REDUCING SINGLE-USE MATERIALS IN
MEDICINE AND HEALTHCAREAn exploratory study on sustainability of commonly used materials
in hospitals
DGEM/DPPC/LE/20022
Final report – June 2023

Liesbet Demarré*
Katrien Vanderwee*
Veerle Duprez*
Simon Malfait*
Sophie Huysveld**
Norbert Fraeyman*

This study was commissioned by the Federal PublicService for Health, Food Chain Safety and Environment,
the Directorate-General for the Environment***

Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent
Ghent University, Faculty of Bioscience Engineering, Department of Green
Chemistry and Technology, Coupure Links 653, 9000 Ghent

The photographs used in the report serve as representations of the medical items. The footage has
been obtained through purchase, and in cases where it was not available, proprietary photographs
were used.

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ACKNOWLEDGMENTSFirstly, we sincerely thank all the members of the FPS steering committee for their supervision of the study.
Next, we would like to thank all the consulted stakeholders for their expertise and sharing their experience,as well as the participating hospitals for their willing cooperation, for providing the necessary data, and foranswering further questions.
Special thanks to Evelien Kieckens, sustainability coordinator of the Ghent University Hospital, for thetremendous help and substantive comments and ideas throughout the project. Our thanks also goes to
Eveline Van Poucke who shared her experiences as sustainability coordinator of the AZ Maria Middelares
Hospital in Ghent.
Furthermore, we are particularly grateful to Krist Henrotin (central sterilisation department, UZ Ghent), Nancy
Dedapper (operating room, UZ Ghent), Mia Blomme (nursing department, UZ Ghent), Fabienne Van Lierdeand Lutgard Van de Putte Lutgard (purchase department, UZ Ghent), and Thienpont Patrick and Deblaere
Lieven (biomedical department, UZ Ghent) to answer our relentless stream of questions for additional
information. Many thanks also to Pascal De Waegemaeker (infection control department, UZ Ghent) to share
his expertise with us and provide critical comments on parts of the project.
We would like to express our gratitude to the companies that were willing to provide us with information
regarding the composition and/or functioning of the materials or their business. Without their input, thesuccessful completion of this project would have been challenging.
Finally, we particularly appreciate the efforts of David van der Ha at the start of the study.

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TABLE OF CONTENTSACKNOWLEDGMENTS ............................................................................................................................ 3
TABLE OF CONTENTS ............................................................................................................................ 5
LIST OF TABLES ..................................................................................................................................... 9
LIST OF FIGURES .................................................................................................................................. 10
GLOSSARY ............................................................................................................................................ 11
EXECUTIVE SUMMARY ......................................................................................................................... 13
1
1.1

INTRODUCTION ...................................................................................................................... 16
Situating the project in an historical context ............................................................................ 16

1.2

Introduction on medical waste .................................................................................................... 162
2.1

EXPLORATION OF EXISTING EVIDENCE AND PRACTICES ON SUSTAINABILITY OF
SINGLE-USE AND REUSABLE MEDICAL DEVICES ............................................................. 18
Literature ....................................................................................................................................... 18

2.1.1

Goal ................................................................................................................................................ 18

2.1.2

Methods .......................................................................................................................................... 18

2.1.3

Results ............................................................................................................................................ 19

2.1.3.1

Laryngoscopes .......................................................................................................................... 19

2.1.3.2

Flexible endoscopes .................................................................................................................. 21

2.1.3.3

Trocars ...................................................................................................................................... 25

2.1.3.4

Laparoscopic stapler, cutter, clip applier and scissors .............................................................. 27

2.1.3.5

Surgical scissors........................................................................................................................ 30

2.1.3.6

Medical blue wrap...................................................................................................................... 32

2.1.3.7

Sharps containers...................................................................................................................... 34

2.1.3.8

Surgical gown, isolation gown, coverall..................................................................................... 35

2.1.3.9

Laryngeal mask airway .............................................................................................................. 38

3
3.1

STAKEHOLDERS .................................................................................................................... 39
Goal ................................................................................................................................................ 39

3.2

Overview consulted stakeholders .............................................................................................. 39

4
4.1

HOSPITAL SURVEY: CONSUMPTION AND COST OF SINGLE-USE MATERIALS .............. 40
Goal ................................................................................................................................................ 40

4.2

Methods ......................................................................................................................................... 40

4.2.1

Design............................................................................................................................................. 40

4.2.2

Setting............................................................................................................................................. 40

4.2.3

Data collection: hospital survey procurement lists ......................................................................... 40

4.2.4

Processing procurement lists ......................................................................................................... 41

4.2.4.1

Consumption of single-use medical items and devices ............................................................ 41

4.2.4.2

Cost of single-use medical devices ........................................................................................... 41

4.2.5

Ethical considerations ..................................................................................................................... 41

4.3

Results ........................................................................................................................................... 41

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4.3.1

Participating hospitals ..................................................................................................................... 41

4.3.2

Procurement data ........................................................................................................................... 42

4.3.2.1

Longlist of single-use medical devices ...................................................................................... 42

4.3.2.2

From longlist to shortlist ............................................................................................................ 42

4.3.2.3

Selection of items ...................................................................................................................... 46

5
5.1

FIVE SINGLE-USE MEDICAL ITEMS AND ALTERNATIVES ................................................. 47
Goal ................................................................................................................................................ 47

5.2

Methods ......................................................................................................................................... 47

5.3

Results ........................................................................................................................................... 48

5.3.1

Kidney tray ...................................................................................................................................... 48

5.3.1.1

Description and Specification .................................................................................................... 48

5.3.1.2

Sustainability ............................................................................................................................. 48

5.3.1.3

Safety ........................................................................................................................................ 51

5.3.1.4

Cost ........................................................................................................................................... 53

5.3.1.5

Efficiency ................................................................................................................................... 54

5.3.1.6

Conclusion on kidney trays ....................................................................................................... 55

5.3.2

Blanket ............................................................................................................................................ 56

5.3.2.1

Description and specification ..................................................................................................... 56

5.3.2.2

Sustainability ............................................................................................................................. 56

5.3.2.3

Safety ........................................................................................................................................ 58

5.3.2.4

Cost ........................................................................................................................................... 59

5.3.2.5

Efficiency ................................................................................................................................... 59

5.3.2.6

Conclusion on blankets ............................................................................................................. 60

5.3.3

Vessel sealing device ..................................................................................................................... 61

5.3.3.1

Description and Specification .................................................................................................... 61

5.3.3.2

Sustainability ............................................................................................................................. 61

5.3.3.3

Safety ........................................................................................................................................ 63

5.3.3.4

Cost ........................................................................................................................................... 64

5.3.3.5

Efficiency ................................................................................................................................... 65

5.3.3.6

Conclusion ................................................................................................................................. 65

5.3.4

Cover caps for thermometers ......................................................................................................... 66

5.3.4.1

Description and Specification .................................................................................................... 66

5.3.4.2

Sustainability ............................................................................................................................. 66

5.3.4.3

Safety ........................................................................................................................................ 68

5.3.4.4

Cost ........................................................................................................................................... 68

5.3.4.5

Efficiency ................................................................................................................................... 70

5.3.4.6

Conclusion on cover caps ......................................................................................................... 70

5.3.5

Vaginal speculum ........................................................................................................................... 71

5.3.5.1

Description and Specification .................................................................................................... 71

5.3.5.2

Sustainability ............................................................................................................................. 71

5.3.5.3

Safety ........................................................................................................................................ 71

5.3.5.4

Cost ........................................................................................................................................... 72

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5.3.5.5

Efficiency ................................................................................................................................... 73

5.3.5.6

Conclusion for vaginal specula .................................................................................................. 73

6
6.1

LIFE CYCLE ANALYSIS (LCA) OF VAGINAL SPECULUM .................................................... 74
Background literature .................................................................................................................. 74

6.2

Goal ................................................................................................................................................ 75

6.3

Methods ......................................................................................................................................... 76

6.3.1

Functional unit ................................................................................................................................ 76

6.3.2

System boundary ............................................................................................................................ 76

6.3.3

Life cycle inventory ......................................................................................................................... 77

6.3.4

Outcome measures ........................................................................................................................ 79

6.3.5

Scenario analyses .......................................................................................................................... 79

6.4

Results ........................................................................................................................................... 80

6.4.1

Life cycle assessment .................................................................................................................... 80

6.4.1.1

Reusable specula (RU) ............................................................................................................. 80

6.4.1.2

Single-use specula from fossil plastic (SU ABS) ....................................................................... 81

6.4.1.3

Single-use specula from biobased plastic (SU PLA) ................................................................. 81

6.4.1.4

Ethylene oxide sterilised single-use specula composed of two types of fossil plastic (EO SU) 81

6.4.2

Scenario analysis ........................................................................................................................... 81

6.4.2.1

Scenario 1: energy mix .............................................................................................................. 81

6.4.2.2

Scenario 2: steam...................................................................................................................... 81

6.4.2.3

Scenario 3: Number of uses ...................................................................................................... 82

6.4.2.4

Scenario 4: Packaging .............................................................................................................. 82

6.4.2.5

Scenario 5: Waste treatment ..................................................................................................... 82

6.4.2.6

Best case scenario .................................................................................................................... 82

6.5

Conclusion on LCA of vaginal speculum .................................................................................. 82

77.1

DISCUSSION ........................................................................................................................... 83
Main findings ................................................................................................................................ 83

7.2

Limitations..................................................................................................................................... 87

7.3

Recommendations ....................................................................................................................... 88

CONCLUSIONS ...................................................................................................................................... 98
8

REFERENCE LIST ................................................................................................................... 99

99.1

APPENDICES ........................................................................................................................ 106
APPENDIX 1: Evidence table LCA’s Methodology .................................................................. 107

9.2

APPENDIX 2: Evidence table LCA’s Results ........................................................................... 113

9.3

APPENDIX 3: Inviting letter in French ...................................................................................... 130

9.4

APPENDIX 4: List items excluded by FAMHP ......................................................................... 134

9.5

APPENDIX 5: List excluded items ............................................................................................ 137

9.7

APPENDIX 7: Longlist of items ................................................................................................. 139

9.8

APPENDIX 8: Example amount/cost ratio for one hospital .................................................... 141

9.9

APPENDIX 9: Consumption of medical single-use items per bed per year for allparticipating hospitals ............................................................................................................... 142

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9.10

APPENDIX 10: Amount/Cost (catalogue prices) - rate ........................................................... 143

9.11

APPENDIX 11: Considerations on sustainability of raw materials ....................................... 144

9.12

APPENDIX 12: Steps in reuse phase of reusable speculum in Ghent University Hospital 148

9.13

APPENDIX 13: Inventory analysis for LCA .............................................................................. 149

9.14

APPENDIX 14: Assumptions for inventory analysis of LCA .................................................. 154

