Single-use disposable plastic devices and packaging have become ubiquitous in all aspects of patient care. In otolaryngology clinics, operating rooms, and emergency rooms all over, we have seen a transition from durable, reusable equipment to single-use devices (SUDs) and increased use of plastic peel packs for reusable items such as nasal speculums and Frazier suctions. Personal protective equipment, including gowns, gloves, and eye protection, patient gowns, linens, and drapes, and complex procedural equipment such as flexible laryngoscopes are increasingly discarded after a single patient encounter.
Explore This IssueDecember 2023
Commonly cited reasons for this transition include infection control, convenience, perceived cost benefit, and industry-driven change in product availability (Health Aff. 2020. doi:10.1377/hlthaff.2020.01118). In actuality, there’s a paucity of data to support the use of SUDs and peel packing for infection control.
Examining the Problem
SUDs and the process of peel-packing reusable devices are costly and detrimental to the environment. Disposable medical devices and packaging are largely composed of plastic—a broad category of synthetic materials of which over 98% are derived from fossil fuels (PLoS One. 2023. doi:10.1371/journal.pone.0281596). Anthropogenic utilization of fossil fuels accounts for over 75% of greenhouse gas emissions and nearly 90% of carbon dioxide emissions globally and is the primary driver of climate change and worsening air quality (https://www.un.org/en/climatechange/science/causes-effects-climate-change).
Although single-use devices are convenient and may be more appropriate in specific patient care scenarios, the environmental, economic, and human health costs must be considered prior to widespread implementation.
Healthcare systems are responsible for 4% to 5% of global and 8.5% of domestic greenhouse gas emissions, with 82% of our sector’s emissions attributable to supply chain (Health Aff. 2020. doi:10.1377/hlthaff.2020.01247). While the recent U.S. Department of Health and Human Services Health Sector Climate Pledge encourages healthcare systems to commit to drastically lowering their emissions (https://www.hhs.gov/climate-change-health-equity-environmental-justice/climate-change-health-equity/actions/health-sector-pledge/index.html), increased reliance on fossil fuel-derived plastic SUDs and packaging threatens to counteract these efforts and perpetuate the ongoing role of the U.S. healthcare system in worsening air quality and climate change.
Additionally, the recent Minderoo-Monaco Commission on Plastics and Human Health describes the widespread water, land, and atmospheric pollution attributable to plastics, with resultant toxicity to humans and ecosystems. While recycling and proper waste segregation have been suggested as a means of mitigating the waste associated with SUDs and peel packs, plastic disposal is highly inefficient, with recycling rates below 10% globally (Ann Glob Health. 2023. doi:10.5334/aogh.4056). The use of plastic disposable surgical equipment, therefore, contributes significantly to the environmental impact of healthcare. Although SUDs are convenient and may be more appropriate in specific patient care scenarios, the environmental, economic, and human health costs must be considered prior to widespread implementation.
Plastics, Climate Change, and Human Health
Climate change is an urgent public health crisis that has a direct impact on human health and social determinants of health. The World Health Organization estimates that nearly one in four deaths globally are due to environmental factors, including climate change; air, water, and soil pollution; and chemical exposures (https://www.who.int/publications/i/item/9789241565196).
Mechanisms through which climate change impacts human health include global warming, increased frequency and severity of extreme weather events, changes in precipitation patterns, worsening air quality, and changes in the infectious disease landscape. Studies increasingly show an association between the climate and worsening cardiovascular, pulmonary, renal, psychiatric, and infectious diseases, particularly in historically marginalized populations (Lancet. 2022. doi:10.1016/S0140-6736(22)01540-9). In otolaryngology specifically, we’re seeing an increased burden of allergic and rhinologic disease (Curr Opin Otolaryngol Head Neck Surg. 2023. doi:10.1097/MOO.0000000000000888; Allergy Rhinol. 2023. doi:10.1002/alr.23128). Plastic manufacturing contributes significantly to climate change, with 3.7% of global greenhouse gas emissions attributable to plastic production.
Plastics and the chemicals associated with their production and use also have a direct impact on the environment and human health. Most plastic products resist breakdown and persist in the environment for decades. In marine environments, plastic pollution impacts humans through contamination of seafood as well as damage to ocean ecosystems, which are responsible for 50% of the oxygen on Earth.
Plastic production and recycling workers, as well as communities adjacent to plastic production and disposal sites, are at a higher risk of leukemia and lung cancer, cardiovascular disease, chronic obstructive pulmonary disease, and neurotoxicity. In addition, plastic use and disposal release toxic chemicals into the environment, many of which have been associated with an increasing risk of adverse birth outcomes, including prematurity, stillbirth, low birth weight, and neurodevelopmental impairment (Ann Glob Health. 2023. doi:10.5334/aogh.4056). Examining the mechanism behind these associations is a relatively new area of research, but studies suggest that plastic-associated chemicals disrupt endocrine and metabolic function, create oxidative damage, cytotoxicity, and inflammation, and alter the gut microbiome (Toxics. 2023. doi:10.3390/toxics11090747).
