Material flow analysis of single-use plastics in healthcare: A case study of a surgical hospital in Germany

Abstract

Plastics have become omnipresent in healthcare but quantitative data on mass flows are scarce. This study, therefore, performed a material flow analysis of single-use medical plastics and their packaging in a surgical hospital in Germany. We quantified the flows of eight different polymers across six product categories of medical consumables, based on the evaluation of the consumption data for 2018 and 2019. A total of 619 g of medical consumables were used per patient per day, of which 86% were polymers (531 g/patient/day). Plastic packaging contributed an additional 16 g/patient/day. The major product categories were personal protective equipment (49%) and incontinence products (22%). Polypropylene with 45 % and latex with 25% were the major polymers, both of which are tied to the use of personal protective equipment. The detailed analysis of the material and waste flows may serve to highlight potential steps for the plastic reduction in hospitals.

Full text

Resources, Conservation & Recycling 185 (2022) 106425
Available online 8 June 2022
0921-3449/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Material ow analysis of single-use plastics in healthcare: A case study of a
surgical hospital in Germany
Tijana Ivanovi´
c
a
, Hans-J¨
org Meisel
b
, Claudia Som
a
, Bernd Nowack
a
a
Empa, Swiss Federal Laboratories for Materials Science and Technology, Lerchenfeldstrasse 5, 9014 St. Gallen, CH-9014 Switzerland
b
BG Klinikum Bergmannstrost, Halle gGmbH, Department of Neurosurgery, Merseburger Strasse 165, Halle (Saale), 06112 Germany
ARTICLE INFO
Keywords
Medical plastic
Single-use plastic
MFA
Hospital
Healthcare
ABSTRACT
Plastics have become omnipresent in healthcare but quantitative data on mass ows are scarce. This study,
therefore, performed a material ow analysis of single-use medical plastics and their packaging in a surgical
hospital in Germany. We quantied the ows of eight different polymers across six product categories of medical
consumables, based on the evaluation of the consumption data for 2018 and 2019. A total of 619 g of medical
consumables were used per patient per day, of which 86% were polymers (531 g/patient/day). Plastic packaging
contributed an additional 16 g/patient/day. The major product categories were personal protective equipment
(49%) and incontinence products (22%). Polypropylene with 45 % and latex with 25% were the major polymers,
both of which are tied to the use of personal protective equipment. The detailed analysis of the material and
waste ows may serve to highlight potential steps for the plastic reduction in hospitals.
1. Introduction
Plastics are indispensable materials in healthcare and an integral
part of medical care nowadays. Because they are functional lightweight
materials with a spectrum of favorable properties, plastics have
permeated a wide variety of activities in healthcare (Joseph et al. 2021).
While “healthcare sector” is an umbrella term that encompasses diverse
medical establishments, hospitals are one of its most resource-intensive
parts due to a combination of diagnostics, treatment procedures, and
inpatient care, which they operate daily.
In recent years, hospitals have increasingly relied on diverse plastic
products in both their medical and support activities (Joseph et al. 2021;
Sastri 2014). In fact, because hospitals are a combination of medical
services and support activities, plastics are omnipresent. On one hand,
medical use of plastics involves medical devices (MD) and personal
protective equipment (PPE) in ambulatory care, operating theaters,
emergency rooms, patient wards, etc. Non-medical applications, on the
other hand, include kitchens, cafeterias, catering, cleaning, laundry,
maintenance, administration, etc. Furthermore, plastic products in
healthcare can be durable or disposable, i.e. consumable (see Fig. 1). Du-
rables have a longer life span, normally more than 3 to 5 years.
Disposable products are designed to be used once (hence single-use) and
thrown away thereafter. They are largely sterile, delivered in primary
packaging, and are neither reused nor reprocessed after use.
The European Union (EU) has issued a Directive on single-use plas-
tics targeting non-medical plastic products (cups, bottles, cutlery, bags,
food containers, etc.) to minimize and rationalize their consumption and
decrease the associated environmental impacts and health risks (Euro-
pean Commission 2019). Comparable efforts in medical consumables
are lagging and there is a rather limited body of research on how to
reduce their use. Medical consumables are almost entirely composed of
commodity polymers or are composites with other materials. The most
common plastics in medical devices are polyethylene (PE), poly-
propylene (PP), polyvinyl chloride (PVC), polystyrene (PS), and poly-
carbonate (PC) (Sastri 2014), with the rst four commodity plastics
accounting for 70% of the mass of medical devices (Joseph et al. 2021).
Half of all PPE is plastic, made from materials like PP, PC, or PVC
(Kumar et al. 2020). Furthermore, the hospital waste – here a combi-
nation of medical and municipal waste – was found to have a signi-
cantly higher plastic content (25%) than municipal waste and that
two-thirds of all hospital plastic waste were attributed to cafeteria
plastics, sharps (e.g. syringes with needles or buttery needles), medical
packaging, blood bags and tubing (Lee, Ellenbecker, and Moure-Eraso
2002). Similarly, an audit of recyclable waste done for an intensive
care unit (McGain, Story, and Hendel 2009) found that 30% of its waste
consisted of plastic.
The research related to plastics in hospitals so far focused predomi-
nantly on the waste output. The studies include waste management
E-mail address: nowack@empa.ch (B. Nowack).