9.15

APPENDIX 15: Distribution details for reusable and single-use specula ............................. 156

9.17

APPENDIX 17: Graphs midpoint and endpoint estimates ...................................................... 158

9.18

APPENDIX 18: Scenario analyses ............................................................................................ 160

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LIST OF TABLES
Table 1: Summary LCA's on laryngoscopes .................................................................................................. 20
Table 2: Summary LCA's on flexible endoscopes ......................................................................................... 22
Table 3: Summary cost studies on flexible endoscopes ................................................................................ 24
Table 4: Summary LCA’s on trocars .............................................................................................................. 25
Table 5: Summary LCA on laparoscopic scissors and clip applier ................................................................ 28
Table 6: Summary study on surgical stapler .................................................................................................. 28
Table 7: Summary LCA’s on surgical scissors .............................................................................................. 31
Table 8: Summary LCA’s on blue wrap ......................................................................................................... 32
Table 9: Summary cost study on blue wrap ................................................................................................... 33
Table 10: Summary LCA’s on sharp containers ............................................................................................ 34
Table 11: Summary LCA’s on medical textiles .............................................................................................. 36
Table 12: Summary LCA's on laryngeal mask airways ................................................................................. 38
Table 13: Overview of type of provided data of the participating hospitals ................................................... 42
Table 14: Shortlist of items ............................................................................................................................ 43
Table 15: Overview of the five items with selection criteria ........................................................................... 46
Table 16: Most commonly used materials for kidney trays ............................................................................ 48
Table 17: Summary LCA’s on trays ............................................................................................................... 49
Table 18: CO2 emissions of the raw materials of different types of kidney trays........................................... 49
Table 19: Occupational risks associated with the use of single-use or reusable kidney tray. ....................... 52
Table 20: Purchase cost (including VAT) per type of kidney tray .................................................................. 53
Table 21: Overview of the costs related to the use of a single-use or reusable kidney tray ......................... 54
Table 22: Overview on efficiency of using a reusable and single-use kidney tray ........................................ 55
Table 23: Most commonly used materials for blankets ................................................................................. 56
Table 24: CO2 emissions of raw materials of different types of blankets ...................................................... 57
Table 25: Purchase/rental cost (including VAT) per type of blanket (per piece/use) .................................... 59
Table 26: Overview total cost (including VAT) ............................................................................................... 59
Table 27: Overview on practical matters of using a reusable and single-use blanket................................... 60
Table 28: Overview total cost......................................................................................................................... 64
Table 29: Overview on practical matters of using a reusable and single-use vessel sealing device ............ 65
Table 30: Overview of types of thermometers for non-invasive measurement ............................................. 66
Table 31: Materials needed to (re)use thermometers ................................................................................... 67
Table 32: CO2 emissions of raw materials of different types materials needed to (re)use thermometers.... 67
Table 33: Overview infection prevention risks and handling ......................................................................... 68
Table 34: Purchase and use cost (including VAT) per type of thermometer ................................................. 69
Table 35: Waste cost (including VAT) related to materials needed for reuse ............................................... 69
Table 36: Purchase and reuse cost (including VAT) per type of speculum (per piece/use) ......................... 72
Table 37:Waste cost (including VAT) per type of speculum .......................................................................... 72
Table 38: Total cost (including VAT) per type of speculum per use .............................................................. 73
Table 39: Summary LCA’s on vaginal speculum ........................................................................................... 75
Table 40: Speculum and packaging composition data .................................................................................. 78
Table 41: Overview of the global warming impact (kg CO2eq) per phase for the four types of specula ....... 81
Table 42: Comparison of single-use and reusable medical material based on exploratory literature search86
Table 43: Comparison of single-use and reusable medical material based on the studied items ................ 86
Table 44: Overview gap analysis and recommendations to improve the environmental sustainability whenusing medical items ....................................................................................................................................... 95

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LIST OF FIGURES
Figure 1: Steps followed to identify the five single-use items for further research ........................................ 43
Figure 2: Median consumption rates (Amounts/bed/year) ............................................................................. 44
Figure 3: Cost (hospital prices)/Amount of participating hospitals – rate 2019 ............................................. 45
Figure 4: Waste sorting of single-use kidney dish ......................................................................................... 50
Figure 5: Disinfection options of a reusable kidney dish ............................................................................... 51
Figure 6: System boundary reusable specula ............................................................................................... 77
Figure 7: System boundary single-use specula ............................................................................................. 77
Figure 8: Life cycle greenhouse gas emissions of one use of a speculum for the four types of specula...... 80
Figure 9: Overview of consumption of medical single-use items per bed per year ..................................... 142
Figure 10: Amount/Cost – rate procurement data based on catalogue prices ............................................ 143
Figure 11: Greenhouse gas emissions intensity factors and material flows ................................................ 145

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GLOSSARY
A0

Value "A"/"A0" (disinfection value)
A0 is a physical parameter denoting the inactivation of microorganisms. The concept of
A0 is intended to allow equivalent disinfection efficiencies to a referencetime/temperature to occur at other disinfection temperatures.
Corresponding time in seconds at a temperature of 80 °C to achieve a given
disinfecting effect. If the temperature is 80 °C and the Z value is equal to 10, the term
"A0" is used.

ABS
Attributional
LCA
Blue waterBlue water
footprint

CirculareconomyCogeneration
Consequential
LCA
Cradle-tograve

Critical item
DALY
DKK
EO
EO SU
ERCP
EU
FAMHP
GHG
HDPE
HMW
LCA

LCC
LCIA
LDPE
LLDPE
LMA

(Hoge Gezondheidsraad 2023)
Acrylonitrile Butadiene Styrene (type of fossil plastic)
See LCAFresh surface and groundwater; the water in freshwater lakes, rivers and aquifers
Volume of surface and groundwater consumed as a result of the production of a goodor service. Consumption refers to the volume of freshwater used and then evaporated
or incorporated into a product. It also includes water abstracted from surface orgroundwater in a catchment and returned to another catchment or the sea. It is theamount of water abstracted from groundwater or surface water that does not return tothe catchment from which it was withdrawn.
The production and consumption of existing materials and products as long as
possible by extending the life cycle of products through sharing, leasing, reusing,
repairing, refurbishing and recycling.
Combined Heat and Power (CHP), simultaneously produced using a single (fossil orrenewable) fuel engine.
See LCA
Approach that considers impacts at each stage of a product's life-cycle, from the timenatural resources are extracted from the ground and processed through eachsubsequent stage of manufacturing, transportation, product use, and ultimately,
disposal
Item/device in contact with sterile tissue or bloodstream (Spaulding Classification)
Disability-adjusted life years
Danish Krone
Ethylene oxide
Ethylene oxide single-use

Endoscopic retrograde cholangiopancreatography
EuropeFederal Agency for Medicines and Health Products
Greenhouse gas
High density polyethylene
Hazardous Medical Waste
Life cycle analysis - Life cycle assessment
An Attributional LCA (ALCA) estimates what share of the global environmental burdens
belongs to a product.
A Consequential LCA (CLCA) gives an estimate of how the global environmental
burdens are affected by the production and use of a product.
Life cycle costing study
Life cycle impact assessment
Low density polyethylene
Linear low-density polyethylene
Laryngeal mask airway

Final report June 2023 – Study single-use materials in medicine and health care11Medical
device

NHMW
Non-critical
OR
PDT
PE
PET
PLA
PP
PPE
PVC
ReCipeRU
SDG
Semi-critical
SMMS
SMS
SpauldingclassificationSU
SU ABS
SUD
SU PLA
TMR

VAT
WHO

Any instrument, apparatus, appliance, software, implant, reagent, material or otherarticle intended by the manufacturer to be used, alone or in combination, for humanbeings for one or more of the following specific medical purposes:a) diagnosis, prevention, monitoring, prediction, prognosis, treatment or alleviation of
disease,b) diagnosis, monitoring, treatment, alleviation of, or compensation for, an injury or
disability,c) investigation, replacement or modification of the anatomy or of a physiological or
pathological process or state,d) providing information by means of in vitro examination of specimens derived fromthe human body, including organ, blood and tissue donations,and which does not achieve its principal intended action by pharmacological,
immunological or metabolic means, in or on the human body, but which may beassisted in its function by such means.
The following products shall also be deemed to be medical devices:– devices for the control or support of conception;– products specifically intended for the cleaning, disinfection or sterilisation of medical
devices.
(Hoge Gezondheidsraad 2023) (MDR 2017/745)
In this report the term “medical device” has been used in a broader sense thanthe definition mentioned above. The term was also used as a synonym
encompassing all categories of medical items or medical materials
Non-hazardous medical waste
Item/device in contact with intact skin (Spaulding classification)
Operating room
Percutaneous dilatational tracheostomy
Polyethylene
Polyethylene terephthalate
Polylactic acid
Polypropylene
Personal protective equipment
Polyvinylchloride
ReCipe is a method for the impact assessment (LCIA) in an LCA. Life cycle impact
assessment (LCIA) translates emissions and resource extractions into a limited
number of environmental impact scores by means of mid-and endpoint indicators.
ReCiPe calculates: 18 midpoint indicators and 3 endpoint indicators (human healthdamage, ecosystem damage and resource depletion)
Reusable
Sustainable development goal
Item/device in contact with mucous membranes or non-intact skin (Spauldingclassification)
Spunbond/ Meltblown/Meltblown/Spunbond
Spunbond/Meltblown/Spunbond
A classification for cleaning, disinfection or sterilisation of items and devices which isbased on the degree of risk involved during use
Single-use
Single-use containing fossil plastics acrylonitrile butadiene styrene
Single-use device
Single-use containing biobased plastic polylactic acid
Total material required. TMR is defined as the total mass of resource flows needed forthe production of a given good or performing a service caused by economic and noneconomic activities, which includes hidden flows arising from non-economic activities
such as waste disposal, as well as direct and indirect flows from economic activities.
Although TMR does not indicate environmental impacts directly, it can be considered
as indicative of the ‘potential’ impacts from the total mass of natural resources.
Value added tax
World Health Organisation

