4

Environmental Impact

The third session of the workshop examined the environmental effects of increased adoption of reusable health care textiles (HCTs) within health care settings. These effects, including risks and benefits, were discussed within the context of life-cycle analysis (LCA). The session highlighted differences in U.S. and international policies, practices, and reusable HCT adoption rates. Kelly Wright, director of the Division of Minimally Invasive Gynecological Surgery and associate professor at Cedars-Sinai Medical Center, moderated the session.

ENVIRONMENTAL IMPACTS ACROSS THE LIFE CYCLE

Michael Overcash, chief executive officer at Environmental Genome Initiative, outlined benefits of reusable versus disposable medical gowns—such as increased sustainability and cost savings—in a presentation developed in collaboration with Jodi Sherman, associate professor and director of the Program on Health Care Environmental Sustainability at Yale University. Overcash stated that harms stemming from the mechanical world, the chemical world, and human behavior are inevitable. Given this context, the goal of “zero harm” is inherently challenging, making risk management a more practical goal (Thomas, 2020). Managing risk entails (1) understanding and identifying causal chains of events that lead to harm, (2) prescribing interventions to prevent harm, (3) tracking safety events, (4) measuring compliance with prevention protocols, and (5) ensuring accountability. Managing health care–related risk should involve exploring the complexities of the health care system to identify

health care factors that influence a given problem. Overcash noted that government and business leaders are seeking to provide quality personal protective equipment (PPE) while achieving the objectives of causing the least harm to the environment and lowering costs. He noted that literature is uniform in indicating that reusable PPE meets these objectives, while single-use PPE does not. However, barriers in the U.S. health care system impede the adoption of reusable PPE.

Reusable Gown Supply Chain and Environmental Footprint

Overcash described the reusable gown supply chain, which begins with natural resources used to make HCTs, such as the petroleum used to make polyester, a material commonly used for surgical and isolation gowns. A complicated process to create polyester involves building and improving molecular structures through chemical reactions until achieving terephthalic acid and ethylene glycol, which together form polyethylene terephthalate (PET), or polyester. The polyester is formed into pellets, a working material that can then be used to make fibers. These fibers are then manufactured into a variety of colors of yarn and woven into polyester fabric. Reusable gowns are manufactured from fabric and carbon thread, which is used for its anti-static properties. The gowns are packed into cardboard boxes or other types of packaging—all of which are manufactured via separate supply chains—and transported to commercial laundry facilities. Once laundered, the gowns are sent to hospitals, where they are used and then returned to the laundry facility for reprocessing. Laundering uses municipal water and expels wastewater to water treatment plants. The gowns are cycled between health care use and laundering until they reach the end of their use life, at which point they are typically sent to the landfill. Overcash noted that reusable gowns average 60 uses, thus 1,000 uses require 16.7 gowns. Given that reusable gowns can be used repeatedly, one reusable gown replaces 57 disposable gowns, said Overcash. Thus, reusable gowns create a smaller environmental footprint than disposables despite the complex supply chain involved in the manufacturing, transporting, and reprocessing of reusable gowns. Overcash emphasized that pursuing alternatives to disposable products that cause less harm to the environment is a worthwhile endeavor.

An ancillary benefit of the reusable gown supply chain is the recovery of items inadvertently discarded with soiled gowns, said Overcash. Recovered items include surgical instruments, trays, and pans as well as personal items such as cell phones, jewelry, and wedding rings. When laundry facilities recover these items, they decontaminate them and return them to hospitals. He highlighted that one laundry facility estimated the total value of items recovered each month at $5,000–15,000. In health care

settings using disposable gowns, these items would unwittingly be sent to the landfill among the disposable gown waste.

Environmental and Cost Savings Associated with Reusable HCTs

Overcash has collaborated on research measuring the reduced environmental effects or “environmental savings” of various types of reusable HCTs compared with disposable counterparts. They found that employing reusable surgical gowns in place of disposable gowns decreases greenhouse gas emissions by 66 percent (Vozzola et al., 2020). Conversely, the choice to use disposable gowns increases the global warming potential associated with gowns by 300 percent. Disposable gowns also generate more solid waste, blue water consumption, and natural resource energy consumption than reusable options (Vozzola et al., 2018a,b, 2020).