Contents lists available at ScienceDirect
Resources, Conservation & Recycling
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https://doi.org/10.1016/j.resconrec.2022.106425
Received 15 March 2022; Received in revised form 29 April 2022; Accepted 23 May 2022

Resources, Conservation & Recycling 185 (2022) 106425
2
practices for plastic and non-plastic waste streams, among others (Prem
Ananth, Prashanthini, and Visvanathan 2010); composition of waste in
different hospital units (Dettenkofer et al. 2000; McGain et al. 2009;
Rizan et al. 2020; Sousa et al. 2020); recycling options for
plastic-containing products (Joseph et al. 2021); and resource efciency
in waste management (Tudor et al. 2008). Research related to specic
plastic products includes life cycle assessments on material substitution
in medical devices (Unger et al. 2017), their reprocessing (Unger and
Landis 2016), and reduction efforts (Leissner and Ryan-Fogarty 2019).
Plastics in hospitals are normally addressed through waste management
and recycling because hospital waste management involves hazardous
and diverse non-hazardous streams. Notably, Dettenkofer et al. (2000)
found that waste emission in the hospital varies with its size (number of
beds) and ranged from 2.9 kg/bed/day in small to 5.4 kg hospital
waste/bed/day in large hospitals. It was indicated that only 15% of
medical waste is indeed biohazardous (Sousa et al. 2020) and is,
therefore, subject to special regulation for waste management and is
normally incinerated. For example, only up to 5% of plastic healthcare
waste is recycled in the United Kingdom (Rizan et al. 2020). In the last
20 years since (Lee et al. 2002) and (Dettenkofer et al. 2000) published
their works on the hospital waste composition, the amount of plastics in
healthcare has further increased as plastics replaced metal, glass, and
ceramics wherever possible (Joseph et al. 2021) and single-use products
expanded in use (Sastri 2014).
In the light of such changes, this study aimed to quantify the current
single-use plastics consumption in hospitals by determining the use of
plastic-based medical consumables per patient per day and to analyze
the hotspots of plastic consumption to provide a basis for the appro-
priate mitigation strategies for practitioners and decision-makers. To
our knowledge, there are no studies that detail the polymer streams in
different functional product groups. Such an approach would also
facilitate the determination of polymer availability for recycling and
other end-of-life options. We, therefore, conducted a material ow
analysis (MFA) of six commodity polymers; PE, PP, PVC, PS, poly-
ethylene terephthalate (PET), and polyurethane (PU); rubber (natural
and synthetic) and other minor polymer streams together with non-
plastic materials (metal, cellulose uff and paper, cotton and others)
in plastic consumables in a surgical hospital in Germany as shown in
Fig. 1.
2. Method
2.1. System denition
The system boundary of our research is the surgical hospital BG
Klinikum Bergmannstrost in Halle, Germany. The hospital is part of the
BG clinics (original: BG Kliniken) group in Germany, a hospital associ-
ation of the statutory employer’s liability insurance. The hospital is a
certied cross-regional trauma center with approval for the severe
injury type procedure (SAV). The system boundary (Fig. 2) takes into
account the regular medical operations of the hospital, i.e. work in
emergency rooms, operating theaters, patient care wards (incl. intensive
care units), ambulatory care, and the sterilization of reusable medical
equipment. The home care that the clinic provides remains outside of
the scope, as do the hospital’s support services like maintenance,
administration, and food provision. This large hospital contains 571
beds (29 for intensive care and burns) with an average occupancy rate of
83.5% in 2018/2019 and performed an average of 9367 surgeries and
ER cases annually in the same period (hospital’s data).
The six major product categories listed in Table 1 are examined in
this study: contact devices, anesthesia, personal protective equipment
(PPE), general care, incontinence, and sterilization needs. The cate-
gories are dened based on the hospital’s product groups (through
group agglomeration) and interviews with the hospital staff members.
Data processing is further elaborated in section 2.2. Contact devices
include MDs that penetrate the skin (needles, blood taking), wounds
(suction), or urinary tracts (catheters), which are used to transport
medication and infusion liquids (infusion sets and tubbing) or for
transfusion. Anesthesia refers to anesthesia masks. General care of
patients refers to consumables used in in-patient care such as washing
gloves and personal hygiene items, medicine dispensers (single-use
cups), swabs, and other ordinary products. PPE includes protective
clothing like aprons and gowns, as well as masks, caps, gloves (sterile
and unsterile), face protection, etc. designed to prevent the wearer from
injury or limit the spread of infection (U.S. Food & Drug Administration
2021). In this context, PPE is divided into three sub-categories (Table 1)
to distinguish between the use cases and includes the 1) gloves; 2) face &
body protection and 3) single-use surgical textiles that protect the pa-
tient and the surgical team during the procedure. Incontinence includes
single-use protective bed sheets, adult diapers, and female sanitary
products. Finally, sterilization refers to products used for the in-house
sterilization of durable materials, largely bags and caps/fasteners for
sterile containers.
As to the material streams, in this study, the words "plastic" and
"polymers" are used interchangeably and refer jointly to all examined
polymer streams – PP, PET, PE, PVC, PS, PU as well as, latex (natural
rubber) and synthetic rubber. This approach is based on denitions and
categorization of plastic by (Hartmann et al. 2019) which allows for a
collective term for all examined streams. Every material ow is pro-
cessed separately. Hence, "other polymers" include polymeric materials
not listed above, examples of which include polycarbonate, elastics,
polyamide, superabsorbent polymer (SAP in diapers), etc. "Other ma-
terials" include non-plastic components of products predominantly
metal, cellulose uff, paper, and cotton.
2.2. Data processing & material ow analysis
The procurement and consumption data
The consumption and procurement data for diverse medical and non-
medical products and services for the hospital and its subsidiaries were
obtained for two consecutive years (2018 and 2019). The study, is
hence, not impacted by the effect of the Sars-Cov-2 pandemic. The
originally provided datasets consisted of 8637 and 8659 different
products procured and used in 2018 and 2019, respectively. For each of
these entries, the following points were made available: hospital’s
article number and article description; the product group as per the
Fig. 1. Examples of different uses of plastics in healthcare. The medical con-
sumables in hospitals are the primary interest of this study.