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EXECUTIVE SUMMARY
Over the past decades the use of single-use materials in medicine and healthcare has increased
considerably. Single-use materials were considered advantageous for - amongst others - the safety of care,the low cost per item, and the permanent availability. Environmental implications were seldom questioned.
Currently, the unlimited use of single-use materials in medicine and healthcare became a leading topic in
discussions on sustainability in healthcare. To date, such discussions are led by limited evidence. Therefore
this project aimed to strengthen the body of knowledge on whether it is beneficial to replace single-use
medical materials by reusable ones. This study aims to investigate possibilities and alternatives for to use of
single-use materials in medicine and healthcare, in line with the principles of the circular economy and taking
into account the constraints associated with each solution, such as safety, efficiency and cost. Thereby
offering evidence-based guidance to policymakers and healthcare facilities (hospitals) in determining onwhether to use single or reusable materials in medicine and healthcare for a number of items. The initiative
for this project has been taken by the Directorate-General for the Environment of the Federal Public Service(FPS) Health, Food Chain Safety and Environment and was executed by the Ghent University Hospital.
An exploratory study on environmental sustainability of commonly used materials in hospitals was performed
in four consecutive steps:
1) In order to substantiate and refine the study, literature data on sustainability of single-use and reusable
medical devices were studied. 2) In order to further focus the study, current consumption of single-use
materials was explored from 12 Belgian hospitals. 3) A selection of five single-use medical items and theirreusable alternatives were studied on four parameters, namely environmental sustainability, safety, costs andefficiency. 4) A Life Cycle Analysis (LCA) was performed to evaluate the environmental impact of single-use
compared to reusable vaginal specula.
The literature review revealed that most studies focused on one single item and were often LCA’s whereby
the environmental impact and costs of different scenarios replacing reusable medical devices by single-use
equipment were compared. The literature search identified medical devices varying from examination devices(e.g. laryngoscope, cystoscopes), laparoscopic devices (e.g. trocars, surgical staplers), aiding devices (e.g.
surgical scissors, medical blue wraps), clothing and linens (e.g. surgical gown) to other medical devices(sharps containers). For most medical devices existing studies demonstrated that using a reusable alternative
is more environmental friendly than disposable equivalents (for example, surgical staplers, reusable packing
options, sharps containers; surgical and isolation gowns). The financial cost is also lower than for the singleuse alternative (for example, scissors). Conflicting or inconclusive evidence was found for trocars,
laryngoscopes and flexible endoscopes. For laryngoscopes, the energy mix used in a country has asignificant impact on the conclusions concerning environmental impact.
A hospital survey on the consumption of single-use materials was extracted from procurement data of 12
Belgian hospitals (four Walloon, six Flemish and two hospitals from Brussels-Capital region; eight general
hospitals and four university hospitals). Data were aggregated on the type of single-use medical devices mostfrequently used, and on the consumption in relation to the cost. A large variation in consumption between
hospitals became apparent. It was important to reflect on both, items with high consumption rates, as well as
on a diversity in the circular processes needed for reuse. Several circular processes were detected:
sterilisation or high level disinfection, thermal disinfection or low level disinfection, laundry process, andchange of item/device. This led to the selection of five single-use medical devices of relevance to explore thereplacement by reusable alternative: kidney trays, blankets, vessel sealing devices, cover caps forthermometers and vaginal specula. Pragmatically, in light of available project time and budget, one LCA wascarried out. The other four items were compared on life cycle stages and the carefully studied literature data
combined with own observations lead to valid general conclusions.
The selected single-use medical items and their reusable alternatives were studied related to fourparameters: environmental sustainability, safety, costs and efficiency. Sustainability used data for raw
materials, manufacturing, transport, (re)use, end-of-life (waste), and carbon footprint. Safety focused on
infection prevention and occupational safety. Costs focused on costs for purchase, reuse, waste elimination
or recycling. Efficiency focused on availability, handling, and time consumption for (re)use. By taking theseparameters into account, a balanced conclusion could be drawn for kidney trays, blankets, vessel sealing
devices, and cover caps for thermometers. For example, based on the available data, it seems that reusable
kidney trays are more environmentally friendly. However, the method of disinfection has also an
Final report June 2023 – Study single-use materials in medicine and health care13

environmental impact as well as a large impact on cost. The safety is comparable, whereas the efficiency
might be in favour of the single-use kidney tray based on the time consumption.
To evaluate the environmental sustainability of single-use compared to reusable vaginal specula, a life cycle
analysis (LCA), cradle-to-grave, was performed according to well established methodology and guidelines(ISO 14040/14044 guidelines, modelled using SimaPro 9.4.0.2). The ecoinvent database (version 3.8) wasused to retrieve secondary data. The functional unit was one pelvic examination by a stainless steel reusable,
or by three types of single-use specula, of which one containing fossil plastics, one containing biobased
plastic, and one containing two types of fossil plastics and sterilised using ethylene oxide (EO). The primary
outcome was global warming impact, with total greenhouse gases expressed as carbon dioxide equivalents(kgCO2eq). The secondary outcome was the environmental impact representing damage to human health,ecosystems and resource scarcity.
From global warming perspective the most favourable option is the use of a stainless steel reusable speculum
producing 78% less greenhouse gas (GHG) emissions than a single-use speculum from fossil plastic, 65%
less emissions than a single-use biobased plastic speculum, and 74% less emissions than an EO sterilised
single-use speculum consisting of two types of fossil plastic. Emissions from reusables were largely due topackaging and, to a lesser extent the reprocessing (treatment) of the specula, whereas emissions from singleuse alternatives were mainly due to raw materials and manufacturing, incineration at the end of life, andpackaging.
From an environmental perspective and for costs, mixed pictures were obtained. Reusable equivalents ofmost devices are favourable, although it cannot be decided with certainty if reusable laryngoscopes, trocars,
flexible endoscopes are more or less beneficial for the environment than their single-use equivalents due to
conflicting evidence in literature. Single-use devices are more expensive although the impact on costs should
be interpretated with caution since far less data were available. From a safety perspective, the single-use
and reusable devices are equal. Concerning efficiency, referring to availability, handling, and time
consumption for (re)use, the results are in favour of the single-use devices. The most trustworthy conclusion
can be done for the LCA study on vaginal specula. From a sustainability perspective, the use of stainlesssteel reusable specula is most favourable.
Finally, whatever technique is used, destruction of solid medical waste is not easy and requires great attention
from economical, ecological and healthcare perspective. All efforts to minimize the need for incineration or
any other technique are highly welcomed to obtain the sustainable development goals, particularly thosegoals on responsible consumption and production. Equally important are the WHO recommendations on arevised management of medical waste.
In summary, using reusable or hybrid systems can help to meet environmental targets as well as reduce
financial costs. Although results were robust with regard to several modelling scenarios, optimizing
sterilisation processes remains an area of concern to minimize the environmental impact and specifically the
impact on human health. By using research triangulation, the main findings allow the most balanced
conclusions possible in the complex field of environmental sustainability. The results of this project helped todemonstrate the applicability of the methods and stimulate further research of the sustainability aspects
specifically in hospitals and in the healthcare sector in general.
Recommendations for hospitals, companies, regulatory bodies and waste/recycling departments have been
made and are summarized below.

Final report June 2023 – Study single-use materials in medicine and health care14

1. Recommendations for hospitalsa) Include validated sustainability requirements in the procurement process of medical materialb) Give appropriate weight to sustainability characteristics in the decision process for procurement of
medical material in addition to costs, logistics, etc.
c) Inform companies that sustainability will be integral part of the decision process during procurement of
medical materiald) Convince the users within the hospital of remanufactured medical material on the quality of this materiale) Further diversify the waste streams as to optimise the possibility of recyclingf) Set up activities and take initiatives to develop the fundamentals and practical applications ofsustainability among all employees in the hospital
2. Recommendations for companiesa) Provide purchasers with information allowing to decide on sustainability quality to medical materialb) Adapt construction methods and raw material as to respond to higher sustainability quality of the goods
3. Recommendations for regulatory bodiesa) Review legal obligations necessary for reusing medical material after remanufacturingb) Review legal obligations for waste selection based on scientific evidencec) Set up projects to study sustainability of medical material using sophisticated and science based methodsd) Set up a list of validated criteria helping all stakeholders to decide on the quality of the variables withinsustainability research. This is imperative for the procurement departments of hospital (see 1a & 1b)
4. Recommendations for waste/recycling departments within the hospital and waste treatment
organizationsa) Contribute to the optimization of the waste handling processes from practical point of view in collaboration
with the medical department of the hospital (health care personal, prevention department, infection
prevention department, sterilization department, etc.)
5. Recommendations for further researcha) Compare sustainability through life cycle analysis (and life cycle cost studies) of several disinfection
methodsb) Compare sustainability through life cycle analysis (and life cycle cost studies) of single-use and reusable
surgical sets/instruments handled by in-house sterilisation department or external sterilisation companyc) Compare sustainability through life cycle analysis (and life cycle cost studies) of single-use and reusable
kidney trays, including the various types disposal (maceration/waste/recycling) and disinfection methods(see also 5a)d) Design and test reusable textiles as alternative for single-use items (such as isolation gowns, surgicalcaps, bibs,…) and compare sustainability through life cycle analysis (and life cycle cost studies) of both

The results of this project demonstrated clearly that decisions on whether to use single-use or reusabledevices within a hospital cannot be taken light heartedly. Instead, detailed analysis of literature data coupledwith meticulous observations at the work floor are necessary. Only in this way evidence based advice ispossible and this is needed to convince the users to change their habits. In this respect, this project was an
excellent exercise and the conclusions confirm this statement.

Final report June 2023 – Study single-use materials in medicine and health care

15

1

INTRODUCTION

1.1

Situating the project in an historical context

This project is situated in the broad context of circular economy. In the second half of last century, society
evolved quickly from a society in despair after the war into wealthy society characterised as a throwaway
society. At first this attitude concerned simple and cheap material used within a daily context but later also
more complex and more expensive devices were similarly used for a limited time and considered as easily
expendable and destructible. The attempts to refurbish material was considered useless with arguments ashigh costs, unlimited supply of raw basic material, etc. It was pure consumerism: make-take-throw away.
Since the 1990’s, however, people realised that this attitude was leading to a number of societal problems
that were not considered before: huge waste production, growing shortness of natural resources, increasing
costs, etc. Hence, a tendency to reverse the consumerism became more prominent and new working
definitions were introduced, “circular economy” being the most used. The “make-take-throw way” slogan was
replaced by the 3R “reduce-reuse-recycle” or even the 6R “reuse, recycle, redesign, remanufacture, reduce,
recover” slogans (Winans et al. 2017). The evolution from the throwaway economy into a circular economy
is nicely described by Winans et al.(2017).
The healthcare profession has not escaped from this evolution and a lot of throwaway materials wereintroduced in medical care some decades ago. Single-use devices (SUD) in Western health routine carepractice included needles, tubing, syringes, bandages, etc. and this has been very advantageous for thesafety of the individual patients and for avoiding cross-contamination among patients (Costa and Costa 2021).
The overall characteristics of this group of material are low cost per item, use in massive amounts, technically
uncomplicated, mostly small and made of low-costs basic raw material and after use frequently contaminatedwith patients body fluids such as blood, saliva or other excretions. No one questions the validity andirreplaceability of these SUD’s. Last decade, however, we witnessed the appearance of other SUD medical
devices which do not correspond to these criteria and are much more complex such as staplers, laparoscopic
instruments often containing expensive components eventually composed of high-costs raw materials:
batteries, sensors, miniaturized camera’s, etc. (Grantcharov et al. 2019; Pandey and Vora 2019; Guzzo et al.
2020).
The decision to use SUD’s for a particular medical intervention is almost always guided by the ultimate
argument stressed by the manufacturers i.e. the written guarantee of sterility and thereby assuring patient
safety which is from legal point of view, very attractive for healthcare organizations (Hailey et al. 2008; Popp
et al. 2010). Collateral advantages are the nearly permanent availability of the material, the easiness of use
and the reliability during the procedure; questions on costs or the implications for the environment wereseldomly put forward with some exceptions (Monmousseau et al. 2021).
After the 2015 declaration on sustainability and the formulation of the sustainability goals – in particular SD
goal 12 - the use of SUD’s was questioned (Guzzo et al. 2020). The criteria such as environmental burden
through the waste and the costs were weighted against the advantages of the SUD’s. Hence, the quest toreconsider the unlimited use of single-use material became an important and leading theme in discussions
on sustainability in healthcare.

