Reusable Totes,
Blue Wrap Recycling
and Composting
Environmental Best Practices for Health Care Facilities | November 2002 jcaho Environment of Care
Standards 1.3,2.3,4.0
How Much Waste is Wasteful?
Although medical and infectious wastes are often highlighted in evaluations of
a hospital's waste stream, these hazardous wastes constitute only 15% of a hos-
pital's total waste generation. The remaining 85% of a hospital's waste, which is
considered to be nonhazardous solid waste, is similar to a combination of
wastes from hotels, restaurants, and other institutions providing lodging, food
services, data processing and administration, and facility operations. In fact,
disposal costs for hospital solid waste in 2000 ranged from $44 to $68 per ton,
depending on local conditions, disposal method (landfilling versus incinera-
tion), and proximity to the disposal facility. Often, solid waste is mistakenly
placed in "red bag" or medical waste containers, thus increasing the cost of
disposal and unnecessarily raising the level of treatment needed for the waste.
By implementing effective solid waste reduction and recycling programs, hospi-
tals can significantly reduce their solid waste streams.
This fact sheet highlights case studies for three of the largest components of
an average hospital's solid waste stream: paper material (including cardboard),
plastics, and food waste. The case studies provide detailed information on
costs, savings, and implementation issues to help your facility evaluate these
waste reduction and recycling techniques.
Reusable Totes: Cardboard Pollution Solution
Cardboard and other paper materials represent almost half of a typical hospital's solid waste stream. The following case study describes how one
large healthcare system decreased cardboard and packing material use by implementing reusable totes for internal distribution of supplies. The
cost-effectiveness of using reusable totes varies among hospitals and greatly depends on the structure of the health care organization. The reusable
totes are most cost-effective when they replace a constant cardboard need, such as when a health care system has a central distribution center and
uses new cardboard boxes to distribute materials to satellite locations. However, the scale of a reusable tote program can be tailored to meet the
needs of the organization - even on a small scale, reusable totes may be a cost-effective alternative for replacing a constant cardboard need.
case study | Cutting Cardboard with Kaiser Permanente
Kaiser Permanente (Kaiser) operates three distribution facilities that serve as central supply warehouses for all its hospitals and
clinics throughout the United States. Kaiser sorts and repackages the medical supplies delivered to the central supply facilities
(most often on pallets) based on the needs of each hospital and clinic. In 1990, Kaiser implemented a pilot program that has since
changed the way it manages inventory: Kaiser began using reusable totes in place of disposable cardboard boxes for distribution.
The program began in Kaiser's Livermore, California, supply warehouse, which serves 12 northern California hospitals. Initially,
Kaiser purchased a total of 11,000 totes in four sizes: large, medium, small, and tiny. This enabled warehouse employees to
select totes based on the volume of material to be distributed, nearly eliminating the packing material needed to fill partially full
containers. Since implementing the program in 1990, Kaiser has saved approximately $40,000 a year by dramatically reducing
the cardboard boxes, tape, and filler purchased. Because Kaiser had previously recycled the cardboard at no cost, most of it was
continues
Hospital Solid Waste Composition
Other Wood Glass Plastics Food Metals Paper
10% 3% 7% 15% 10% 10% 45%
From Bisson, McRae. and Shaner, 1993
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page 2 Environmental Best Practices for Health Care Facilities | Reusable Totes, Blue Wrap Recycling and Composting
already being diverted from the landfill and does not represent a
significant savings in avoided disposal costs. Unlike cardboard
boxes, the totes do not require assembly for use and resulted in
a significant increase in productivity, saving approximately 500
labor hours or $12,100 in wages annually.1
Kaiser also reduced the amount of labor required for delivery
of supplies to end-users by color-coding the totes according to
their content. Kaiser employees can identify the contents—and
general destination — simply by noting the color of the tote.
Because the large, medium, and small totes each have the
same footprint, they are easily stackable ("nestable") and do
not require much storage space — the medium and large totes
have an average footprint of 15 by 21 inches, varying in height
between 6 and 9 inches. The smaller totes are 6 inches high
and have a footprint of 10 by 10 inches.
In addition, the totes have proven to be very durable. Since the
initial purchase, Kaiser has bought an additional 500 to 700 totes
per year (5 to 7% of total inventory) to replace totes that were
damaged, "lost" in the system (used for storage), or stolen.
Kaiser's color coded totes helped reduce labor cost
and simplify routing
GREY
BLUE
BROWN
YELLOW
For non-perish- For pharmacy For initial pre- For refrigerated
able consum- refills that scriptions that medication that
able goods such are less time- are urgently must be kept
as intravenous critical needed cold
bags, tubing,
and bandages
Lastly, the totes have not posed a significant maintenance issue.