Overcash stated that growing evidence demonstrates that reusable HCTs for PPE improve environmental indicators, including reduced carbon emissions, water usage, solid waste, and energy consumption. The COVID-19 pandemic illustrated that the circular reusable PPE system is more stable than the linear disposable PPE supply chain. Despite these benefits, reusable HCTs constitute a small portion of the U.S. PPE supply. Group purchasing organizations (GPO) represent numerous health care providers and aggregate purchasing volume to negotiate price discounts with manufacturers and distributors. Overcash remarked that GPOs are more likely to contract for goods (e.g., disposable gowns) than for services (e.g., laundering services for reusable gowns). Thus, he concluded that achieving increased use of reusable PPE will involve addressing the barrier of GPO support for single-use products versus circular laundry services. Increasing circularity in systems through reusing and recycling drives environmental improvement.

A CASE STUDY OF ENVIRONMENTAL SUSTAINABILITY IN CLINICAL CARE

James Marvel, clinical assistant professor at the Stanford University School of Medicine, discussed the impetus for the reusable gown pilot program underway at Stanford Health Care (SHC) and explored implementation barriers. He described his interest in health care sustainability stemming from his fellowship in wilderness medicine and the health effects connected to climate change, particularly those related to the severe California wildfire seasons in recent years. Treating patients in the emergency department (ED) and discharging them to return to an environment that is potentially deleterious for their health inspired him to investigate ways to mitigate the effects of the health care system on the

environment. During the onset of the COVID-19 pandemic, he witnessed the surge of demand for isolation gowns. At that time, SHC was solely using disposable gowns, and the PPE supply challenges during the pandemic generated interest in exploring reusable HCTs. For a brief period, the SHC ED used reusable gowns, but this effort was a stopgap measure that did not involve a comprehensive plan for continuation. A group of Stanford University undergraduates and medical students advocated for the implementation of reusable gowns and coordinated with the university’s Office of Sustainability to develop a plan.

Shifts from using disposable products to reusable ones generate cost and environmental savings, said Marvel. Disposable PPE carries additional environmental cost when unnecessarily treated as biohazardous waste. Marvel clarified that disposable gowns soiled with body fluids or other contaminants are biohazards. However, when health care workers (HCWs) doff PPE, they often do not consider whether it has been contaminated and routinely place all disposable PPE in the biohazardous waste bin. Because biohazardous waste must be processed by an autoclave before going to the landfill, health care facilities lacking an in-house autoclave must transport biohazardous waste to a separate facility for processing. Thus, processing disposable gowns as biohazardous waste can unnecessarily increase energy expenditures, Marvel noted.

To increase sustainability at the SHC ED, Marvel and colleagues established the ED Green Team. Various SHC departments use green teams to propose and implement sustainability initiatives (e.g., recycling, reprocessing, and redistributing pulse oximeters). The ED Green Team selected implementation of reusable gowns as its flagship project, a complex effort requiring consideration of numerous barriers. For example, the logistics of using reusable gowns involves locating space for the storage of both clean and soiled gowns, said Marvel. Reusable gowns are bulkier than their disposable counterparts, requiring cabinet storage space and laundry bins within patient rooms. Additionally, because SHC has a cache of disposable gowns, the ED Green Team has worked to align the timing of reusable gown implementation with depletion of the disposable gown supply. Reusable gown attrition is another logistical challenge. Given the complexity of the reusable gown supply chain and the volume of resources per unit compared to disposable gowns, a gown must be used a certain number of times to recoup its cost; reusable gowns lost before the break-even point result in a net loss. The ED Green Team identified a slight attrition rate of reusable linens at SHC, resulting in the need to periodically reorder linens sooner than expected. In exploring this issue, the team discovered an agreement in place with other area hospitals that allows emergency medical services staff to restock their ambulance gurneys with hospital linens.

To address potential staff resistance to change, the ED Green Team is currently administering a survey to gauge understanding and solicit feedback about the upcoming change to reusable gowns, said Marvel. The team selected the ED and intensive care units (ICUs) for implementation of the pilot program because these areas traditionally have the highest isolation gown usage rates within the hospital. The survey will capture and address any concerns staff may have about reusable gowns, such as their comfort or infection prevention efficacy. Prior to the survey, some staff members expressed concern that wearing the reusable gowns would be uncomfortably warm. To address this concern, Marvel and team have organized a “roadshow” to showcase samples of eight varieties of reusable gowns for staff to try out and determine the most comfortable options.