1.2

Introduction on medical waste

Medical waste in the context of this project, contains any material used during diagnosis, treatment and carefor patients in a hospital and eventually discarded after use. This material might be dangerous (e.g.
contaminated with pathogens, containing sharps or carrying the residues of chemicals) and this is identified
in Europe as EWC/EURAL Code 18.01.03. If not dangerous (e.g. packaging materials) it is identified inEurope as EWC/EURAL Code 18.01.04 and considered comparable to household waste (Hossain et al.
2011).
The elimination of dangerous medical waste is in Europe mostly obligatory by incineration. Of note is the factthat the destruction of dangerous medical waste is between three and ten times more expensive than thedestruction of non-dangerous waste. In this project we focus on solid medical waste. Whatever technique isused, destruction of medical waste is not easy and requires great attention from economical, ecological andFinal report June 2023 – Study single-use materials in medicine and health care16healthcare perspective. All efforts to minimize the need for incineration or any other technique are highly
welcome (Hassan and Shareefdeen 2022).
Solid medical waste is subject of an ongoing discussion both in the scientific and lay press, related to its
impact on the environment, on public health and on costs for destruction. In the last decade, these fragmented
discussions focus on a new point of interest, i.e. sustainability. Although sustainability and sustainable
development goals and the corresponding targets are deeply embedded in societal problems like poverty
and hunger (SDG 1 and 2), and in environmental and climate related problems (SDG’s 6. 7. 11, 13, 14 and15), sustainable development goal 12 is on sustainable consumption and production with the defined related
subjects: chemicals and waste. Hence, the activities on the management of waste in general and hospitalwaste in particular should be interpreted against a background of sustainability. In this document we want toreport on our attempts to comply with the SDG’s as far as solid medical waste is concerned (Sachs 2012;
Sachs et al. 2019).
Second and very recently, the world was confronted with a devastating pandemic caused by the SARS-Cov2 virus, causing the COVID-19 disease. It is an understatement that the COVID-19 pandemic has shaken theentire world in many aspects: societal, physical and mental healthcare organization, economics, logistics,
etc. to name the most visible or at the forefront of discussions. Less visible but equally important are thequestions related to the management of the huge volume of medical waste and solid medical waste inparticular. Although the waste during the pandemic contained in majority light weighted personal protection
equipment (gloves, aprons…..) the question to reconsider the disposal of medical waste went far beyond thisand referred to the whole of basic considerations related to medical waste (Fraeyman et al. 2022). The WHO
is even calling for an urgent need to improve waste management systems (WHO 2018, 2022).
In this manuscript we describe our efforts to construct a scientifically sound basis in order to be able to decideon whether single-use or reusable devices should be used in hospitals. The project developed basically infour steps, starting from a survey of the available literature data. This was followed by an overview of mostused medical devices in twelve hospitals (78 items) and narrowing down this high amount of information to
one device (vaginal specula) for which a detailed life cycle analysis was performed and to four devices forwhich literature data related to aspects of sustainability were collected. For the latter, a conservative
conclusion and for the specula, a scientifically based conclusion on the sustainability properties is possible.
Details of the four steps are described in the method section.
The results of this project should demonstrate the applicability of the methods and stimulate further researchof the sustainability aspects, specifically in hospitals and in general in the healthcare sector.

Final report June 2023 – Study single-use materials in medicine and health care

17

2

EXPLORATION OF EXISTING EVIDENCE AND PRACTICES ONSUSTAINABILITY OF SINGLE-USE AND REUSABLE MEDICAL DEVICES

2.1

Literature

2.1.1

Goal

In order to inform, substantiate, refine and focus the study, the literature on sustainability of single-use andreusable medical devices was explored.

2.1.2

Methods

A literature database was constructed from references in The Medline and ISIWeb of Science databases
from January 2010 to July 2022. Keywords were Life Cycle Assessment, LCA, Reusables, Single-use
Devices, Disposable Equipment, Waste Management, Medical Waste, Environmental Sustainability and
Sterilization. Relevant references within the database were included. Articles with a main focus on developing
regions and countries were excluded. Reference lists of included studies, reports and related reviews were
examined and gray literature was checked to identify any additional relevant studies.
Specific to LCA’s, the HealthcareLCA Database was screened to identify additional studies between April
2022 and July 2023 (Drew and Rizan 2022).
Only of those items for which at least two LCA’s were available were included in the literature review. Thus,
studies on, for example, blood pressure cuffs (Sanchez et al. 2020), disinfection cloths (Maloney et al. 2022)
or dental burs (Unger and Landis 2014) were not included in the literature review below.
The literature search identified articles in a range of medical devices varying from examination devices (e.g.
laryngoscope, cystoscopes), laparoscopic devices (e.g. trocars, surgical staplers) aiding devices (e.g.
surgical scissors, medical blue wrap), clothing and linens (e.g. surgical gowns) to other medical devices(sharps containers). Some of these devices are described hereafter in detail.
The studies describing an LCA were synthetised in evidence tables. The evidence tables describing the LCA
methodology and an evidence table with the results were included in Appendices 9.1 & 9.2.
Grade quality and risk of bias were not determined due to the breadth of the review, the qualitative synthesisof results and the need for a pragmatic approach.

Final report June 2023 – Study single-use materials in medicine and health care18

2.1.3Results

2.1.3.1

Laryngoscopes

Laryngoscopes are designed for visualisation of the vocal cords and for placement of tube into the trachea
under direct vision. It consists of a handle and a blade. Blades are available in different sizes to be usedaccording to the age of the patients (Health Care Without Harm Europe 2021a).

Example of laryngoscope blade
The environmental impact of single-use and reusable laryngoscopes (blades and/or handles) was comparedin two studies (McGain et al. 2017; Sherman et al. 2018) (See Table 1 and Appendices 9.1 & 9.2).
Sherman et al. (2018) considered the environmental impact and cost throughout the life cycle of reusable
and single-use rigid laryngoscopes using a cradle-to-grave life cycle assessment (LCA) and life cycle costing(LCC) method. The study revealed that reusable laryngoscopes produced fewer environmental emissions,and are significantly cheaper.
Depending on the cleaning strategy, reusable handles produced the least CO2 when high level disinfection
was performed, followed by low level disinfection, and produced the most CO2 in case of steam sterilisation.
Using single-use laryngoscope blades resulted in approximately 25 times more emissions than the use of areusable handle treated with high level disinfection (Sherman et al. 2018).
Similar results were found for the laryngoscope blades. Blades are semi-critical items that need a minimumof high level disinfection. Depending on the cleaning strategy, reusable blades produced the least CO2 whenhigh level disinfection was performed, and increased by 400% in case of steam sterilisation. The latter isstandard practice in Belgian hospitals. Single-use blades produced approximately 40-50% more CO2 than areusable blade treated with steam sterilisation (Sherman et al. 2018).
Contrary to Sherman et al. (2018), the study of McGain et al. (2017) found that replacing reusable by singleuse laryngoscope blades would decrease emissions. McGain et al. (2017) modelled the environmental andfinancial costs of different scenarios of replacing reusable anaesthetic equipment (circuits, face masks,
laryngeal mask airways, direct and video-laryngoscope blades and handles) with single-use variants. The
authors defined five different scenarios, scenario 1 using reusable anaesthetic equipment; scenario 2 using
disposable anaesthetic equipment but retaining reusable direct laryngoscope handles and reusable videolaryngoscopes; scenario 3 replacing all reusable with single-use anaesthetic equipment; scenario 4 identicalto scenario 1 but replacing only reusable with single-use face masks; and scenario 5 identical to scenario 1
but replacing only reusable with single-use direct laryngoscope blades.
The authors found that converting from single-use to reusable equipment in Australia would result in an
increase of CO2 emissions from 9%. The switch from single-use to reusable laryngoscope blades increased
CO2 emissions, due to the energy mix used in Australia.
Of note, in the UK or a European country the power mix is principally sourced from renewables, whereas in
the US natural gas is the most important source. Both differ from the Australian power mix, which is principally
based on coal. In the study of Mc Gain et al. (2017), converting from single-use to reusable anaesthetic
equipment reduced CO2 emission by 84% in UK/Europe and by 48% in the USA.
Replacing reusable direct laryngoscope blades with single-use would create an additional cost of AUD$9690
for one hospital over one year (McGain et al. 2017).

Final report June 2023 – Study single-use materials in medicine and health care19

Table 1: Summary LCA's on laryngoscopes
Reference
McGain et al.
(2017,
Australia)

Objective LCA
Environmental impact andcosts of different scenarios
replacing RU anaesthetic
equipment by SU equipment

Sherman et al.
(2018, US)

Environmental impact andcosts comparing SU and RU
metal and plastic
laryngoscope handles andbladesFunctional unit
Use of breathing circuits, facemasks, laryngeal masks airways
and laryngoscope handles andblades, and videolaryngoscopes at one hospitalover one year
1 handle and 1 blade for a single
patient encounter

Results
Global warming: Scenario 1 (all reusable
equipment) – Scenario 5 (replacement of
reusable with single-use blades) = 5575 (S1)
– 6763 (S5) = - 1 188 kg CO2eq/year.
Water depletion: 82.2 (S1) -69.7 (S5)= 12.5
kilolitres/year
Global warming
Handles
RU with HLD: 0.06 kg CO2eq/use
RU with LLD: 0.08 kg CO2eq/use
RU with STZ: 0.23 kg CO2eq/use
SU plastic: 1.41 kg CO2eq/use
SU metal: 1.60 kg CO2eq/use

Blades
RU with HLD: 0.06 kg CO2eq/use
RU with STZ: 0.22 kg CO2eq /use
SU plastic: 0.38 kg CO2eq /use
SU metal: 0.44 kg CO2eq /use
RU: reusable, SU: single-use, HLD: high level disinfection, LLD: low level disinfection, STZ: steam sterilisation,

In summary, the level of disinfection and the energy mix (source) had a significant impact on the
produced emissions and is country-dependent. Whereas in the US and Europe (more renewable andgas sourced) the use of reusable laryngoscope blades or anaesthetic equipment would lead to lower
emissions compared to single-use, this was not the case in Australia (brown coal sourced).
Both studies found that reusable laryngoscope blades, or laryngoscopes were less costly thansingle-use alternatives.