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hospital’s procurement classication (further "product group"); supplier
information and supplier’s article number; annual consumption in
relevant units (1 piece, 1 pair, 1 roll or 1 primary packaging). Equally,
the waste management data of the hospital was provided for special and
hazardous, mixed municipal, and recyclable waste by its Environmental
Health and Safety Department (EHS).
Since the study focuses on plastic consumables in the hospital,
several steps displayed in Fig. 3 were taken to lter out the relevant data
from the originally provided datasets. Namely, all product groups used
outside of the system boundary (hospital’s medical operations) were
removed from the database (step 1). Next, in steps 2 & 3, all groups of
durable products (e.g. electronics, medical equipment, implants) were
removed, together with medical consumables that do not principally
contain plastics (e.g. cotton dabs, wound dressings, and sutures, plasters,
and bandages). Details on which product groups were removed and why
are available in the Supplementary information, Table S1.
As to the remaining plastic-based medical consumables, due to the
large diversity of remaining products (1379 products in 2018 and 1344
in 2019), several approximations had to be made. The consumption rate,
i.e. the number of items used annually in 2018 and 2019 of each product
was calculated as the average of the consumption for the two years (step
4). Only 140 products where the annual consumption surpassed 5000
pieces were processed further to obtain their weight and composition
(step 5, see Section 2.2.2. for details). This threshold of 5000 was chosen
as a compromise between the number of products that could be handled
and relevance based on used articles. These products cumulatively
accounted for 95.1% of the total consumables in 2018 and 95.2% in
2019 in terms of the number of units (details provided in Table S3 of the
Supporting Information). Table S3 gives an overview of the so-called
capture rates of the chosen approach for all 19-product groups as per
the hospital’s classication. The remaining products, which accounted
for 4.9% and 4.8% of the total plastic-based consumables in 2018 and
2019, were assumed to have the same weight and composition as the
140 elaborated products. The extrapolation of weight and composition
data to the full dataset was done in step 6. Finally, in step 7, all 19
product groups were agglomerated based on the product function and
group similarity into six product categories as listed in Table S3.
Article weight and composition
Of 140 products stemming from step 4 (see Fig. 3), 131 products
were sampled from the hospital’s main storage to be further investi-
gated. For that purpose, the primary packaging, i.e. the individual sterile
packaging or joint packs of several pieces were removed from the
product and treated separately.To evaluate the composition and weight
of each product, the use of manufacturer data, weighting, sensory
analysis, and visual approximations were deployed. No chemical or
physicochemical analysis was performed on any product. The polymer
composition of each product was evaluated based on the corresponding
manufacturer information and sourced from original supplier brochures
and catalogs, online pharmacies and PPE suppliers based on the article
Fig. 2. The system boundary of the material ow analysis of single-use medical plastics. PPE stands for personal protective equipment. End-of-life treatment for
plastic consumables, in this particular case, is synonymous with incineration.
Table 1
Denition of eight product categories and a non-exhaustive list of examples of
belonging products.
Product
category
Examples of products
Contact
devices
infusion sets; syringes; intravenous & buttery
needles coupled with blood taking equipment;
regular and special urinary catheters; drainage
& postoperative suction
Anesthesia anesthesia masks for patients
General care medication dispensers; washing gloves &
hygiene items; razors; swabs; medical bags
PPE Gloves single-use examination gloves; surgical gloves
Surgical textiles protective textiles for patients and sterile
equipment in surgery
Face & body
protection
surgical masks; caps; aprons; single-use coats
Incontinence adult diapers; female sanitary products;
single-use protective bed sheet
Sterilization bags for in-house sterilized goods; container
closers
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number given on its packaging (code). Where composition of product
parts was known from manufacturer data (e.g. tubing or valves) but
weight data was missing, products were physically dismantled in our
workshop. After being separated, components were weighted individu-
ally on a lab-scale (with 0.001 g accuracy). Products that are very similar
to a known representative (e.g. infusion set with or without valve;
needles with similar gauge) were approximated with the said repre-
sentative. As to the remaining 9 products which were not investigated in
detail due to product complexity (normally composite products) or un-
availability of data, the composition, and weight data were taken from
the literature. The weight and composition for both types of surgical
masks used in the hospital (part of PPE) is approximated with data from
(Schmutz et al. 2020). The composition (as % mass) of all 7 types of
adult diapers and female sanitary products used in the hospital (part of
incontinence category) was taken from (Ajmeri and Ajmeri 2016). The
weights of these 7 items were measured from the representative prod-
ucts sourced at the hospital. The composition of each product was
expressed as % of specic polymer stream and other materials in the
total weight of the product.
Packaging & waste data
Plastic packaging appears in several forms – primary, secondary, and
tertiary. Primary packaging relates to all individual, unit packaging of
sterile medical devices and PPE. Secondary packaging is a pack con-
taining several items, for example, those of non-sterile PPE or inconti-
nence products. Packs are usually added up in cartons, which are
stacked on a euro palette for delivery and wrapped by stretch foil (ter-
tiary packaging). Due to a great diversity of primary and secondary
Fig. 3. Data processing for material ow analysis. A list of eliminated product groups is available in Table S1.
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packaging, several approximations based on eld observations were
made, details on which are available in Table S2. In this project, only the
primary and secondary plastic packaging were taken into account. For
simplicity, all plastic foil was assumed to be made from PE, even though
other materials like PVC can be used for the same purpose. Paper boxes
and cartons were not accounted for, while other types of packaging were
not observed (e.g. expanded PS). The number of packs per carton and
cartons per palette varies greatly per product rendering the approxi-
mations for stretch foil consumption too complex to be included. Ter-
tiary packaging, therefore, lies past our research scope. Finally, the
weight of plastic packaging was multiplied by the consumption rate of
corresponding products and added up for each product category. The
plastic packaging was scaled and agglomerated in the same manner as
for the product groups to which it refers.