Marvel remarked on the importance of demonstrating benefits from a pilot before scaling implementation; therefore, the SHC will implement the reusable isolation gown pilot program in the ED and ICU before attempting an institution-level change. As issues or concerns arise during the pilot, the ED Green Team will continue to respond by investigating and problem solving, thereby establishing a strong foundation for the reusable gown program. He stated his optimism that the pilot will reflect cost savings, staff acceptance, and environmental benefits that constitute a compelling case for expanded rollout throughout the hospital, particularly given Stanford University’s commitment to sustainability.

PANEL DISCUSSION

Enhanced Circularity of HCTs for PPE

Wright asked about approaches to enhancing the sustainability and circularity of production processes for both disposable and reusable HCTs. Gajanan Bhat, professor at the University of Georgia, is currently involved in research to create the next generation of PPE via melt-blowing technology. He explained that some disposable medical gowns are largely composed of polypropylene, a plastic made from fossil fuels. Disposable PPE entails a linear supply chain that involves depleting natural resources and generating waste that will not degrade for hundreds, if not thousands, of years. He added that the challenges posed by the linear supply chain for plastics extend beyond PPE to packaging and other non-health-related products. In contrast to linear supply chains, cradle-to-cradle supply chains are truly circular, turning used products back into raw materials that can be used in manufacturing. During the past 20–30 years, scientists have developed an alternative polymer, polylactic acid (PLA), that offers opportunities for sustainability innovations. Made from cornstarch, PLA is essentially plant-based. NatureWorks and other

biopolymer companies are exploring additional renewable sources, such as sugarcane, for PLA production. Bhat explained that PLA features properties comparable to synthetic polymers such as polypropylene and could potentially be used to make both reusable and disposable PPE. He noted that although manufacturers claim that PLA is biodegradable, its breakdown requires industrial composting conditions.

Bhat highlighted polyhydroxyalkanoate (PHA) as another polymer produced from vegetable oil, which is a renewable source. Manufacturers are using waste cooking oil from restaurants and mixing it with oil waste to produce PHA, a fully biodegradable polymer (Ruiz et al., 2019). Currently, PHA cannot be converted into fibers, but researchers are working to develop this capability. Furthermore, the National Institute of Standards and Technology is funding a research initiative involving several universities and industries striving to create truly biodegradable PPE from PLA, PHA, or PLA-PHA blends (Hanacek et al., 2024). After use, such products would break down into simple molecules or become raw material, Bhat explained. He is involved in research that has led to the development of N95 filtering facepiece respirators made from PLA with 99 percent filtration efficiency, the successful production of PLA spunbond polyester, and the production of singlemode-multimode-singlemode structures within PLA melt-blown fabric.

Bhat emphasized that further LCA and techno-economic analysis are needed on these innovations. Reducing the cost of biodegradable materials for PPE is of primary concern for implementation, but this will require increased investment, production capacity, and demand. Reducing cost and demonstrating the performance of polymers made from renewable sources would drive demand. He remarked that some sectors and certain applications will continue to rely on disposable PPE, but the innovation of sustainable, disposable PPE with a circular, cradle-to-cradle life cycle could meet these PPE needs while decreasing environmental effects. Overcash commented that full-scale manufacturing plants are currently operating in the United States and abroad that process PET from waste plastics by depolymerizing it, eliminating color and other components, and reforming it into PET pellets that can be used in manufacturing. The technology to similarly recycle polypropylene is in place, but it is currently processed at smaller volumes than PET. The life-cycle benefit of reusable PPE increases when products are made from materials within a circular supply chain, he added. Although circularity entails additional energy expended to recycle materials, it reduces waste.

Wright asked about findings from LCAs—particularly on cradle-to-cradle systems—concerning reusable versus disposable HCTs. Overcash replied that studies have examined the environmental implications of manufacturing disposable PPE from hydrocarbons sourced from in--

ground resources and compared these with reusable PPE on a 1000- or 10,000-use basis, finding that processing reusable PPE consumes fewer resources than producing a disposable product. He noted that these analyses consider the heavier weight of reusable HCTs.

Shelley Petrovskis, director of Marketing and Regulatory Affairs at Lac-Mac Limited, described circularity as a method that can contribute to achieving the goal of sustainability. When defined as a practice focused simultaneously on reducing materials used and prolonging the length of time a product’s value remains intact, the term “circularity” applies to reusable medical gowns currently on the market. The ability to downgrade reusable gowns for alternative use once they reach end-of-life for surgical applications further extends the length of time they offer value. Melissa Dawson, associate professor at the Rochester Institute of Technology, highlighted an opportunity to shift the paradigm from considering reusable gowns as waste once they complete use life to designing gowns for eventual reclaiming and recycling. Rather than expecting reusable gowns to ultimately reach the landfill or be incinerated, they could be manufactured from reusable materials in a system designed for circularity, she remarked.