Final report June 2023 – Study single-use materials in medicine and health care20

2.1.3.2

Flexible endoscopes

Flexible endoscopes are complex medical devices used to visualise the inside of various body cavities.
Generally, it consists of a long, thin, flexible tube carrying a light and camera. Examples include a
bronchoscope, which examines the interior of the bronchi, a cystoscope, which examines the urinary tract,
an ureteroscope, which examines the ureters and a duodenoscope, which examines the duodenum, bile duct
and pancreas and is also used during endoscopic retrograde cholangiopancreatography (ERCP).
Information was found for cystoscopes (Kemble et al. 2022; Hogan et al. 2022; Baboudjian et al. 2022);
ureteroscopes (Davis et al. 2018; Sørensen and Grüttner 2018; Duijndam 2022; Bringier et al. 2023),
bronchoscopes (Sørensen and Grüttner 2018; Duijndam 2022; Bringier et al. 2023) and duodenoscopes (Leet al. 2022) (See Table 2: Summary LCA's on and Appendices 9.1 & 9.2). Finally, the cost of single-use andreusable bronchoscopes (Videau et al. 2017; Sohrt et al. 2018; Bringier et al. 2023) and cystoscopes(Boucheron et al. 2022) was evaluated.

Example of a flexible ureteroscope

Example of a flexible endoscope

Hogan et al. (2022) and Baboudjian et al. (2022) concluded that the carbon footprint of a single-use
cystoscope was significantly lower than the multiple use (See Table 2, See Appendices 9.1 & 9.2). The
manufacturing impact of the reusable cystoscope was significantly lower than of the single-use, while thesterilisation impact of the reusable cystoscope was significantly larger. Also the impact of waste to landfill
was significantly higher for the reusable flexible cystoscope.
Baboudjian et al. (2022) found, taking difference in lifespan and in disinfection procedure into account, thatthe single-use cystoscope reduced several parameters of environmental effects between 33 and 71%
compared to the reusable cystoscope (See Table 2). Similar to Hogan et al. (2022), this study revealed thatthe disinfection procedure of the reusable cystoscope had a significant higher environmental impact than theuse of a single-use cystoscope.
On the contrary, Kemble et al. (2023) concluded that the environmental impact of a reusable flexible
cystoscope was considerably lower than of a single-use flexible cystoscope (See Table 2). This LCA showedthat the main contribution to the carbon footprint of a reusable cystoscope was the energy consumption of
the reprocessing process and of a single-use scope it was the manufacturing.

Final report June 2023 – Study single-use materials in medicine and health care21

Table 2: Summary LCA's on flexible endoscopes
Reference
Badoudjian etal. (2022,
France)Objective LCA
To compare the life cycle of
RU and SU flexible
cystoscopes

Functional unit
SU: one cystoscope
RU: reprocessing a cystoscope
one time

Results
Global warming
SU: 2.06 kgCO2eq vs RU: 3.08 kgCO2eq
Mineral resource depletion
SU: 25.03 MJ vs RU: 49.92 MJ
Ecotoxicity
SU: 1.07 kg1.4Beq vs RU: 2.20 kg1.4 DBeq
Acidification
SU: 0.011 kgSO2eq vs RU: 0.037 kgSO2eq
Eutrophication
SU: 0.003 kg PO4eq vs RU: 0.005 kg PO4eq
Bringier et al.
To compare the2000 uses of a flexible intubation Global warming(2023, France) environmental impact of SU
bronchoscope
SU: 7.8 t CO2eq vs RU: 5.8 t CO2eq
vs RU bronchoscopes for(RU: assuming lifespan of 2000
SU: production: 86.1%, packaging, 5.9%,
difficult tracheal intubations
uses)
transport: 3.1%, use: 0%, waste: 5.4.%
RU: production: 0.2%, packaging, 0%,transport: 0.2%, use: 77.3%, waste: 26.3%
Davis et al.
To compare environmental
Use of one ureteroscope
Total global warming(2018,
impact of SU with RU(RU: assuming lifespan of 180
SU: 4.43 kgCO2eq vs RU: 4.47 kgCO2eq
Australia)
flexible ureteroscopes
uses and repairs after 16 uses)
Manufacturing
SU: 3.83 kgCO2eq vs RU: 0.06 kgCO2eq
Sterilisation RU: 3.95 kgCO2eq
Repair RU: 0.45 kgCO2eq
Duijndam
To investigate environmental 450 uses of flexible intubation
Climate change(2022, The
impact of a SU and a RU
bronchoscopes
SU: 1230 kgCO2eq vs RU: 1120 kgCO2eq
Netherlands)
flexible intubation scope(RU: is validated for 450 uses)
No absolute figures on the impact per life(bronchoscope).
cycle phases, only graphs.
Hogan et al.
To compare the carbon
Use of one cystoscope
Solid waste(2022,
footprint of SU with RU(RU: based on a lifespan 7 year
SU: 622 g vs RU: 671.5 g
Denmark)
cystoscopeswith 1220 uses)
Total global warming
SU: 2.41 kgCO2eq vs RU: 4.23 kgCO2eq
Manufacturing
SU: 1.34 kgCO2eq vs RU:0,013kgCO2eq
Sterilisation
SU: 0,3 kg CO2eq vs RU: 3,5 kgCO2eq
Incineration
SU: 0,61 kgCO2eq vs RU: 0.52 kgCO2eq
Landfill
SU: 0.11 kgCO2eq vs RU: 0.22 kgCO2eq
Kemble et al.
To compare the carbon
One use of cystoscope
Total global warming potential:(2023, US)footprint of SU and RU(RU: assuming lifespan of 3920
SU: 2.40 kgCO2eq vs RU: 0.53 kgCO2eq
flexible cystoscopes
uses)
Manufacturing
SU: 1.37 kgCO2eq + 0.22 kgCO2eq(packaging) + 0.3 kgCO2eq (sterilisation)
RU: 0.002 kgCO2eq
Reprocessing RU: 0.20 (reprocessing) +0.005 (repackaging) + 0.3 (PPE) + 0.02
(repair) kgCO2eq; new reprocessor RU: total
1.04 kgCO2eq
Le et al.
To compare environmental
One ERCP procedure
Total global warming potential(2022, US)
and human health effects of(RU: assuming lifespan of 650
SU1*: 36.3 kg CO2 eq , SU2*: 71.5 kg CO2eq
SU and RU duodenoscopes. uses)
RU: 1.53 kg CO2 eq
RU + disposable endcap: 1.54 kg CO2 eq
SU, RU and RU with disposable
Raw material + manufacturing
endcapSU1 – SU2: 91-96% of total impact GWP
Use
RU: electricity: 62% of total impact GWP,
cleaning & disinfection: 26% of total impact
Disposal
SU1- SU2: 3-5% of total impact GWP
Sørensen and
To compare CO2- equivalent
SU: use of one bronchoscope
Total global warming potential
Grüttneremissions and resource
RU: reprocessing one
SU: 1.6 kg CO2eq vs RU: 2.9 kg CO2eq(2018,
consumption from a SU to a
bronchoscope
Energy consumption
Denmark)
RU bronchoscope
SU: 29 MJ vs RU: 48 MJ
Scarce resources consumption
SU: 2,1 DKK vs RU: 2,7 DKK
SU: single-use; RU: reusable; ERCP: endoscopic retrograde cholangiopancreatography procedure; GWP: global warming potential,
DKK: Danish Kron
SU1* and SU2*: because of lack of data on the composition of SU, the authors modelled a lower bound SU scenario (scenario 1 =same % of electronics as the RU) and an upper bound scenario (scenario 2 = same mass of electronics as the RU).

Final report June 2023 – Study single-use materials in medicine and health care22

According to Davis et al. (2018), the environmental impact of single-use and reusable flexible ureteroscopes
was comparable (See Table 2). The main impact for the single-use scope was generated by the
manufacturing, whereas for the reusable ureteroscope it was caused by the sterilisation process. Important
to note is that ureteroscopes have a quite high breakage rate. They frequently require repairs which has anadditional impact (Davis et al. 2018).
For bronchoscopes, the results of Sørsensen and Grüttner (2018) are considered (See Table 2). The results
were based on one cleaned bronchoscope, including per cleaning procedure needed materials (cloth, 3
disinfection wipes, transport container liner, brushes, syringe, disinfection products; energy washing anddrying) and thereby using one set of personal protective equipment (PPE) (gown, gloves, shoe covers, faceshield, … ). Under these working conditions, reusable bronchoscopes had comparable or higher material andenergy consumption as well as CO2 emissions and values for resource consumption compared to single-use
bronchoscopes. However as the LCA was only partial, the results should be treated with care (Sørensen and
Grüttner 2018).

Example of a bronchoscope
Two more recent LCA’s suggest that the utilisation of a reusable flexible video endoscope results in a lower
carbon footprint compared to a single-use flexible video endoscope. These studies indicate a reduction of
8.6% (Duijndam 2022) and 25.7% (Bringier et al. 2023) respectively (See Table 2). In both studies, theproduction and manufacturing of materials for the single-use bronchoscope accounted for the largest
emissions, while the disinfection process contributed significantly to the environmental impact of the reusable
flexible video endoscope.
Analogous results were found in a study on duodenoscopes (Le et al. 2022). This study compared a singleuse duodenoscope with a reusable duodenoscope with and without a disposable protective cap (See Table2). Reusable duodenoscopes pose an increased risk of contamination due to their complex design withmultiple channels and small openings, making cleaning and disinfection challenging. When taking this into
account in the sensitivity analysis, the human health burden associated with single-use duodenoscopes isfound to be comparable to that of reusable duodenoscopes (Le et al. 2022).
The results are up to a certain level conflicting because authors included different processes within the LCA’s.
At the one hand, there was the impact of the manufacturing procedure of both types of equipment, which is
or is not in balance with the disinfection procedure of the reusable item and this balance is different for thedifferent endoscopes and local habits of disinfection. This evidently leads to conflicting results obscuring
straightforward conclusions.
As far as the costs of endoscopes is concerned, some information is available (See Table 3). The costs fora single-use cystoscope and a reusable cystoscope were comparable. The cleaning and disinfection processof reusable cystoscopes accounted for a significant portion of the total cost (Boucheron et al. 2022).
Regarding bronchoscopes, Videau et al. (2017) and Bringer et al (2023) calculated that the overall cost ofusing a reusable bronchoscope was lower compared to a single-use bronchoscope (Videau et al. 2017;
Bringier et al. 2023). However, based on a combination of data from a literature research and a questionnaire,
Sohrt et al. (2018) found a considerably higher average total cost for reusable bronchoscopes compared tosingle-use bronchoscopes (Sohrt et al. 2018). Conflicting results are most likely due to differences inmethodology.