As to the waste data, provided by the EHS Department, mixed
municipal and non-infectious medical waste includes medical and
household plastic items, paper, packaging, cardboard boxes, kitchen and
food waste, and miscellaneous. An item is considered infectious if it
contains blood, secretion, and excretion traces. Sharps, as the name,
suggests all pointed and sharp objects, like cannulas and needles with
and without mounted syringes, collected in separate sealable waste
containers. In addition to these three principle waste categories, the
hospital produces a subset of special waste streams outside of the study
scope. These include anatomical waste, unused medication, and cyto-
static drugs, diverse chemicals, batteries, electric and electronic waste,
rebuilding and construction waste, greenery maintenance, and con-
dential paper data that fall outside of the scope of our study.
MFA calculations
Step 5 of data processing yielded the composition and weight of 140
major products (Fig. 3). Masses of polymer streams were calculated (in g
polymer) for each product from the corresponding composition data and
weight data. By multiplying the consumption rate with the corre-
sponding products and summing all products within the product group
together, the mass of each plastic and non-plastic stream per product
group was obtained. The remainder of the products in each product
group were assumed to have the same composition as the 140 ones
assessed in detail. To allow for this extrapolation, the capture rates from
Table S4, i.e. % of represented products in each group (number of units
of products with 5000+pieces vs total number of product units per
group), were applied. In the last step (step 7 in Fig. 3), several similar
product groups were joined together into product categories based on
the functionality. By extension, their material ows were, therefore
joined together. Finally, for each product category the average mass of
product, i.e. representative products was calculated, available in
Table S3.
2.3. Interviews
In addition to the data analysis, formal interviews and e-mail ex-
changes were conducted with the hospital’s staff, namely with the EHS
Manager, Procurement & Logistics Team, and four Head Nurses (Anes-
thesia, Surgery, Intensive care unit, Neurology). The goal was to un-
derstand the procurement strategy, daily operations, and waste
separation and management in the hospital.
3. Results
3.1. Weight of single-use plastics allocated to product categories
The total use of plastic-based medical consumables (further con-
sumables) amounted to 619 g consumables/patient/day, 531 g of which
were diverse plastic streams and 88 g were other non-plastic materials.
The personal protective equipment - gloves, body and face protec-
tion, and surgical textiles – jointly accounted for 49% of the mass of
examined consumables and 52% of all plastic streams. The hospital used
304 g of PPE products/patient/day, 278 g of which were plastic streams.
Furthermore, face & body protection (surgical masks, FFP2 masks,
aprons, coats, caps) as a standalone sub-category, were the most used
form of consumables. As Fig. 4 shows, gloves were also the most
important consumable in the total plastic consumption, with 138 g of
gloves/patient/day (as a blue column in Fig. 4). Because they are also
the only sub-category of PPE exclusively constituted of plastic (simply
no yellow column in Fig. 4), the material consumption of gloves is equal
to their contribution (138 g plastic/patient/day) to total plastic con-
sumption. Surgical textiles had a negligible effect on the daily con-
sumption of plastics. They are related to 9300+surgical procedures in
operating theaters and as such do not Figure in the daily patient care.
The second highest consumption rate of consumables fell on incon-
tinence products with 135 g product/day, 62% of their total mass being
plastic streams. Furthermore, the hospital used 125 g/patient/day of
contact devices, out of which 121 g were plastics. Contact devices are
one of the most heterogeneous groups. They include products like sy-
ringes, catheters, infusion, and blood-taking devices, which, as Table S3
shows, have vastly different unit weights. Similarly, general care (37 g
patient/day) items also show a great diversity of products within the
group and are related to day-to-day patient care at wards. Examples
include bathing gloves, medical dispensers, and razors that support daily
care most of which are composites and feature other materials like
metals or cotton in the product construction.
Finally, anesthesia and sterilization were the categories with the
lowest contribution to the total use of consumables. Sterilization had
negligible polymer consumption as it largely accounted for sterile
packaging bags for in-house sterilized equipment. The sterilization re-
quirements are effectively contingent on the in-house sterilization of
durable medical devices. As such, they uctuate as the hospital takes out
and/or introduces the durables and single-use products.
3.2. The polymer composition of product categories
Fig. 4 shows that the product categories have vastly different weights
as well as shares of non-plastic materials. Fig. 5 demonstrates that this
diversity extends to the polymer composition of the product categories.
The representation of different polymers in product categories is so
heterogeneous, that no two categories are alike.
Firstly, as PPE (gloves, surgical textiles, face & body protection) was
shown to be the most substantial contributor to the mass ow of con-
sumables, its composition will have the biggest contribution to the nal
weights of plastics. Starting with the sub-category of gloves, their
composition is dominated by latex (98%). They are a rare example of
medical consumables with a single-polymer composition, as all medical
gloves are either 100% latex or 100% synthetic rubber. Normally all
gloves, whether sterile or unsterile, are made from latex. The use of
synthetic rubber is, in fact, a function of latex allergies of staff members.
The most frequent substitutes for the natural latex gloves are those made
from nitrile butadiene rubber (NBR) which gure in the study. Other
options include PVC, known as vinyl gloves, or ethylene-vinyl acetate,
also known as copolymer gloves. Furthermore, the sub-category of body
& face protection (which includes masks, aprons, coats, and caps) is
dominated by PP, specically in the form of non-woven fabric. Other
polymers in use include a minor amount of PU, mostly for mask ear loops
and elastics, which serve to tighten the grip of PPE on the body. On the
level of a single apron or a coat, it is noticed that the composition and by
extension, the weight, are inuenced by the functionality of the product.