Environmental Impact of Single-Use Equipment
The majority of published evidence demonstrates that SUDs are associated with higher levels of greenhouse gas emissions than reusables (Ann Surg. 2020. doi:10.1097/SLA.0000000000003951; Surgery. 2022. doi:10.1016/j.surg.2022.04.010; J R Soc Med. 2023. doi:10.1177/01410768231166135). A recent study of tonsillectomy techniques using life cycle assessment (LCA, a technique that accounts for all components of a process, including raw materials extraction, manufacturing, transportation, use, and disposal) to comprehensively evaluate surgical environmental impacts found that a cold technique was superior to electrocautery or coblation, mainly due to the effect of disposable surgical equipment (Laryngoscope. 2023. doi:10.1002/lary.30866).
In ophthalmology, LCA shows that greenhouse gas emissions for a single cataract surgery are 95% lower in an Indian surgical center compared to the same surgery performed in the United Kingdom. This is primarily attributed to the Indian group’s emphasis on employing reusable equipment wherever possible and maximizing reprocessing and reuse of all surgical equipment (J Cataract Refract Surg. 2017. doi:10.1016/j.jcrs.2017.08.017).
In the rare instances in which the opposite effect is reported, the research setting usually demonstrates an inefficient or highly polluting process for reprocessing reusable devices. An example of this is a study on central venous catheter kits in an Australian hospital that relies on a brown coal-burning plant to supply electricity. The authors used LCA to find that disposable equipment had a lower environmental impact, but they determined that if their hospital used a cleaner energy source for electricity, a reusable kit would have been environmentally favorable (Anesth Analg. 2012. doi:10.1213/ANE.0b013e31824e9b69).
Finally, production of plastics is so water intensive that even reusable items requiring laundering (e.g., gowns, drapes (Anesth Analg. 2012. doi:10.1213/ANE.0b013e31824d9cc3), and head covers (JAMA Surg. 2023. doi:10.1001/jamasurg.2023.3863) actually save water compared to their disposable plastics-based counterparts. This is of particular significance given the worsening U.S. groundwater crisis (https://www.nytimes.com/interactive/2023/08/28/climate/groundwater-drying-climate-change.html).
It’s essential that patient safety and outcomes remain paramount in clinical decision making when it comes to choosing disposable versus reusable medical devices. For example, when discussing the potential environmental benefits of cold tonsillectomy versus monopolar electrocautery and coblation, the risk of postoperative hemorrhage must be considered. While some data have been mixed, several large-scale studies, including a 2017 Cochrane review (Cochrane Database Syst Rev. 2017. doi:10.1002/14651858.CD004619.pub3) and the Swedish National Tonsil Surgery Register that included around 99,000 reported cases, demonstrate a lower postoperative bleeding rate with cold tonsillectomy compared to electrocautery or coblation. Based on these findings, the authors of the Swedish study recommended against any non-cold technique for tonsillectomy (Acta Otolaryngol. 2020. doi:10.1080/00016489.2020.1746396). Similar recommendations were previously made in the United Kingdom on review of the National Prospective Tonsillectomy Audit (Laryngoscope. 2007. doi:10.1097/mlg.0b013e318031f0b0).
Otolaryngology as a specialty has a unique opportunity to consider minimizing draping and SUDs without compromising patient safety given the prevalence of clean-contaminated procedures with very low risk for infectious complications. Field sterility, typically defined as a mask, sterile gloves, and a sterile drape around the surgical field, without head covers, surgical gowns, shoe covers, or full patient draping, has been implemented safely in hand surgery (Plast Reconstr Surg Glob Open. 2019. doi:10.1097/GOX.0000000000002481; J Hand Surg Am. 2018. doi:10.1016/j.jhsa.2017.11.007), small skin and soft tissue cases such as Mohs micrographic surgery (Am J Clin Dermatol. 2021. doi:10.1007/s40257-021-00599-3), and cleft surgery (J Craniofac Surg. 2023. doi:10.1097/SCS.0000000000009579).
Standard sterile draping should be maintained in clean cases and cases with implants, and should be considered for patients who are at higher risk for postoperative infectious complications.
A Call to Action
Simple interventions, like streamlining surgical trays and pick lists, not only reduce waste but usually result in cost savings. Prior data on tonsillectomy demonstrated reductions in waste volume and cost savings with this intervention (Otolaryngol Head Neck Surg. 2012. doi:10.1177/0194599812450681), and newer research confirms cost savings with techniques that minimize disposable equipment (Laryngoscope. 2023. doi:10.1002/lary.30866).
In addition to the direct operational cost of SUDs and peel packs, the health-related costs of plastic production are estimated to exceed $250 billion globally. In the United States, the health cost of disability and disease caused by plastic-associated chemicals is estimated to exceed $920 billion annually (https://annalsofglobalhealth.org/articles/10.5334/aogh.4056).
As surgeons and leaders in healthcare, our duty is to provide patients with the highest quality of care. Assessment of quality requires thorough consideration of the risks and benefits of clinical practices. The human health and environmental risks of SUDs and increasing plastic use must be recognized within the otolaryngology community.
Dr. Dilger is an otolaryngologist in the department of otolaryngology–head and neck surgery at Harvard Medical School and Massachusetts Eye and Ear and at Brigham and Women’s Hospital, all in Boston. Dr. Meiklejohn is an associate professor of otolaryngology–head and neck surgery and Residency Program Director at the University of New Mexico in Albuquerque.