction of resource consumption (14 studies); HCP and staff-led sustainability initiatives (eight studies); dedicated recycling initiatives (eight studies); and creation of sustainable OR committees (six studies).
Scoping review. Searches were conducted in Embase and PubMed for studies published between January 2011 and November 2022. Of 3,534 studies identified, 163 were included following title, abstract, and full text screening using Covidence review software. Included study designs comprised 74 prospective, 21 retrospective, and 11 cross-sectional observational studies, 26 life cycle assessments, 12 product audits, 10 systematic literature reviews, six budget impact and cost-effectiveness studies, and one randomized controlled trial. N=163 included publications.
Healthcare Cost, Utilization & Value: Across included publications, waste segregation and recycling initiatives achieved reductions in OR-generated clinical waste of up to 82%, with one multidisciplinary green OR committee reporting a 75% decrease in biohazard waste over four years, diversion of 12,000 lbs of solid waste from landfills, and annual cost savings of $158,000.
Proper waste sorting over a three-month period reduced the waste-related carbon footprint by 43.6% in one study.
After implementing energy-related interventions across five hospitals over five years, the average reduction in energy use was 27.2 kBtu per square foot per year, with reductions ranging from 3.1% to 24%. One initiative involving occupancy sensors and lighting changes in ORs achieved a yearly reduction of 717 metric tons of carbon dioxide equivalent (CO2eq) and yearly savings of $53,075.
Hospital inpatient and outpatient settings (96 of 107 studies), health-system-wide analyses (six studies), aged-care settings (two studies), and primary care settings (three studies) across high-income countries. Of the 107 included studies, 51 originated from North America, with 46 of these from the U.S. 51 of the 107 studies focused on the operating room within anesthesiology and surgical specialties.
Sustainability principles and interventions implemented in high-income countries to reduce greenhouse gas (GHG) emissions from health-system solid waste, organized according to the waste hierarchy. Waste-management interventions identified across included studies included transition to electronic health records; removal of rarely used single-use items from preprepared sterile surgical packs; reuse of personal protective equipment (PPE), surgical textiles, procedural instruments, and non-invasive medical devices; introduction of recycling streams and recycling of surgical blue wrap; reprocessing and refurbishment of devices labelled as single use; replacement of high-emissions disposable items with lower-emissions alternatives; and staff education and training on appropriate waste segregation.
Systematic review. Five databases (CINAHL, MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar) were searched for studies published between January 1, 2008 and December 31, 2023. Of 5,283 titles and abstracts screened following deduplication, 107 studies were included. Quality was assessed using the Quality Assessment with Diverse Studies (QuADS) tool; 20 studies were rated low quality, 65 moderate quality, and 22 high quality. N=107 included studies.
Healthcare Cost, Utilization & Value: 54 of the 57 studies that reported economic costs found cost savings associated with interventions aimed at reducing waste and emissions. Reuse interventions were the most studied category (45 studies), with notable findings including an estimated $5.55 billion in cost savings had all US health care workers worn reusable respirators with decontaminated filters instead of disposable respirators during the first six months of the COVID-19 pandemic. Use of reusable laryngoscope blades at one US tertiary hospital was associated with cost savings of $180,000 to $265,000 per year. Introduction of commingled recycling across 21 pediatric operating rooms in a US children's hospital achieved annual emission reductions of 58.50 to 91.50 metric tons of carbon dioxide equivalent (CO2e) and annual cost savings of $15,210 to $24,000. A combination of reduce, reuse, and recycle interventions for laparoscopic hysterectomy in one US hospital achieved reductions of 277 kg CO2e per case and 233 metric tons CO2e per year. Waste segregation education and engagement initiatives at one Spanish tertiary hospital yielded net savings of $135,237 per year. Transition to electronic health records at Kaiser Permanente (8.7 million members) was estimated to reduce emissions by 21.80 kilotons CO2e per year due to reduced paper usage, though the authors noted methodological limitations in this estimate.
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