Because the contents of the totes are new, sealed products, the
interiors of the totes stay clean. About every other year, Kaiser
sends 25 percent of the inventory to be steam-cleaned, which
costs $0.50 per tote or $687.50 annually.
The program has since been expanded from the Livermore facil-
ity to the other two central supply warehouses.
Kaiser Permanente Reusable Tote Program
Payback Period: Less Than 4 Years
1 While not quantified for this case study, additional labor may have been saved since Kaiser did not have to breakdown the cardboard boxes for recycling.
2 Exact numbers were not available at the time of fact sheet publication. Kaiser estimates that a cardboard box could be assembled in 5 seconds, or 720 cardboard boxes per hour.
3 The average retail cost for a 12-gallon tote sold by vendors listed on the back page of this fact sheet; considerable discounts are typically offered to organizations purchasing in bulk.
4 Totes are steam-cleaned every other year, costing Kaiser $687.50 annually
5 Since the cardboard was recycled at the facility where the supplies were delivered, cumulative disposal costs were not available.
Blue Sterile Wrap and Plastic Film Recycling
Recently, blue sterile wrap recycling has attracted interest as a way to significantly reduce the amount of plastic disposed as solid waste. For example,
the Nightingale Institute estimated that approximately 19% of the waste stream generated by surgical services is blue sterile wrap. Made of polypropylene
(plastic #5), a polymer with good resistance to chemicals and wear, blue sterile wrap is used in all hospitals to protect patient gowns and toiletries,
medical devices, and surgical instruments from contamination. Blue sterile wrap waste is most often generated in just a few areas of a hospital,
simplifying the collection process. Blue sterile wrap is not reusable, as the material does not withstand the sterilization process between uses. Less
bulky material has been considered; however, the alternatives have not matched polypropylene's ability to 1) resist tearing when holding sharp surgical
instruments and 2) provide a protective moisture barrier to prevent contamination after sterilization. Recently, several manufacturers have begun
using polypropylene as feedstock for other retail products, making it easier to recycle blue sterile wrap and other plastic films (including plastics #2,
#4 and #5). Nonetheless, a few key requirements must be met to make a recycling program practical:
• Identify a local market for polypropylene or #5 plastics. Without a regional recycler, it is unlikely that a program will be economically feasible.
It is inefficient to ship the material significant distances for recycling because of the relatively low market value of #5 plastics and the high volume
and low weight of the material.
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Reusable Totes, Blue Wrap Recycling and Composting I Environmental Best Practices for Health Care Facilities page 3
• Establish a low-cost collection and transport system. Because the market value of polypropylene is relatively low, collection and transportation
costs must be minimized. Essentially, the cost of collection and transport cannot exceed the recycling income (approximately $0.04 per pound)
and avoided disposal fees (approximately $0.03 per pound, or $56 per ton).
• Generate a significant quantity to warrant vendor cooperation. Although arrangements
can be made with local recyclers to supply blue sterile wrap and plastic film collection
containers at little or no cost to a hospital, the facility must generate enough used
polypropylene to make the program worthwhile. However, the quantity required varies
directly with regard to the points above. For example, the further the distance from a
regional recycler, the greater the quantity required to support a program.
These requirements are dependent on other factors as well, such as distance to a regional
recycler and proximity to other healthcare facilities that are also recycling blue wrap and
other plastic films. The following case studies provide details of how two organizations have
implemented successful blue sterile wrap recycling programs and highlight the potential
environmental and economic benefits. The first case study highlights a new program, while
the second features a program that has been operating for over 10 years.
case study | Easy Transition to Recycle Blue
Sterile Wrap and Plastic Film
Dominican Hospital (Catholic Healthcare West) in Santa Cruz,
California, implemented a blue sterile wrap and plastic film
recycling program in May 2001. Dominican's initial objective
was to divert only the blue sterile wrap from the waste stream;
however, the hospital learned that their plastic film often used
to package materials and wrap pallets can also be recycled with
the blue sterile wrap. Clearly labeled collection containers
were placed in the six departments that generated the highest
quantities of blue sterile wrap and plastic film waste: central
distribution, purchasing, the pharmacy, the operating rooms,
outpatient oncology, and labor and delivery. Before implement-
ing the program, the environmental staff discussed program
Dominican Hospital
Cumulative Blue Sterile Wrap and Plastic Film Recycling
May, 2001 through June, 2002
objectives and logistics with department staff members —
including nurses, administrative personnel, and custodial
employees — to address their concerns and convey the benefits
of the program. In total, Dominican's environmental staff spent
about 3 days setting up the program, including gaining buy-in
from hospital staff, working with vendors, and setting up collec-
tion containers and schedules.
Collection Containers and Disinfection
One concern that emerged from the meetings with department
staff was how to disinfect the containers used to collect the
blue sterile wrap and plastic film. Although administrative
departments such as central distribution and purchasing were
satisfied with the standard cardboard containers, the operating
room wanted containers that could easily be routinely disinfected.