Final report June 2023 – Study single-use materials in medicine and health care23

Table 3: Summary cost studies on flexible endoscopes
Reference
Bringier et al.
(2023, France)

Objective Cost study
Overall cost for the hospital

MethodLife cycling costing (LCC)
2000 uses of a flexible intubation
bronchoscope (200/year)

Boucheron etal. (2022,
France)To quantify costs associatedwith a disposable andreusable flexible cystoscopy

Micro-costing approach:- RU: purchase cost of cystoscopes+
towers, maintenance contracts,
reprocessing costs, transport,
sterilisation equipment+consumables,
microbiological test, professionalcharges, administrative and structural
cost (electricity, water,…)- SU: purchase cost of cystoscopes(cost monitor was incorporated into thepurchase price of SU scope)
Costs were calculated per procedure
Minimisation cost analysis based on
an amortisation over 5 years- RU: purchase cost, maintenancecost, disinfection costs- SU: purchase and disposal costs

Videau et al.
(2017, France)

Sohrt et al.
(2018,
Denmark)

To present a minimisationcost analysis to compare
reusable and single-use
fiberscopes(bronchoscopes)

To calculate cost of using
single-use or reusablebronchoscopes perpercutaneous dilatational
tracheostomy (PDT)
SU: single-use; RU: reusable- Systematic literature search on costs- Questionnaire to gather data in 366
hospitals in the US, UK and Germany
regarding repair rates and costs forreusable bronchoscopes

Results
Total cost
RU: €170 000, based on:-Purchase + service costs: €7160 +€2314/year-Cleaning/reprocessing: equipment:€55/procedure, personnel cost: €17.5/1.5h
SU: €450 000, based on:-Purchase cost: €225/ bronchoscope-Waste: €700/tonne (HMW)
RU: €195.65-Purchase/amortisation: €55.56-Maintenance/repair: €32.94-Reprocessing consumables: €39.61-Reprocessing professional costs: €34.18-Reprocessing administrative/structural:€32.61-Microbiological tests: €0.75
SU: €192
RU: €208- Investment: fibroscopes, washingmachine: €69.6- Maintenance:: €79- Consumables: €31.6- Microbiological analyses: €3.02- Waste disposal:€0.2- Personnel cost: €25
SU: €264
RU: $US 406
Purchase: $US 135
Reprocessing: $US 123
Repair: €148
SU: $US 249

In summary, it cannot be decided with certainty if reusable cystoscopes, ureteroscopes orbronchoscopes are more or less beneficial for the environment than their single-use equivalents.
Additionally, the cost studies gave conflicting results.

Final report June 2023 – Study single-use materials in medicine and health care24

2.1.3.3

Trocars

A trocar (or trochar) is a device that is inserted into the abdomen during laparoscopic surgery, as access forother instruments, such as laparoscopic stapler/cutter, clip applier and scissors. Trocars also allow gas or
fluid from cavities within the body to escape.

Example of single-use trocars

Example of reusable trocars

Several manuscripts addressed the ecological impact of surgical procedures using trocars (Unger and Landis
2016; Rizan and Bhutta 2022; Boberg et al. 2022) (See Table 4 and Appendices 9.1 & 9.2).
Unger and Landis (2016) performed an LCA and life cycle cost analysis including processes for sevenmedical devices, more specifically a deep vein thrombosis compression sleeve, a pulse oximeter, a ligasure(vessel sealing device), an harmonic scalpel, an endoscopic trocar, an arthroscopic shaver, and a scissor tip.
Driven by the high consumption of trocars compared to the other devices, the use of trocars (single-use andreusable devices) had the second highest total environmental contribution of the seven devices under study.
When comparing the relative global warming and human health impacts (impact per device) for the sevenanalysed devices, the compression sleeve and ligasure are the devices with the highest environmental
impacts, while the ultrasonic scalpel was consistently third and the endoscopic trocar was consistently fourth(Unger and Landis 2016).
The authors found that reprocessing those devices for reuse slightly reduced global warming impacts, but
concurrently exacerbates human health impacts (i.e., carcinogenic, non-carcinogenic, respiratory effects) due
to suboptimal reprocessing inputs. If those reprocessing inputs, such as the use of ethylene oxide, water andelectricity were optimised, the use of reusable devices offers overall benefits concerning global warming,
human health, and economic benefits compared to single-use (Unger and Landis 2016).
In two recent studies single-use trocars used for laparoscopic procedures were suggested to have a higher
environmental impact compared to hybrid trocars containing both reusable and single-use parts forlaparoscopic cholecystectomies in a UK setting (Rizan and Bhutta 2022), as well as compared to the reusable
trocar systems for laparoscopic procedures in Sweden (Boberg et al. 2022). Both studies found robust resultsof decreased environmental impacts favouring (partly) reusable trocar systems over single-use systems.
Boberg et al. (2022) found that single-use trocars had a 182% higher impact on resources, 379% higher
impact on climate change, and an 83% higher impact on ecosystem quality than the reusable trocars. Rizan
and Bhutta (2022) found a carbon footprint of 27% per operation using four laparoscopic hybrid trocars
compared to its single-use alternative, so almost four times lower (Rizan and Bhutta 2022).
Table 4: Summary LCA’s on trocars
Reference
Boberg et al.
(2022,
Sweden)Rizan and
Bhutta (2022,
UK)

Objective LCA
To compare environmental
impacts of a single-use, amixed, and a reusable trocar
system for laparoscopiccholecystectomy
To compare theenvironmental life cycle costof hybrid and single-use
instruments (trocar) for
laparoscopiccholecystectomy

Functional unit
500 uses ofsingle-use, reusable, and mixed(SU and reusable) trocar
systems
Number of 3 types of
instruments required to perform
one laparoscopiccholecystectomy (=2 small
diameter ports, 2 large diameter
ports, 1 laparoscopic scissor,
and 1 laparoscopic clip applier)

Results
SU trocars
182% higher impact on resources
379% higher impact on climate change
83% higher impact on ecosystem compared
to RU trocars
Hybrid933g CO2eq /4 trocars
Human health: 1.67e−6. DALY
Ecosystem: 3.67e−9 species. yr
Resources: US $ 0.0853
SU3495g CO2eq/4 trocars
Human health: 6.13e−6 DALY
Ecosystem: 1.36e−9 species.yr

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25

Unger andLandis (2016,
US)

To model the environmental
impacts of varying levels of
reprocessing at Phoenix
Baptist Hospital in Phoenix,
ArizonaSeven medical devices:
deep vein thrombosis
compression sleeve,pulse oximeter,
ligasure,harmonic scalpel,
endoscopic trocar,
arthroscopic shaver andscissor tip(=the number of medical devices
needed to fulfil the reprocessed
device supply chain
requirements of the hospital)
RU: reusable, SU: single-use; DALY: disability-adjusted life years

Resources: US $ 0.344473
No absolute nor relative figures on outcome
measures were included in the manuscript(only graphs)

Even in scenarios of high reprocessing inputs, the financial benefits of reprocessing outweighed the singleuse supply chains in the study of Unger and Landis (2016). A finding that was confirmed by Boberg et al.
(2022) where reusable trocar systems were approximately half as expensive as the single-use systems(€17360 and €18560 versus €37600, respectively for 500 uses), and Rizan and Bhutta (2022) were the costof hybrid trocars was 58% compared to single-use ones (GBP £59 vs £102 for one laparoscopic intervention)(Rizan and Bhutta 2022; Boberg et al. 2022).

In summary, conflicting results were found. Using reusable or hybrid systems can help to meetenvironmental targets as well as reduce financial costs. Although results were robust with regard toseveral modelling scenarios, optimising sterilisation processes remains an area of concern tominimise the environmental impact and specifically the impact on human health.

Final report June 2023 – Study single-use materials in medicine and health care26

2.1.3.4

Laparoscopic stapler, cutter, clip applier and scissors

These sophisticated instruments for laparoscopic procedures, often involving the separation or removal oftissue, require the approximation of the cut edges or tissue to close the wound. Modern surgical staplingsystems are available in a diverse range of forms and incorporate various features depending on the surgicalapplication. Each surgical stapler contains a power handle (including battery) which is held by the surgeon,an adapter fixed to the power handle, and a disposable cartridge holder which houses the staples (Meissner
et al. 2021). Laparoscopic scissors are used to cut tissue, such as fibrotic or calcified tissue, sutures, andoccasionally tissue containing staples. Laparoscopic clip appliers are utilized to ligate tubular structuresduring laparoscopic and other procedures. They are available in various lengths and diameters and for use
with various sized clips.

Example of laparoscopic scissors

Example of a surgical stapler

Two studies (Meissner et al. 2021; Rizan and Bhutta 2022) were suitable for inclusion. Another LCA
comparing 2 single-use staplers (Freund et al. 2022) was not included because it did not provide acomparison with a reusable stapler.
Rizan and Bhutta (2022) evaluated very comprehensively the environmental impact of single-use and hybrid(containing both reusable and single-use parts) laparoscopic clip appliers and scissors as part of their study
on laparoscopic cholecystectomies (See also Trocars). This LCA determined an 83% reduction in carbon
footprint per operation for a reusable clip applier compared to its single-use equivalent, and a 66% reduction
for laparoscopic scissors compared to its single-use equivalent (See Table 5). The majority of the carbon
footprint of single-use instruments was due to raw material extraction and manufacturing, followed bytransportation and waste. For hybrid instruments, single-use parts and disinfection of reusable components
were a major contributor to the carbon footprint. Using the hybrid laparoscopic scissors and clip appliers
substantially reduced the impact categories (See Table 5) (Rizan and Bhutta 2022).