For instance, single-use coats and aprons are constituted of either a
single layer of spun lace PP or several alternate spun-bond or melt-blown
PP layers, depending on the necessary level of uid resistance or
repellency. Other noticeable solutions include a PP base with a layer of
PE foil for water resistance. In our case, fabric blends of non-woven PP
and polyester (PET) or PE, which exist on the market, were not used.
Furthermore, a combination of PP (non-woven) and PE (tear-proof foil)
are predominant components of surgical protection. Since surgical
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protection accounts largely for single-use sheets and drapes used to
cover the patient on the operating table, the presence of a combination
of polymers in a waterproof cover is no surprise. In the past, however,
surgical drapes were composed of washable natural materials, but the
comfort of disposable, sterile, and by default, synthetic drapes overtook
the operating theaters.
Incontinence products, which consist of diapers, female pads, and
bed protection sheets, are also related to the use of non-woven PP (50%
of plastics, 31% of product mass). When it comes to PE, a mere 10% mass
of an average diaper and pad falls on PE; the same polymer accounts for
44% mass of single-use sheets. This effectively translates to 30% of all
plastic in incontinence being PE. As Fig. 4 shows, incontinence products
are the study category with the biggest participation of non-plastic
materials. For example, adult diapers contain large amounts of
Fig. 4. Daily consumption of plastic-based medical consumables and their packaging allocated to six product categories (in g/patient/day). PPE is separated into 3
sub-categories as classied in Table 1. Details on the product categories are available in Table S6, and on packaging in Table S5.
Fig. 5. The polymer (plastic and rubber) content of each product category. Note that this graph relates to the polymer mass of the product category and is based on
Tables S6/7. Non-plastic streams are subtracted. The total composition is available in Fig. S1.
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cellulose uff and this regenerated material and adhesives account for
65% of the diaper mass. Therefore, the entire category of incontinence
products contains 38% of non-plastic materials.
Furthermore, contact devices are the most diverse fraction of con-
sumables in terms of composition. They are composed of 8 out of 9
possible plastic streams. Notably, contact devices feature a substantial
amount of PVC, which accounts for 41% of the plastic in this group. PVC
is used in tubing for products like infusion sets and catheters, which have
high unit weights in this category. PVC is malleable and has a wide
operating temperature span, which makes it an ideal candidate for blood
bags besides tubbing. In this study, blood bags were not directly
accounted for, due to their low consumption (do not surpass 5000 items
annually). Notably, anesthesia is the only other category where PVC is
present and accounts for 48% of the mass of the plastic. Its application is
again, tied to the tubing and the malleability of anesthesia masks.
Conversely, syringes and non-metallic parts of needles are made
from hard PE, PP, or PS due to their cheap cost of manufacturing. Lately,
such medical devices have proted from installing safety mechanisms
against injury and these have become increasingly complex. Plastics are
added as a sort of encapsulation of the needle, which is dispatched
automatically or semi-manually after the contact with the patient. The
safety mechanisms, made from plastic tubes for needle protection after
use and before disposal, increase the relative ratio of plastic per needle
and render - previously uninsured or less secured needles - heavier. The
diversity of products grouped in contact devices is illustrated in gure S2
in the Supplemental Information.
General care items are predominantly made out of cheap commodity
plastics like PP and PE. PE, in the form of a foil, also dominates the
sterilization category. The polymer is connected to the use of sterile
transparent bags where one side is made from plastic foil and the other
from medical paper. As the specic weight of such a thin material is very
low, the resulting category mass (visible in Fig. 4) is also modest. Note
that the investigated hospital does not use the typical "blue wrap" for
wrapping the sterile instruments. The typical blue wrap is a typical PP-
based non-woven fabric, which if it were used in the hospital would
increase the mass ows of plastics. The hospital, instead, opts for crepe
paper-like, cellulose-based wraps. In effect, if hospitals increase the in-
house sterilization of durable instruments in place of single-use items,
the sterilization requirements will increase accordingly.
3.3. Mass ows of plastic packaging
The 619 g/patient/day of plastic consumables used in the hospital
are directly associated with 16 g/patient/day of packing. There is a great
diversity in the contribution of packaging to each product category, as
depicted in Fig. 4.
In absolute terms, contact devices are related to the highest amount
of plastic packaging (8 g/patient/day), followed by gloves (3 g/patient/
day) and incontinence (2 g/patient/day). In relative terms, packaging
contributes the most to contact devices items where for every kg of
products, there is another 7% of packaging. In the case of surgical tex-
tiles, this ratio amount to 5%, followed by anesthesia at 4%. In effect,
plastic packaging is strongly associated with product sterility, which is
why these three aforementioned product categories are associated with
the highest need for plastic packaging. Virtually all contact devices
require sterile packaging, which is particularly true of syringes, needles,
infusions, etc. All studied surgical textiles require sterile plastic pack-
aging, for safety in operating theaters. Anesthesia masks are also sterile;
hence a correlation between product mass and plastic packaging can be
expected. The remainder of the product categories shows small amounts
of packaging used, relative to their weights. Details on the packaging can
be found in Table S5.
3.4. Mass ows of polymers
As a nal step in the analysis, we brought together the quantities of
plastics from each product category to understand the available quantity
of each polymer stream. The biggest contributor to the total sum of
plastics in consumables was PP, with 45%. It appears in all six product
categories in two forms: hard plastic and non-woven fabric. The latter
accounted for 83% of the entire PP mass and is largely related to the use
of PPE. As Fig. 6 shows, the quantity of PP was almost double that of the
second most relevant ow – latex, which accounted for over a fourth of
the entire polymer mass in consumables. It is synonymous with gloves
since it gures exclusively in these products. PE also appears in all 6
product categories meaning that it has very diverse use cases. To illus-
trate the effect of "virtual" plastics, Fig. 6 also displays the contribution
of plastic packaging to the total mass of PE. The consumption of PVC,
predominantly related to anesthesia and contact devices, accounted for
9% of the total polymer mass in consumables.
