Healthcare’s paradox
Our healthcare sector is responsible for around 5% of our global greenhouse gas emissions, of which the majority stem from the supply chain. This percentage varies greatly between countries and increases even further for high-income nations. For example, in the Netherlands, the healthcare system accounts for 7.3% of the national climate change footprint and 13% of their material extraction footprint.
These numbers are due to the system’s linear supply chain. Hospitals have adopted this approach to protect patients, save costs, and provide ease of use. However, this results in them being dependent on the continuous stream of input materials to maintain their quality of care. As a consequence, hospitals are vulnerable to disruptive situations such as the COVID-19 pandemic, where we need them to operate at their best despite supply issues they are facing.
Sustainable healthcare means changing the process
If we want to cut down on our healthcare’s emissions and make hospitals more resilient, we need to implement a circular economy in our healthcare systems. By reusing, repairing, repurposing, reprocessing, or recycling medical devices, their material value can be maximized, while their waste production is minimized. The material and energy loop can either be closed by allocating materials to fulfill other purposes after usage or slowed down by designing products for enhanced durability or reusability, keeping the materials within the same product.
A current area of investigation in this respect is reusing medical devices, in which single-use medical devices (SUDs) are reprocessed through cleaning, disinfection, and sterilization to allow multiple reuses. Alternatively, medical devices can be specifically designed for reuse purposes; they are called reusable medical devices (RMD). Generally, both have clear advantages in terms of reducing costs, improving global health, securing ample supply, and having a positive environmental impact. But since these products differ substantially from one another, their benefits are best studied individually.
Measuring the economic and environmental benefits of medical devices can be done by performing a life cycle assessment (LCA). This is a standardized approach analyzing all inputs and outputs throughout a device’s life cycle. Ultimately, the environmental impact and cost of a product is not only influenced by its reuse capabilities, but also by the production and sterilization methods used. This can lead to conflicting results for the LCA of the same product type when used in different settings. So, implementing RMDs in healthcare means not only developing a good product, but also adapting your process for positive impact.
Safety first
On paper, RMDs look like a promising and logical step to achieve circularity. In practice, however, there are still a lot of hurdles to overcome. The most important reason to keep SUDs is safety. There are concerns regarding the infection risk that reprocessed medical devices could pose.
These concerns have led to several countries, including France, Austria, and Italy, remaining hesitant to reprocess SUDs. There is, however, a lack of consistent, high-quality research investigating the safety of reprocessed SUDs compared to conventional SUDs. A study on the implementation of the EU regulation on medical devices on the EU market states that there’s “hardly any evidence-based decision making for allowing/not allowing the reprocessing of SUDs”.
For RMDs, these concerns are less pronounced. An exploratory study on sustainability of commonly used materials in hospitals highlights that the safety of SUDs is equal to RMDs. But the safety of the product depends on how it is implemented, meaning that clear, standardized reprocessing guidelines should be made available and followed to safeguard the health of every patient. Furthermore, safety should be assessed for every product and process individually.
The right device with the right design
The FDA highlights that “the risk of acquiring infection from an inadequately reprocessed medical device is relatively low given the large number of such devices in use, although the potential for outbreaks of infection associated with their use remains an important public health concern.” In 2013, an association was reported between reusable duodenoscopes and multi-drug-resistant bacterial infections, despite following the correct reprocessing procedures.
This issue reflects the importance of making the right devices reusable, both from an environmental as well as a safety point of view. Reusing complex devices reduces the cost while being more beneficial for the environment, but they are also harder to clean, increasing the risk of infections, as was the case for the duodenoscopes. This should be taken into account during the developmental and design phase of RMDs.
Fixing the chain
Even if these devices were deemed completely safe, there are still several links in the chain which need to be optimized for RMDs to drive circularity in hospitals. Firstly, many hospital infrastructures count on ‘just-in-time’ delivery, lacking a material logistics infrastructure for the reprocessing of medical devices or recycling of devices which cannot be reused. Secondly, current business models incentivize SUDs since manufacturing them in high volumes creates high revenue. Lastly, there’s a lack of clear and consistent guidelines regarding the reprocessing of medical devices, resulting in device consumers opting for SUDs to avoid potential errors.
Preparing for positive impact
Thankfully, various companies and organizations acknowledge the clear need for change, investing in new products and projects to boost circularity in the healthcare sector.
In Belgium, the Flanders Circular Economy, a partnership between governments, companies, non-governmental organizations, and the knowledge community, are working towards a circular Flanders, including the healthcare sector. One of the projects by Ghent University focuses on reducing single-use materials in healthcare through sustainable disinfection. They are investigating which single-use materials can be replaced by existing reusable alternatives suitable for disinfection with an automatic laundry disinfector. Another one of their projects aims to make wound care more sustainable by introducing reusable instruments. After successful implementation in their hospital, they will, together with several partners, help other healthcare institutions adopt their methodology.
The Dutch company Layco is committed to making healthcare more sustainable as well as globally accessible. Their first product Vela® is a reusable vacuum extractor, an assisted birth delivery tool designed for accessible reprocessing by reducing the number of components from 25 to just 5. The initial 25 components make the instrument difficult to clean, promoting single-use. Vela® aims to address these problems, promoting sustainability while supporting the health of babies and mothers worldwide.
The global technology company Philips, which produces large- and small-scale medical equipment as part of its portfolio, aims to promote circular economy in the healthcare sector through developing new business models. Their product-as-a-service model offers devices such as ultrasound as a subscription service, where customers have access to devices, such as transducers, while Philips remains owner of the hardware. They are also committed to closing the loop on equipment by taking back medical equipment to be refurbished where possible. If this is not feasible, valuable parts are recovered and the materials are recycled.
These innovations are paving the way towards a more sustainable healthcare system. For our systems to really change, all stakeholders must commit to high-value quality care and move away from linear supply chains to achieve a more sustainable and healthy tomorrow.