Final report June 2023 – Study single-use materials in medicine and health care27

Table 5: Summary LCA on laparoscopic scissors and clip applier
Reference
Rizan and
Bhutta (2022,
UK)

Objective LCA
To compare theenvironmental life cycle cost
impact of hybrid and singleuse laparoscopic
instruments (focus on
scissors and clip applier)used for a laparoscopiccholecystectomy

Functional unit
Number of 3 types of
instruments required to perform
one laparoscopiccholecystectomy:
Focus on 1 laparoscopic scissor(Hybrid: assuming lifespanreusable components of 500
reuses)

Focus on laparoscopic clip
applier(Hybrid: assuming lifespanreusable components of 500
reuses)Results
Laparoscopic scissor
Total global warming
SU: 1138 gCO2eq vs Hybrid: 378 gCO2eq-Manufacturing SU: 660 gCO2eq vs Hybrid
232 gCO2eq (SU parts), 1.27 gCO2eq (RU
parts)-Transportation SU: 324 gCO2eq-Decontamination Hybrid: 79 gCO2eq-Waste SU: 154 gCO2eq
Human health
SU: 2.90.e−6 DALY vs Hybrid: 1.28 e−6 DALY
Ecosystem:
SU: 5.22 e−9 species.yr vs Hybrid 1.84 e−9
species.yr
Resources
SU: US $ 0.1176 vs Hybrid: US $ 0.0314
Laparoscopic clip applier
Total global warming
SU 2559 gCO2eq vs Hybrid 445 gCO2eq-Manufacturing SU: 1342 gCO2eq vs Hybrid
112 gCO2eq (SU parts), 4,37 gCO2eq (RU
parts)-Transportation SU: 923 gCO2eq-Decontamination Hybrid: 247 gCO2eq-Waste SU: 294 gCO2eq
Human health
SU: 6.30.e−6. DALY vs Hybrid: 1.09 e−6.
DALY
Ecosystem
SU: 1.24 e−9 species.yr vs Hybrid:1.96 e−8
species.yr
Resources
SU: US $ 0.2944 vs Hybrid: US $ 0.0464

SU: single-use; RU: reusable; DALY: disability-adjusted life years

In the study of Meissner (2021), the total material requirement (TMR) approach was applied. TMR is basedon the concept of material input per service and is a metric which reflects all abiotic and biotic material aswell as the moved soil needed to manufacture a product or perform a service. The use of air and water in the
manufacturing process is not taken into account in this metric. The TMR approach is different from an LCA
given that it considers a narrower range of environmental impacts focusing on quantifying the material needs(Meissner et al. 2021).
Shifting from a single-use to a reusable stapler resulted in a total waste reduction for laparoscopic sleeve
gastrectomy by 40%, for laparoscopic gastric bypass of 70% and for video-assisted thoracoscopy lobectomy
by 62% (See Table 6). In all three surgical procedures, the TMR was reduced by over 90% when switchingfrom single-use to reusable stapler, suggesting that over 90% of total raw material inputs can be saved byconverting to reusable staplers. Meissner et al. (2021) concluded that for each surgical procedure evaluated,
switching from single-use to reusable staplers facilitates a significant reduction in total surgical waste and thetotal material requirement.
Table 6: Summary study on surgical stapler
Reference
Meissner et al.
(2021,
Germany)

Objective study
To evaluate the waste
prevention potential andextended resources use of
RU versus SU powered
surgical stapling systems.

MethodCalculation for 3 surgical procedures(laparoscopic sleeve gastrectomy,
laparoscopic gastric bypass, andvideo-assisted thoracoscopic (VATS)
lobectomy) of:- Total waste (disassembling both
systems) per surgery- Extended resource use (Total
Material Required (TMR)) per surgery

Results
Total waste-Sleeve gastrectomy
SU: 0.72 kg vs RU: 0.43 kg-Gastric bypass: SU: 1.38 kg vs RU: 0.41
kg
-VATS lobectomy: SU: 1.39 kg vs RU:
0.53 kg
kg
TMR-Sleeve gastrectomy
SU: 329 kg vs RU: 27 kg-Gastric bypass: SU: 633 kg vs RU: 25 kg-VATS lobectomy: SU: 633 kg vs RU: 34
kg
SU: single-use; RU: reusable; VATS: video-assisted thoracoscopy TMR: total material required

Final report June 2023 – Study single-use materials in medicine and health care28

In summary, it can be concluded that the use of reusable laparoscopic stapler, cutter, scissors andclip applier devices are more environmentally friendly than the use of their single-use equivalents.

Final report June 2023 – Study single-use materials in medicine and health care29

2.1.3.5

Surgical scissors

Surgical scissors are not only used during surgery, but also in other departments of a hospital, including
general and surgical wards, laboratories, and outpatient clinics. They make up a relevant share of the
production volume of surgical instrument suppliers, as well as of the number of instruments that need to besterilised (Ibbotson et al., 2013).

Example of surgical scissors
The environmental impact of single-use and reusable surgical scissors was compared in two studies(Ibbotson et al. 2013; Rizan et al. 2022a).
Ibbotson et al (2013) compared the impacts and total cost throughout the life cycle (called “total cost ofownership”) for reusable stainless steel scissors with single-use scissors made of either stainless steel orfibre-reinforced plastic. The overall impacts of the single-use steel product exceeded those of the two others
by 80 % for single-use plastic scissors and by 99 % for reusable steel scissors. Differences in total cost ofownership revealed significant economic advantages of reusable stainless steel scissors compared to bothtype of single-use scissors. An economic break-even analysis revealed that the payback period of thereusable stainless steel scissors is valid at 19 use cycles when compared with the plastic single-use scissors
and at 25 use cycles when compared with the stainless steel single-use scissors. The authors concluded thatusing reusable stainless steel scissors was the most eco-efficient choice (Ibbotson et al., 2013).
Rizan et al (2022) focused on the environmental impact and financial cost of repairing surgical scissors in 3
scenarios, no repair (lifespan of 40 uses), onsite repair (hospital) and offsite repair. Repairing surgicalscissors rather than replacing them with a new pair can reduce environmental and financial cost. Emissions
were reduced by 20% through use of onsite repair every 40 uses instead of replacement, and by 19% throughuse of offsite repair every 40 uses. The use phase, and more specifically decontamination, impacted thecarbon footprint across all baseline scenarios. Life cycle cost was GBP £1.43 per use of reusable scissors,
and when repaired either on- or offsite this decreased by 32% to GBP £0.97 per use (Rizan et al. 2022a).
Detailed results of both studies were included in Table 7 and Appendices 9.1 & 9.2.
Surgical scissors as part of laparoscopic devices were described elsewhere (See 2.1.3.4).

Final report June 2023 – Study single-use materials in medicine and health care30

Table 7: Summary LCA’s on surgical scissors
Reference
Ibbotson et al.
(2013,
Germany)

Objective LCA
To evaluate theenvironmental impact andtotal cost of ownership(customer perspective)
comparing SU scissors of
stainless steel, SU scissorsof fibre-reinforced plastic
and RU stainless steel
Rizan et al.
To evaluate the(2022, UK)environmental impact andfinancial cost of repairing
surgical scissors for 3
scenarios: no repair, onsite(hospital) and offsite
SU: single-use; RU: reusable

Functional Unit
4500 use cycles of surgical scissors
during 18 years

Results
Impact RU stainless steel scissors:
11 times lower for the plastic SU scissors
52 times lower than stainless steel SU
scissors

One use of a reusable surgical scissor(type 17-cm, straight Mayo reusable;
manufactured in Germany and used in
the UK)

Global warming
70.3 g CO2eq/use
Onsite repair: 56.3 g CO2eq/use
Offsite repair: 57 g CO2eq/scissor use

In summary, using reusable stainless steel scissors was more beneficial for the environment andfinancial cost compared to their single-use alternatives. Repairing surgical scissors (onsite andoffsite), rather than replacing them with a new pair, reduces environmental and financial cost.

Final report June 2023 – Study single-use materials in medicine and health care31

2.1.3.6 Medical blue wrap
It is of utter importance that medical devices used in the OR (operating room) are completely sterile.
Therefore, blue wrap (sterilisation wrap) or sterilization containers are typically used. Blue wrap is a multilayer
non-woven packaging material made from polypropylene supplied as sheets. Surgical instrument nets arewrapped in two sheets of blue wrap (Friedericy et al. 2022; Hoge Gezondheidsraad 2023).

Example of blue wrap

Example of rigid sterilization container(Friedericy et al. 2022)

The environmental impact of single-use packaging for sterilisation of surgical instruments and reusable
sterilisation containers was compared in two cradle-to-grave LCA’s (Stiegler et al. 2016; Friedericy et al.
2022), while Friedericy et al. (2022) also studied the cradle-to-cradle or recycling option (See Table 8 andAppendices 9.1 & 9.2). The processes and cost of alternative packaging options were analysed by Krohn etal. (2019).
Stiegler et al. (2016) demonstrated that the reusable aluminium containers had approximately half of thegreenhouse gas emissions impact compared to the disposable polypropylene blue wraps annually (See Table
8). For both alternatives, the use phase had the largest environmental impact of all phases, due to the large
amount of energy consumption during sterilisation and decontamination process.
Correspondingly, according to Friedericy et al. (2022) the use of a rigid aluminium sterilisation container gave
a reduction of 85% in carbon footprint compared to the use of blue wrap. The reusable container had 84.5%
less impact in eco-costs. An ecological advantage already occurred after 98 use cycles while the rigid
containers are used up to 5000 times. (Friedericy et al. 2022).
Table 8: Summary LCA’s on blue wrap
ReferenceFriedericy etal. (2021, The
Netherlands)

Objective LCA- To compare environmental
impact of SU and RU
sterilisation packaging for
surgical instruments- To investigate
environmental break-evenpoint of use-cycles

Functional unit
Sterile packaging of a standard
format instrument tray for 5000
sterilisation cycles

Stiegler et al.
(2016, US)

To compare SU
polypropylene blue wraps
and RU aluminium
containers

Sterilisation protection for 100
surgical toolsets used 365 times
per year over 10 years

Results
Global warming potential
SU incineration: 1869 kgCO2 eq
RU landfill: 285 kgCO2 eq
Eco-costs:
SU incineration: €669
RU landfill: €104
Break-even point (SU incineration-RU landfill)
Carbon footprint: 98 use-cycles
Eco-cost: 67 use cycles
Global warming potential
SU: 823 000 kgCO2eq
RU: 377 000 kgCO2eq
Manufacturing:
SU: 22.2% of total impact
RU: 1.6% of total impact
Use:
SU: 77.3% of total impact
RU: 97.5% of total impact
End-of-Life:
SU: 2.5% of total impact
RU: 0.9% of total impact

SU: single-use; RU: reusable

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32

The cost of four (2 reusable and 2 disposable) different packaging options of sterile medical devices wasanalysed by Krohn et al. (2019) (See Table 9). The results of the analysis revealed that ‘the sterile container
without inner wrap’ was the most cost-effective alternative per use. Under numerous (33) scenarios(concerning personnel cost, material and special costs, changes in usage and extreme scenarios), the sterile
container without inner wrap remained most cost-effective. The two sheets sterilisation option brought about
the highest costs in most cases. This is due to the higher process times and thus higher personnel costs. The
authors remarked that each central sterilisation department should analyse its own situation, requirements
and circumstances (Krohn et al. 2019).
Table 9: Summary cost study on blue wrap
Reference
Krohn et al.
(2019,
Germany)

Objective Cost study
To analyse and compare
processes and costs of 4
packaging alternatives

Method- Defining main and sub-processes
directly related to the packaging
options- Time measurements- Distribution fitting (time consumption
and costs) and simulation for all subprocess

Results- Sterile container without inner wrap:€2.05- Sterile container with inner wrap: €3.24- Two sheets non-woven sterilization wrap:€ 3.87- One-step non-woven sterilization wrap
(made of two sheets): €3.44

In summary, both LCA studies have clearly demonstrated that the use of reusable containers are
beneficial to the environment compared to the use of disposable blue wrap. The cost study was also
in favour of a reusable packaging option.