PET was the only polymer other than PP that appeared in two forms –
as a non-woven fabric (ber) and as hard plastic. Effectively only 5% of
PET was related to hard plastic parts, while the overwhelming majority
(95%) was related to polyester ber. However, PET was negligible in the
total mass of plastics. It accounted, together with rubber, PU, PS, and
other plastics for only 6% of the total plastic consumption.
3.5. Waste streams
Based on information from the EHS services, the hospital emitted an
average of 530 tons of mixed municipal and non-infectious medical
waste per year, or 3.1 kg/patient/day. In addition, 7.4 tons of mixed
infectious waste/year (43 g infectious waste/patient/day) and 7.9 tons
of sharps/year (45 g sharps/patient/day) were produced. All waste is
separated at the point of use, and staff members are trained to separate
recyclable, non-hazardous waste streams. However, regardless of
whether waste streams are hazardous or not, all waste is incinerated by
the local waste operator due to the origin and perceived threat of
contamination.
3.6. Trends in product categories
The conducted interviews with the staff members demonstrated
several trends in the use of plastics. We found ve different trends
connected to the use of plastics: health & safety; convenience; logistics;
costs, and nally environmental concerns. Namely, the health and safety
concerns for staff members have driven the trend of insuring and (over)
protecting hazardous medical devices such as needles and syringes. The
safety systems built into these devices decrease the risk of injury be-
tween the use and disposal and, as consequence, raise the mass per item.
These products are part of the special waste category called sharps and
are disposed of separately in special tanks. Such boxes are permanently
sealed after being lled and are ultimately incinerated without opening.
It was made known to us during the staff interviews that this trend is
largely driven by suppliers who are phasing out the "ordinary" needles.
The substitution of heavier materials like glass and metal for plastic is
increasing due to health and safety, ease of logistics, and cost. This trend
has two components: the suppliers have increasingly phased out the
brittle materials prone to breaking during transport and handling and
hospitals prefer the plastics due to the health and safety of staff during
the use, e.g. to avoid breaking of bottles on the infusion stand. By
substituting metal and glass wherever possible, single-use products
become a more desirable option relative to durables requiring further
processing post-use.
Furthermore, probably the most visible and talked-about trend in
plastics is the adoption of single-use sterile packs of medical devices
instead of their durable counterparts. This switch has the advantage to
avoid the need for the on-site sterilization of durable products and multi-
use equipment. It however creates more plastic as well as packaging
waste. It was adopted largely because it decreases the need for the
workforce, which operates sterilization and washing, and decreases the
cost of in-house sterilization facilities (e.g. autoclaves or dry
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sterilization). It was, seemingly, a matter of convenience for the staff and
operational costs.
Finally, environmental concerns become more and more prominent
lately due to environmental protection, resource efciency, and climate
protection. As a consequence, durable or washable alternatives are
coming back to healthcare, and by extension, the price of waste man-
agement is expected to decrease. In our case in 2020, the hospital
leadership started making several changes in the procurement and
consumption strategy of PPE, neither of which are reected in this study.
4. Discussion
Based on the MFA, the investigated hospital uses 619 g of plastic-
based medical consumables per patient per day, 531 g of which are
plastic streams. Consumables, therefore, accounted for a fth of all
relevant waste (3.1 kg/patient/day). In comparison, Dettenkofer et al.
(2000) found that hospital waste emissions vary based on hospital size
(number of beds). For a hospital of medium size like the one in Halle
(400-700 beds in their classication), the waste production was pre-
dicted to be 4.7 kg/bed/day (Dettenkofer et al. 2000). This number,
however, includes a cafeteria, catering, and other non-medical waste
and its packaging. It is therefore worth noting that the present hospital
does not have catering or external delivery of prepared meals. Instead,
there is a fully operational kitchen and staff cafeteria, which operate as a
subsidiary of the clinic. All meals for patients and staff are prepared
in-house, and served on reusable food trays, where cutlery, plates, cups,
and bowls are collected and washed after every meal. The kitchen,
however, still procures plastic-packed food items as is the case in a
regular household.
A previous study found that the plastic content of hospital waste
(25%) was signicantly higher than in domestic waste in the year 2002
(12% mass) (Lee et al. 2002). By accounting for plastic consumables
only, our study found that the plastic content of the waste (hazardous
and mixed municipal) amounts to 17%. It can be expected that, if food
plastics and other items were added to our study, the ratio could rise past
the said initial assessment of 25%. Lee et al. (2002) also showed that up
to 67% of plastic waste in the hospital falls on cafeteria plastics, medical
packaging, syringes (sharps), blood bags, and tubing.
The hospital collected 45 g of sharps/patient/day. The relevant
consumables in the category of contact devices (syringes and needles)
that are parts of the sharps waste amounted to 34 g/patient/day.
Combined with other hazardous materials, incl. sharp metal objects
which were not covered by our study, the studied consumables are
therefore within the range of expected values.