Overcash commented that he is aware of two suppliers for hospital systems that ship gowns that have completed use life to countries lacking PPE. Shawn Gibbs, dean of the School of Public Health at Texas A&M University, noted that reusable gowns are sometimes retired before they complete use life due to aesthetic factors such as color fading or the hospital logo having worn off; such gowns would be particularly appropriate for donation. Wright added that colorfastness and other aesthetic aspects sometimes involve additional chemicals in HCT manufacturing that may be of concern to HCWs. Donation could provide a mechanism for extending the length of time a product offers value without additional chemicals.

Environmental Benefits Associated with Reducing Transportation and Medical Waste

Emphasizing that reusable products constitute 80–90 percent of total HCTs in Canada and some other countries, Wright asked about the potential environmental effects of adopting reusable PPE at similar rates in the United States. She added that other countries may not accept discarded textiles from the United States in the future. Overcash remarked that when reusable gowns eliminate the purchase of disposable gowns, it yields a direct reduction of nonrenewable resource use and landfill waste. However, methods for increasing demand for reusable gowns are unclear, he said. Bhat remarked that LCAs on disposable gowns indicate the effects of packaging and transporting goods on greenhouse gas emis-

sions. He noted that the environmental footprint of both reusable and disposable PPE can be reduced through more localized manufacturing that decreases shipping distances. Overcash has calculated the effects of transporting PPE on the environment, finding that effects are less substantial than might be expected due to the lightweight nature of gowns. He clarified that reusable gowns weigh more than disposable ones, but the environmental effects of transporting reusable gowns remain relatively small compared to those generated by manufacturing processes. Petrovskis commented that U.S. purchases from one of the several manufacturers of reusable PPE based in North America eliminates the need for overseas shipping. Overcash replied that his calculations only included manufacturers based in Asia; he has not compared the environmental effects of transporting PPE from Asia with those of transporting PPE from North America.

Gibbs, a certified industrial hygienist who specializes in the disruption of high-consequence infectious diseases, highlighted a difference between transporting Category A waste—that is, material reasonably expected to contain a pathogen capable of causing permanent disability or death—and regulated medical waste. Transporting Category A waste is substantially more expensive than transporting regulated medical waste, requires far more packaging, and can involve political issues necessitating transportation routes circumventing entire states. Gibbs described how transporting a bin of disposable PPE can entail an additional 60–70 pounds of packaging material and increased mileage. Therefore, PPE that is safely decontaminated, repurposed, and reused drastically reduces end-of-life cost and environmental effects. Wright commented that as much as 70 percent of regulated medical waste in hospitals is generated by incorrect triaging of items that are not actually regulated medical waste (Duong, 2023). Thus, this additional waste unduly burdens the economic and environmental costs of transporting regulated medical waste. Overcash added that public health research has resulted in decreasing the PPE recommended for seeing patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Staphylococcus aureus; this demonstrates that safely reducing PPE recommendations via deeper scientific understanding of risk would benefit the environment.

Environmental Regulations Regarding HCTs

Wright asked about regulations already in place that address the environmental impacts of HCTs and about regulations needed to adequately address these impacts. Regulations stipulate that laundries must treat wastewater—or transport it to a facility that treats it—to attain a certain level of purity before discharge, said Overcash. These regulations are

included in permit regulations established by the state in which the water will be discharged. A standard is also in place requiring laundry facilities to thermally oxidize gas emissions. Bhat remarked that European regulations on pollutants and waste are generally more restrictive than U.S. regulations. Noting that the size of U.S. land contributes to a lack of urgency in placing limits on waste, Bhat emphasized the need to invest in expediting research and development to decrease waste. Wright stated that the U.S. health care sector’s carbon emissions and waste have received relatively little scrutiny, despite hospitals frequently being among the largest producers of waste in their communities. Although regulations are adequate for addressing the safety and quality of HCTs and PPE, regulations may be inadequate for associated effects on the environment, she remarked.

