Lujain Al-Saleh, Sustainability Fellow, June 2017

Dr. Seema Gandhi: Reducing Waste & Changing Behaviors in the Operating Room

Dr. Seema Gandhi is no stranger to waste. As an anesthesiologist at UCSF for over a decade, Dr. Gandhi has observed the vast amount of waste that is generated from daily hospital operations. On the national scale, a staggering ⅓ of all hospital waste is produced from operating rooms (ORs). And she wants to do something about this.

“Since childhood my parents have instilled mindfulness towards using natural resources like water, electricity, and everything big and small in life,” said Dr. Gandhi.

Born and raised in India, the importance of “using only as much as you need” and “not wasting” were intrinsic, core values that Dr. Gandhi grew up with.

At an early age, Dr. Gandhi’s parents encouraged her, and her siblings, to plant trees on their birthdays and watch them grow over the years. Her interest in the carbon footprint of heath care has been a natural progression from these values.

Working in the fast-paced environment in the OR, she began to critically analyze the workflow of multiple single-use devices (SUDs), meaning that the device can only be used once before it is tossed into the landfill.

When the Bair Paws forced-air warming gown, and the HoverMatt, an air-assisted safe patient transfer device, were introduced to the Moffitt-Long Hospital, Dr. Gandhi noticed that the two single-use devices were often placed on a patient, not used, and thrown away soon after.

Driven by her passion in sustainability, Dr. Gandhi reached out to the Office of Sustainability to coordinate an observational waste audit. Over the course of a month in fall 2016, a total of 735 patients were monitored throughout the surgery process to evaluate the use and disposal of the Bair Paws gown and HoverMatt. Overall, $51,400 in HoverMatts and Bair Paws were distributed to patients throughout the study period; this equates to $1,042,277 in annual costs. Through reprocessing HoverMatts, the Medical Center could recover $386,880 of the annual costs.

Due to Dr. Gandhi’s work, the Medical Center is beginning to phase out the gown with reusable ones. Based on preliminary analysis, the annual savings potential in using reusable gowns, instead of Bair Paws, is at least $184,000.

A Brief History on HoverMatts & Bair Paws
Along with most hospitals across the country, the number of disposable, single-use medical devices has increased at UCSF over the past decade. For example, in July 2014, the UCSF Medical Center replaced reusable gowns with the Bair Paws gown and mandated that the gown be distributed to every patient to prevent hypothermia before undergoing surgery.

Nearly a year later, the HoverMatt was introduced to the UCSF Moffitt-Long Hospital to reduce staff injuries and the time associated with cleaning reusable devices.  Before the HoverMatt was introduced, the lateral transfer board was the primary device used in the patient transfer process.

However, we found that the HoverMatt and Bair Paws were often distributed to a patient, not used, and immediately disposed of before or shortly after their use. During the observation period, nearly half of the distributed Bair Paws gowns and HoverMatt were immediately disposed in the OR. On the other hand, the usage rate was shockingly low. Before the operation, only 3% of the distributed Bair Paws gowns were turned on to warm the patient.

“While I knew Bair Paws had a limited use to warm patients, the degree to which we underused them was shocking,” said Dr. Gandhi. “I was saddened to see us throwing them out without even turning them on in more than 30% of our cases,” she explained.

Along with the minimal use of the Bair Paws, only 7% of distributed HoverMatts were used to help transfer patients from the pre-operative to post-operative stage. In 98% of all cases, the reusable lateral body transfer board was used to transfer patients after the surgery.

Reprocessing: An innovative waste diversion & cost savings strategy
Although the HoverMatt is a single-use device, it can be reprocessed. Reprocessing is a process whereby a device is cleaned, sterilized, and repurchased at a discounted price, so that it can be used again.  Currently UCSF has been reprocessing about 44,000 pounds of single-use devices per year, saving over $1M annually in the process.

However, 43% of HoverMatts were thrown into the landfill and not reprocessed throughout the study. Along with the OR, we found that four floors that did not have reprocessing bins.  Even if reprocessing bins were added to these floors, it is unclear of whether the HoverMatt would be placed in the reprocessing bin since staff on the four floors were not aware that HoverMatts could be reprocessed.

The Nationwide Shift Towards Single-Use Devices
About 20 years ago, concerns regarding higher risks of infection and device failure rose in the United States. As a result, there was a nationwide shift in replacing reusable devices with single-use devices. Today, most devices used in ORs are single-use and not reusable.


There is often a fine line between what constitutes a single-use versus reusable device. Medical devices are labeled as reusable or single-use by the Original Equipment Manufacturer (OEM) and are subject to review under the Food & Drug Administration (FDA).

To label a device as reusable, the OEM must provide the FDA with data that the device can be safely reused. Due to the time and costs associated with evaluating the device, the OEM can choose not to evaluate whether the device can be used. Even if the device has the potential to be reused safely, it is often automatically labeled as single-use. Unfortunately, this is the easiest, cheapest path for the manufacturer to take. Inevitably, it is predicted that the U.S demand for single-use medical supplies will expand 4.1 percent annually to $49.3 billion in 2018

As the amount of single-use devices continues to increase, so will the amount of waste that is sent to the landfill.  Approximately 85% of this medical waste will end up in “municipal landfills and other hazardous facilities that are disproportionately located in poor and minority neighborhoods.” image

A growing number of public health studies illustrate that environmental factors, such as pollution, predominantly jeopardize the health and wellbeing of lower-income communities and communities of color. There are clear socioeconomic and racial disparities that exist within the distribution of waste sites throughout the U.S.

Shifting towards a system-wide sustainability framework
Thinking about the larger picture, the study led Dr. Gandhi to explore practices across other UCs. Soon after the study, Dr. Gandhi teamed up with Professor Sangwon Suh at the UCSB Bren School of Environmental Science & Management to conduct a life-cycle analysis (LCA) of the HoverMatt to assess environmental impacts associated with all the stages of a product’s life from manufacture to disposal.

As a leading health sciences university, we need to be thinking about the cycle of healthcare system waste generation; we need to be evaluating how waste production directly contributes to environmental issues; we need to be addressing that how this system leads to more and more patients; and we need to be actively institutionalizing sustainability into our daily practices and operations.

“We are realizing that the nature of our energy-intensive waste-producing operations impacts community health‎ and global health,” said Gail Lee, the UCSF Sustainability Director. “And we are taking steps to address these issues and a strategic plan to ensure thoughtful and impactful actions.”

Although it may not be possible to purchase reusable HoverMatts, streamlining the workflow can help to ensure that more HoverMatts are used and not immediately discarded throughout the perioperative process. To reduce waste and costs, the distribution of a HoverMatt should depend on the patient, mobility, and type of procedure.

Overall, the shift towards sustainable procurement, improving the existing reprocessing program, and staff engagement are all critical steps in waste diversion and cost savings. In order to improve reprocessing efforts, we will distribute reprocessing bins and signage to the floors that do not have bins. With the limited space in the OR, case carts can be utilized to provide ease of access for staff and ensure that all HoverMatts are collected and reprocessed in a designated area.

Establishing Hospital “Green-Teams”
Staff-led initiatives and projects not only generate awareness, but can elicit lasting behavioral change. A growing number ‘green’ staff teams around the U.S. have improved waste diversion programs and reduced energy and water consumption.

We will address existing gaps on reprocessing and general hospital waste by providing staff training on the study results and identifying “sustainability champions” on each floor that will monitor reprocessing on their floors.

“Knowledge is power, and one of the primary solutions in my mind is education and awareness towards this effort,” said Dr. Gandhi.