In terms of product categories, PPE was the most important
consumable in the hospital. The consumption rate of PPE is also tied to
the point of use; intensive care units are more resource-intense relative
to general wards, which equally differ amongst themselves. In partic-
ular, gloves were the most numerous item. They are made from latex by
default and used for examination, patient care, and surgery. Synthetic
gloves are used only if a staff member has a latex allergy. Furthermore,
single-use coats and aprons have the highest unit weights. Their total
weight and composition are product-specic and substantially affected
by the density of weaving, number of layers, and fabric blends. For
example, PP/PE/PET blends are also common in non-woven textiles and
particular mixes depend on the producers. The aprons and coats where
liquid and body uids may spill have a waterproof layer of PE or are
composed of denser weaving; for others, a 3- or 5-layer non-woven PP
textile composition sufces. The hospital can therefore differentiate the
procurement of single-use aprons and coats to minimize the weight of
waste but preserve their functionality.
The second most relevant category per mass was incontinence
products which contain 62% of plastics in their composition. The
heaviest unit weight in this group is related to diapers. In reality, diapers
and products alike on the market have a very diverse, product-specic
composition with changing ratios of cellulose uff and polymers. As
things currently stand, PPE and incontinence products together account
for 71% of product mass and are the rst step in mitigating plastic
consumption in the hospital.
The highest diversity of products is noticed in the contact devices.
These products are highly functional disposable medical devices and
have a wide span of unit masses. Contact device weights span from 2 g to
42 g/product (Table S3). Furthermore, they are normally sterile in unit
packaging, which is why this group has the highest ratio (7%) between
the consumption rate (125 g product/patient/day) and plastic pack-
aging (8 g packaging/patient/day).
In total, plastic packaging was found to contribute an additional 3%
to the mass of consumables (16 g plastic/patient/day), and was, there-
fore, only a small additional contributor to the overall mass of studied
plastic in the hospital. The type and amount of packaging are largely
driven by the sterility of products as explained earlier. In that light,
sterilization requirements can also be viewed through the prism of
Fig. 6. The total quantity of polymers (plastics and rubber) used in consumables and associated packaging in g/patient/day. Other materials are available in Fig. S3.
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Resources, Conservation & Recycling 185 (2022) 106425
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packaging as they account for sterile packaging bags and plastic locks for
containers. Such products have negligible unit masses, amounting to 4 g
plastic/patient/day for sterilization. A small portion of medical devices
and utensils are still sterilized in-house, hence a low consumption rate of
sterilization requirement. The vast majority of the products comes in
pre-packed sterile forms. If hospitals should increase the sterilization of
their medical devices, plastic packaging is expected to decrease, how-
ever, sterilization packaging and the resource consumption for sterili-
zation would increase. The exact trade-offs are beyond the scope of this
work and reect the dynamic nature of policies on packaging and single-
use products.
In terms of the polymer mass, it was found that PP is the most rele-
vant polymer, accounting for 45% of all plastics; followed by latex
(25%), PE (12%), and PVC (10%). Previous research found that the main
plastics in hospitals were PE, PP, their copolymers, and PVC (Rizan et al.
2020). In stricter terms, not accounting for rubber, PP, PE, and PVC
combined also represent 67% of our hospital’s plastic.
We can use the data from the investigated hospital to estimate the
total use of medical single-use plastics in Germany. Germany has a total
of 661,448 hospital beds, 497,182 in curative and 164,266 in rehabili-
tation care (Eurostat 2020). This translates to 800.2 beds per 100,000
inhabitants, which is signicantly above the EU-27 average of 537.8
beds per 100,000 people (Eurostat 2020). Linear upscaling of the con-
sumption of plastic consumables obtained in this study to all German
hospitals, assuming the same occupancy rate of hospitals beds (83.5% of
beds occupied by patients), would therefore mean that 342 tons of
plastic consumables are emitted in German hospitals each day; that is
124,830 tons annually. Moreover, the upscaling of the total waste
emissions from our investigated hospital to all German hospitals yields
1684 tons of mixed waste daily or 614.858 tons annually. In comparison,
German households emitted 50.6 million tons of mixed municipal waste
in 2019 (Destatis 2021). Hospitals could therefore jointly emit plastic
consumables to the tune of 0.2% of municipal waste. By extension, the
overall waste production of hospitals could be 1.2% of what the
households emit. Furthermore, previous research showed that plastic
and plastic-containing products in healthcare contribute to 2% of total
EU-28 plastic ows (EU-27 and United Kingdom); when the plastic
composition of those products is taken into account, plastics from
healthcare accounted for 1% of the total plastic waste (Hsu, Domenech,
and McDowall 2021). The results are therefore comparable with the
existing estimates. In terms of the packaging, researchers had found that
in Germany 26.3 kg of post-consumer plastic waste is produced per
capita annually (Picuno et al. 2021) while we nd that packaging from
medical consumables produces 16 g of plastic/patient/day. However,
this upscaling from one specic hospital needs to be treated with great
care as different hospitals may have diverse procurement strategies and
varying needs for single-use plastics based on their specialization.
As noted, our work found several trends in the use of plastics.
Notably, the environmental concerns prove to be a worthy counter-
weight to the cost spiral and convenience of single-use products. As
people become more aware of the overconsumption of plastics in the
throwaway culture, the hospital management is incentivized to bring
change and improve the state in procurement policies, reuse, reduction,
differentiated waste management, etc. The effectiveness of such
switches should be examined and quantied via techno-economic and
life cycle assessments of the alternatives. Such a step is, however, out of
the scope of this paper. Authors like (Sousa et al. 2020), (Unger and
Landis 2016), and (Unger et al. 2017) have already taken steps to inform
the reprocessing of medical devices, material-intensity of procedures,
and the effects of polymer substitution in medical devices. The use of
plastics in hospitals is therefore not a static issue. On the contrary, it is
dynamic and these trends will keep on acting in opposing directions. If
one is interested in the reduction of impacts, the hotspot analysis
coupled with basic principles of waste management in the circular
economy – favoring reduction over recycling provides a solid starting
point.