Therefore, a stainless-steel frame that could be easily wiped
down was used to collect blue wrap in individual operating rooms.
S -
7 -
6 -
5 -
3 -
2 -
Tons -
4-
May '01
July
June Aug
Sept
Oct
Nov
Dec
Jan '02
Feb
Mar
Blue sterile
wrap represents
about 19% of
all surgical
sendee waste1
May
April June
Material Management
The custodial staff spends less than 30
minutes each week emptying all the
collection containers in the hospital as
they are filled. Full bags, weighing
about 17 pounds each, are transferred
to a 3-cubic-foot dumpster on the
building's loading dock. Dominican
donates the sorted blue sterile wrap
and plastic film to a local nonprofit
recycling organization, Grey Bears, that
uses the proceeds from the sale of recy-
clable commodities to buy and prepare
hot meals for disadvantaged senior citi-
continnes
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page 4
Environmental Best Practices for Health Care Facilities | Reusable Totes, Blue Wrap Recycling and Composting
zens in the community. Grey Bears picks up the dumpster each
Friday and bales the blue sterile wrap and plastic film until a
full-enough load has accumulated to warrant a pickup by Marathon
Recovery of Oakland, California, which purchases the material
to be used as a binding agent in making siding materials.
A similar program was established throughout the Legacy Health
System (LHS) in Portland, Oregon. Since summer 1991, house-
keeping employees collect sorted recyclable commodities, including
blue sterile wrap and other polypropylene plastics, at four LHS
hospitals in the greater Portland area. The material is col-
lected in either clear or
Legacy Health System Blue Sterile
Wrap Recycling Savings
Monthly Diversion Amount:
3.5 tons
Monthly Diversion Savings:
blue plastic bags and is
delivered to the recy-
cling depot in each
building.
LHS owns and operates
its own recycling center
just two blocks from
Good Samaritan
Hospital, one of LHS's
facilities. LHS has established a cooperative relationship with
several of its vendors, including Kimberly-Clark, Owens and
Minor, and BioMed, to transport the recyclable commodities to
Monthly Labor Costs:
' $250
Once the recyclable commodities are dropped off at the recycling
center, employees of the Susan Christiance Vocational Program
(SCVP), a non-profit organization that employs challenged indi-
viduals, sort the material. The blue sterile wrap is placed in a
40 cubic-yard roll-off container provided at no cost by Waste
Management Incorporated. The container is hauled three to
four times per month, diverting 3.5 tons of blue sterile wrap
from the solid waste stream and saving $400 in disposal costs.
Waste Management bales the blue sterile wrap and, once enough
has accumulated, transports the material to Marathon Recovery.
Getting Green in the Kitchen
The kitchen and food service operations of a hospital leave a unique mark in the hospital's environmental footprint. Although food waste itself can
represent 10% of the hospital's waste stream, for every patient tray, another 15 pounds of waste is generated (including glass, cans, and cardboard
from food and washing solution packaging).2 Although the kitchen and food service operations of a hospital
generate a variety of solid wastes, source reduction and recycling programs often overlook this area of the
facility- especially the opportunity to divert organic matter through composting food waste. However, there
are several obstacles to consider when implementing a food waste composting program:
• Space limitations. In many cases, space constraints are the primary factor dictating which composting
method a hospital can adopt. Because hospitals are often located in urban areas where space is limited,
they must either make arrangements to haul the food waste to an off-site composting facility or pur-
chase a compact, in-vessel composting unit.
• Beating the stigma. The benefits of composting are often misunderstood and overshadowed by miscon-
ceptions. For example, many people fear that composting will produce a strong odor and attract pests
such as insects or rats. Consequently, a composting program should feature (1) management buy-in to
ensure that employees participate in the program and (2) well-run operations to prevent odor and the
presence of pests.
• Program participation. For composting to be cost-effective, a hospital must tailor the scale of the pro-
gram to the quantity of food waste generated and must ensure that employees participate in the pro-
gram. Both points are especially important for facilities that make a significant capital investment in
purchasing on-site composting technologies.
Vermitech system
(worms, digester and shredder):
$25,000
Building and supplies:
$31,000
Labor:
$62 per week
Composting Program
Costs
1/S.
Savings
Diversion savings:
§59.50 per ton
Worm castings:
$1 per pound
the LHS recycling center.
The commodities are
hauled as "backfill" mate-
rial, meaning that they
are collected on return
trips when the vendors'
trucks are empty. In addi-
tion to the four LHS hos-
pitals, LHS has begun
Blue sterile wrap recycling at accepting blue sterile
Dominican Hospital wrap vv;|S,e from Qther
Portland-area hospitals
that can make similar transport arrangements with their vendors.