Petrovskis noted that the Canadian Environmental Protection Act establishes guidelines regarding air and water pollutants that apply to Canadian PPE manufacturers and are similar to those in the United States.¹ She added that Lac-Mac Limited’s efforts to increase energy efficiency in PPE manufacturing include green energy sources and the use of LED lighting, which has reduced their electricity consumption for lighting by 70 percent. Overcash emphasized that many of the emissions associated with reusable and disposable gowns are generated in countries outside of North America that manufacture and export the raw materials or the finished products to the United States. In response to a question about measures to prevent unregulated contaminants from the laundry process—such as plastic microfibers from synthetic fabrics—from entering water treatment systems, Bhat replied that this is an ongoing issue that companies are working in earnest to address.

Drivers of Reusable PPE Adoption

Replying to a question about the factors that underlie the higher adoption rate of reusable HCTs in Canada versus the United States, Petrovskis noted that Canadian commercial laundry facilities successfully highlighted the merits of reusable HCT programs to customers. Market forces in favor of disposable PPE are at play, yet commercial laundries retain customers by consistently providing a safe, reliable product that meets performance expectations. She remarked that during the COVID-19 pandemic, when PPE supply shortages drove U.S. health care facilities to source products outside of the United States, she was struck by their lack of understanding about how reusable PPE programs operate. For example, many health care facilities did not understand the importance of partnering with a laundry facility for safe reprocessing.

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¹ Canadian Environmental Protection Act, 1999 (S.C. 1999, c. 33).

Gibbs commented on the initial investment involved in establishing a reusable respirator program. Given a healthy supply chain, hospitals can purchase disposable filtering facepiece respirators for just a few dollars apiece, depending on purchasing power. A reusable elastomeric respirator costs up to a few hundred dollars plus additional costs for the associated replaceable cartridges. However, when the supply chain for disposable respirators is strained—as was the case during the COVID-19 pandemic—reusable respirators carry added benefit, particularly given that an elastomeric respirator cartridge lasts weeks to months.

Advocacy for Sustainable PPE

Wright asked about advocacy approaches to increase adoption of sustainable, environmentally friendly PPE. Marvel remarked that effective advocacy largely hinges on understanding staff concerns and using—or creating—relevant data to support efforts to implement reusable PPE. The SHC ED Green Team seeks to be inclusive by encouraging and responding to input from a range of perspectives, including nurses, technicians, residents, physicians, and pharmacists. This can highlight ongoing issues (e.g., the discarding of pulse oximeters) and gauge willingness to adopt reusable PPE. For instance, the reusable gown roadshow that Marvel’s team developed is designed to simultaneously gather input and provide education about the efficacy of reusable HCTs in infection prevention. They will conduct a survey along with the roadshow to gauge staff members’ concerns and willingness to adopt reusable gowns; this feedback will inform educational campaigns to address major concerns. Additionally, recommendations about product selection will be based on the favored reusable gown tested during the roadshow. He noted that institutional support is already in place and that the reusable gown initiative could potentially roll out in the ED within the next 2–3 months. After implementation, the ED Green Team will collect data on gown usage patterns, attrition rates, and other information needed to facilitate institution-wide implementation. Infrastructure needs associated with scaling the pilot—such as space considerations and laundering facility contracts—will also be identified and addressed before implementation expands.

Overcash commented on the common concern that reusable gowns would be uncomfortable to wear. He has only located one study on the comfort of reusable gowns, which involved surgeons at Walter Reed National Military Medical Center receiving randomized gowns before surgeries without knowing beforehand whether the gowns would be disposable or reusable (Conrardy et al., 2010). Upon completing the surgery, participants rated the comfort of the gown, with reusable gowns overwhelmingly reported to be more comfortable than disposable ones.

Bhat raised a concern that potential resistance from the disposable PPE industry could postpone enactment of regulations regarding end-of-life PPE disposal. He argued that technology is currently in place that would enable industry to meet more restrictive environmental regulations. Advocates should share data to educate representatives at all levels of industry and government about the current capacity to increase sustainability in PPE, said Bhat.

In response to a participant’s question about how incentives could be used to increase adoption of reusable PPE among HCWs, Wright remarked that HCWs typically do not have a choice between reusable or disposable products. Efforts to educate HCWs about reusable PPE, especially opportunities to try on products, could generate interest and buy-in during implementation of reusable PPE programs. Overcash mentioned instances of hospital physicians collectively and successfully lobbying for a transition to reusable PPE in the facility. He remarked that physicians are highly valuable to hospitals and can leverage this influence with hospital leadership, who have a vested interest in simultaneously achieving cost and environmental savings.

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