Finally, our study based the material ow analysis on the set of
particular articles used in one particular hospital. Other medical in-
stitutions are not expected to use the same equipment; however, the
products should remain similar due to their functional requirements.
Due to a high diversity of products, the study assumes that major
products (most used products) in their representative groups reect the
group’s average composition. This may be skewing the analysis to
smaller and more used products, instead of heavier products with lower
consumption rates (e.g. blood bags, dialysis equipment). Regardless,
140 articles that were processed in detail correspond to a large majority
of total consumables by the number of items. As mentioned in the
methods, these 140 articles corresponded to 95.1% and 95.2% of total
consumables in 2018 and 2019 respectively. Furthermore, such an
approach yields different representativeness of the data in their product
groups and categories. We have to note that our approach shows low
reliability of certain product groups such as catheters (in contact de-
vices) and the entire category of anesthesia. They are rarely used over
5000 items per product, hence the capture rates in our method are low.
The study does not differentiate the place of the consumption – general
care, ICU bed incl. burns and divides the entire consumption on the total
occupied bed capacity. The difference in the care intensity in different
wards is therefore not taken into account, even though professional in-
terviews clearly show the discrepancy. In terms of plastic packaging, this
study does not account for tertiary stretch foil or other forms of pack-
aging. Further research steps in this eld could be based on the differ-
entiation of consumption places or account for all types of packaging.
5. Conclusions
Hospitals use plastic in almost every activity they operate. Our study
provides a detailed material ow analysis of single-use medical plastics
and a distinction between different polymers. We found that there is a
great prevalence of commodity plastics in the total mass of studied
consumables. In fact, the hospital is found to use 619 g of plastic-based
consumables/patient/day, 531 g/patient/day of which are polymer
streams including PP, PET, PE, PS, PU, PVC, rubber (incl. latex), and
other minor streams. The studied consumables account for about a fth
of all hospital waste. We, therefore, found that other waste streams have
a higher contribution to the total mixed waste production, as we looked
at a limited number of product categories.
On the product level, PPE and incontinence are the biggest contrib-
utors to the total mass of consumables. PPE stands out by accounting for
49% mass of all consumables. In the total polymer sum, polypropylene
in the non-woven form and latex are the most dominant materials. Both
are tightly related to their application in personal protective equipment.
The second most relevant products are incontinence products, which
feature a large variety of compositions on the market. The particularities
of each product available on the market arenot fully reected in our
study as we build the study on the available data on the average
composition. Incontinence products are only partly plastic-based which
is whyProcurement specialists could opt for products with lower plastic
content, compensated by higher cellulose contents.
Moreover, given the importance of PPE in the total mass of con-
sumables, the rst plastic reduction efforts in medical institutions should
focus on the rationalization of PPE consumption. Competent health &
safety and procurement specialists at hospitals would have to evaluate
the viability of different solutions in their particular cases knowing the
provided hotspot analysis. In light of the ongoing pandemic of the Sars-
Cov-2 virus and increased measures to curb its spread, additional pro-
tection measures have been put in place for staff, patients, and visitors
across the medical sector. Future research could therefore focus on the
quantication of this "corona effect", if any, on PPE in medical
institutions.
The complexity and heterogeneity of medical devices, namely con-
tact devices, as well as the perception of risk and hazardousness may be
an important point in recycling efforts. Namely, even though the studied
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hospital operates a developed waste separation at the point of use, even
the recyclable, non-contaminated fraction of medical waste is inciner-
ated because of the ease of unied management and perception of risk
from the operator side. These issues require further work, but the
complexity of medical products, and the need for processing and sepa-
ration of specic polymers do play an important role in opting for energy
instead of material recovery.
Finally, this study provided a baseline for understanding the con-
sumption of plastics in hospitals and as such is a solid ground for un-
derstanding consumption hotspots and laying out future research
directions. However, to understand the environmental trade-offs of
switching from single-use consumables to reusable alternatives that
require in-house or service sterilization, one would have to perform life
cycle assessments for targeted products and alternatives. Techno-
economics also play a major role in the transition, as sterilization in-
lieu of single-use products includes more workforce, energy, and
water consumption. Until favorable conditions for switching (back) to
reusable products are met, plastics will keep on being an essential
backbone in medical treatment due to their versatility and
functionalities.
Supplementary materials
Available in a separate document.
CRediT authorship contribution statement
Tijana Ivanovi´
c: Conceptualization, Formal analysis, Investigation,
Visualization, Writing – original draft, Writing – review & editing. Hans-
J¨
org Meisel: Writing – review & editing. Claudia Som: Conceptuali-
zation, Writing – review & editing, Supervision. Bernd Nowack:
Conceptualization, Writing – review & editing, Supervision, Funding
acquisition.
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Acknowledgments
We would like to address our special thanks to Ms. Caroline Gr¨
absch
(Research, BG Bergmannstrost Halle) for her exhaustive assistance in the
organization of the eldwork and coordination support, and Mr. Felix
Bürger (EHS, BG Bergmannstrost Halle) for his enabling contributions in
data acquisition. Furthermore, we owe sincere thanks to Ms. Petra
Storek and Mr. Martin Antal (Procurement and Logistics, BG Berg-
mannstrost Halle) for their genuine and timely contribution and inten-
sive communication in data acquisition and processing; as well as to the
logistics and storage staff who provided vital support during the eld-
work, and to our interview participants for their insight into the daily
functioning of the hospital. We thank the support of Dr. Merve Tunali
(Empa) who contributed to the quality of this paper through an internal
review and the ofcial reviewers for their time and effort.
Funding
This project was funded by the Federal Ministry of Education and
Research (BMBF) of Germany in course of the PromatLeben – Polymere
research project.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.resconrec.2022.106425.
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