1 "Medcycle Offers Opportunities for Nurses as Front-Line Recyclers," Nightengale Institute, www.nihe.org/medcyc.html
: "Saving Disposal Dollars: Hospital Finds Winning Waste Reduction Formula" BioCycle, January 1999
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Reusable Totes, Blue Wrap Recycling and Composting I Environmental Best Practices for Health Care Facilities page 5
The following case study provides details of how one facility has begun
to divert food waste from their cafeteria and discusses some of the
obstacles to implementing a successful program.
case study | Putting Worms to Work at the
Medical University of South Carolina
In a continuing effort to cut material from its waste stream and
noting the success of other universities' composting programs,
the Medical University of South Carolina (MUSC) in
Charleston, South Carolina, implemented a food waste com-
posting program in July 1999. Three state and national organi-
zations provided approximately 70 percent of the startup costs;
the Department of Health and Environmental Control
(DHEC), the 1)1 II C Energy Office, and the Sustainable
Universities Initiative. Because of its urban location and signifi-
cant space contraints, MUSC chose to install the Vermitech
Systems Incorporated in-vessel vermi-organic digester.
MUSC built a simple, 18 by 24-foot building to house the
digester; building features include a sloped floor coated with
acrylic for easy cleanup, a ventilation fan, and a 10-gallon water
heater. (The digester can also be placed in an existing structure
or in a secure outdoor location.) Necessary supplies include
four 45-gallon, wheeled containers; a scale; a long-handled
squeegee; gloves; a long-handled plastic broom; a flat headed-
shovel; a hose with multi-option spray nozzle; a dustpan; and
pH and moisture meters.
Contracted kitchen staff collect preconsumer food waste from
the hospital's cafeteria kitchen in a 45-gallon container. Once
a day the recyling staff collects the container, which varies in
weight according to its contents. The contents are fed into a
Medical University of South Carolina
Composting Food Waste Diversion Amounts
1999 through 2001
16 r t,
Ol 02 03 Q4 Ol 02 Q3 04
VY'99-00 I X 00 Ol
Thousands of-worms live in the Vermitech Systems composting digester
at MUSC, turning food waste into a valuable soil amendment.
shredder, where the food waste is mixed with cardboard until
the appropriate moisture level is obtained. The mixture is then
fed into the in-vessel digester by a conveyer belt. The worms in
the digester can eat 250 pounds per day, reducing the volume
of the food waste and cardboard mixture by 80 percent
overnight. The worms produce castings that are used as a soil
amendment and have a value of about $1 per pound. The cast-
ings also slightly reduced the hospital's need for commercial fer-
tilizers and actually improved the condition of the soil. Because
the worms tend to stay near the top of the in-vessel digester
(near the fresh food), the castings are mechanically harvested
from the bottom of the container. The castings fall to the floor,
where they are swept up using a broom and squeegee. The cast-
ings are then given to MUSC's grounds department. It typically
takes no more than 1 hour each day to collect the food from
the cafeteria and transport it to the composting building,
process the food through the digester, and clean up after pro-
cessing a batch of food waste. The recycling coordinator also
spends 30 minutes per week checking the depth of the digester
bedding and the health of the worms and their environment.
MUSC composts 115 pounds of food waste each day, repre-
senting 50 percent of the digester's operating capacity. At this
rate, the program can sustain itself, but is not paying back the
capital costs required to set up the program. MUSC believes
that the low participation rate is due to ongoing employee resis-
tance and skepticism. Although the MUSC recycling staff
makes constant efforts to convey the benefits of the program
and encourages MUSC kitchen staff to participate in the pro-
gram, staff participation level ranges result in using only 30 to
70 percent of the digester capacity. If the program operated at
100 percent capacity, processing 250 pounds of food waste per
day and harvesting 3,000 pounds of castings per month, the
payback time would be approximately 6 years (which is compa-
rable to other in-vessel unit payback periods).
continues
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page 6 Environmental Best Practices for Health Care Facilities | Reusable Totes, Blue Wrap Recycling and Composting
Reusable Totes
Kaiser Permanente
(818) 321-2276
Akro-Mils
(800) 253-2467
Remcon Plastics Inc.
(800) 253-2467
Blue Sterile Wrap and
Plastic Film Recycling
Dominican Hospital
(831) 462-7674
Legacy Health System
(503) 413-6066 '
Conigliaro Recycling
(888) 266-4425
Marathon Recovery
(510) 636-4191
Composting
Medical University of South Carolina
(843) 792-4066
Green Mountain Technologies
(802) 368-7291
Vermitech Systems Inc.
(416) 693-1027
Consider taking the "Hospitals for a Healthy Environment Pledge." Find out more at www.h2e-online.org
This fact sheet was produced by the Environmental Protection Agency (EPA) Region 9 Pollution Prevention Program. Mention of trade names, products,
or services does not convey, and should not be interpreted as conveying, official EPA approval, endorsement, or recommendation.
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