Final report June 2023 – Study single-use materials in medicine and health care33

2.1.3.7

Sharps containers

Sharps containers provide safe disposal of syringes, needles and other small sharps. In Belgium, it iscurrently not allowed to use reusable sharps containers (FAGG-AFMPS 2022). Waste containers are in the
top 20 contributors to the supply chain carbon footprint in the UK (NHS 2017). Single-use containers are used
once and the intact container and contents are incinerated. Replacing disposable by reusable alternatives
has been investigated in the UK where companies processing reusable sharps containers are present..
Reusable containers, certified for a specific number of uses, are being transported to a processing plant,
automatedly decanted of its contents, robotically cleaned, decontaminated, and quality checked (Grimmondet al. 2021).

Example of reusable sharps container
The environmental impact of the supply of reusable versus single-use sharps containers was compared inthree cradle-to-grave LCA studies in the US and UK (See Table 10 and Appendices 9.1 & 9.2) (Grimmondand Reiner 2012; McPherson et al. 2019; Grimmond et al. 2021).
Replacing single-use sharps containers by reusables reduced GHG (greenhouse gas) emission between
65% to 83% depending on the lifespan of the reusable containers. Furthermore, converting from single-use
to reusable eliminated tonnes of plastic cardboard, depending on the size of institutions involved in the study.
Table 10: Summary LCA’s on sharp containers
Reference
Grimmond etal. (2021, UK)

Mc Pherson etal. (2019, US)

Grimmond
and Reiner(2012, US)

Objective LCA
To evaluate theenvironmental impact,
expressed as global
warming potential in metrictons of carbon dioxide
equivalent (MTCO2eq), of
replacing SU SC by RU SC

Functional unit
Total fill line litres (FLL) of
sharps containers needed todispose of sharps for 1-year
period in 40 trusts

To evaluate theenvironmental impact,
expressed as greenhousegas emissions in metric tonsof carbon dioxide equivalent(MTCO2eq), of RU SC andSU SC

Total of single-use and reusable
sharps containers, needed todispose of sharps for 1-year
period in 5 hospitals

To evaluate theenvironmental impact,
expressed as global
warming potential (GWP), of
replacing SU SC by RU SC
in metric tons (MTCO2eq)

Not reported

Results
Global warming potential
Reduction of 3267.4 MTCO2eq
SU SC: 3896.4 MTCO2eq
RU SC (lifespan of 18 years): 628.9 tonnes
CO2eq+ elimination of 900.8 tonnes plastic (landfill+ incineration), 132.5 tonnes cardboard.
Global warming potential
Reduction of 162.MTCO2eq
SU SC:248.6 MTCO2eq
RU SC (lifespan of 26.4 years): 86.20
MTCO2eq+ reduction of 50.2 tons plastic (31.8 landfill+ 18.4 incineration), and 8.1 tons cardboard
Global warming potential
Reduction of 127 MTCO2eq
SU SC:139.1 MTCO2eq
RU SC (lifespan of 39.6 years): 25.1
MTCO2eq+ reduction of 30.9 tons of plastic and 5.0
tons of cardboard from landfill
SU SC: single-use sharps container; RU SC: reusable sharps container; MTCO2eq metric tonnes carbon dioxide equivalent

In summary, all three studies have clearly demonstrated that the use of reusable sharps containers
is beneficial to the environment compared to the use of single-use sharps containers.

Final report June 2023 – Study single-use materials in medicine and health care34

2.1.3.8

Surgical gown, isolation gown, coverall

Surgical gowns, isolation gowns and coveralls are medical textiles which can be woven, knitted, braided, orconsists of non-woven structures, depending on the application. It can include both, natural and synthetic
fibres (Health Care Without Harm Europe 2021b; Martínez-Barbosa and Moreno-Corral 2022). Surgicalgowns serve a critical role in infection prevention (Overcash 2012). They protect patients from microbial
contamination by surgical personnel and protect perioperative personnel from microorganisms andcontamination related to the patient’s body fluids. Isolation gowns also have a critical role in infection
prevention by protecting healthcare workers and patients from the transfer of microorganisms and body fluids
in isolation settings. Finally, a coverall can be used as a type of isolation gown which was often used in thecorona pandemic. Cleanroom coveralls are also used in e.g. pharmaceutical industry when cleanroom
standards are required.
Overcash (2012) performed a literature review on reusable and single-use perioperative textiles, including
surgical gowns and surgical drapes. Six life cycle studies were included, dating from 1993 to 2011. The author
concluded that reusable surgical textiles offer substantial sustainability benefits over single-use products interms of natural resource energy by 200 to 300%, water footprint by 250 to 330%, carbon footprint by 200 to
300%, volatile organics, solid wastes by 750%, and instrument recovery. All other factors such as cost,protection, and comfort were relatively similar (Overcash 2012).

Example of a reusable surgical gown

Example of a single-use surgical gown

Example of a single-use isolation gown
In more recent studies, single-use and reusable surgical gowns were evaluated using a cradle-to-grave
LCA (Vozzola et al. 2020; Bijleveld and Uijttewaal 2022) (See Table 11, See Appendices 9.1 & 9.2). In the
study of Vozzola et al. (2020), the surgical gown was defined as single-piece, long-sleeved, size extra-large
with AAMI (Association for the Advancement of Medical Instrumentation’s) Level 3 barrier protection rating.
Global warming was substantially lower (66%) for the reusable gowns than for the single-use gowns (SeeTable 11). The laundry procedure accounted for 50% of the GHG emissions for the reusable surgical gowns.
Furthermore, the use of reusable gowns reduced also natural resource energy consumption (64%), blue
water consumption (83%), and solid waste generation (84%). Bijleveld and Uijtewaal (2022) compared two
Final report June 2023 – Study single-use materials in medicine and health care

35

types of reusable and two types of single-use surgical gowns. The environmental impact of the reusable
surgical gowns was considerably lower than the impact of the single-use gowns (See Table 12). For reusable
surgical gowns, packaging and washing in particular have a large share in climate impact and for single-use
gown the production of the gown had the largest impact.
Comparable to the literature review of Overcash et al. (2012), these study results showed that selection of
reusable surgical gowns rather than disposable gowns was more favourable (Vozzola et al. 2020).

Example of a single-use coverall
Using an identical methodology, the same authors also investigated the environmental impact of reusableand disposable isolation gowns and cleanroom coveralls (Vozzola et al. 2018a, b). The isolation gown
was defined as a single-piece, long sleeved, extra-large or one-size -fits-most garment with AAMI Level 1
barrier protection rating (See Table 11). The gown manufacturing and delivery life cycle steps had a huge
impact on the environmental indicator for single-use isolation gowns. On the other hand, for reusable gowns
the laundry procedures had the largest impact. The results also showed that selection of reusable gowns
rather than disposable gowns reduced natural resource energy consumption (28%), GHG emissions (30%),
water consumption (41%) and solid waste generation (93%).
A cleanroom coverall was defined as a single-piece, long-sleeve extra-large zip up garment, excluding ahood, gloves, or booties. Two single-use and one reusable coverall were examined.
The reusable cleanroom coverall showed also substantial improvement over both single-use coveralls in allenvironmental impact categories (See Table 11). The improvements over the single-use HDPE (high density
polyethylene) coverall and the single-use SMS PP coverall were respectively 34% and 59% lower processenergy, 23% and 56% lower natural resource energy, 27% and 57% lower GHG emissions, and 73% and
77% lower water consumption. Between the two single-use cleanroom coveralls, the flash spunbonded HDPE
coverall shows a considerable environmental improvement over the SMS PP coverall.
Table 11: Summary LCA’s on medical textiles
Reference
Bijleveld andMeis (2022,
The
Netherlands)

Objective LCA
To compare
environmental
impacts of RU and
SU surgical gowns

Vozzola et al.
(2018a, US)

To compare theenvironmental
impact of RU and
SU cleanroom
coveralls

Functional unit
1 use of surgical gown

Results
No absolute figures are given, only graphs.

-

RU1: 100% polyesterwith C6
fluorcarbonfinish
RU2: 100% polyester
SU1: 90-95%
SMMMS PP, 5-10%
other (PET, cellulose)
SU2: 86-99%
SMMMS PP, 1-14%
non-woven PET)
1000 uses of a cleanroom
coverall(50 uses before discarding
was used resulting in
manufacture and disposal

Global warming
RU: 517 kgCO2eq
SU HDPE: 712 kgCO2eq
SU SMS PP: 1220 kgCO2eq
Process energy
RU: 4560 MJ

Final report June 2023 – Study single-use materials in medicine and health care36

of 20 gowns for 1000
uses)
(60% was laundered tocleanroom standards and
40% as laundered andsterilized)-

Vozzola et al.
(2018b, US)

To compare
environmental
impacts of RU and
SU isolation gowns

SU: spunbonded highdensity polyethylene(HDPE)
SU: spunbondmeltblown-spunbond
polypropylene (SMSPP)
RU: wovenpolyethylene
terephthalate (PET)
1000 uses of isolationgown(60 uses before discarding
the RU gown resulting in
manufacture and disposalof 16,7 gowns for 1000
uses)-

Vozzola et al.
(2020, US)

To evaluate
environmental
impacts of RU and
SU surgical gowns

SU:non-woven
polypropylene
RU: primarily woven
polyester fabric1000 uses of surgicalgown(60 uses before discarding
the RU gown resulting in
manufacture and disposalof 16,7 gowns for 1000
uses)-

SU HDPE: 6930 MJ
SU SMS PP: 11100 MJ
Natural resource energy
RU: 8380 MJ
SU HDPE:10900 MJ
SU SMS PP:19200 MJ
Water consumption
RU: 80.7 kg
SU HDPE: 304 kg
SU SMS PP: 345 kg
Solid waste
RU: 10.2 kg
SU HDPE: 171 kg
SU SMS PP: 238 kg

Global warming
SU: 310 kgCO2eq vs RU: 218 kgCO2eq
Global warming
SU manufacturing: 300 kgCO2eq
RU laundry: 146 kgCO2eq
Natural resource energy
SU: 5150 MJ vs RU: 3712 MJ
Manufacturing SU: 4996 MJ
Laundry RU: 2538 MJ
Water consumption
SU: 74.6 kg vs RU: 43.8 kg
Manufacturing SU: 74.6 kg
Laundry RU: 8.71 kg
Solid waste
SU: 63.4 kg vs RU 0.41-4.42 (depending on 100% or 0%
recycling)
Global warming
SU: 1636 kgCO2eq vs RU: 557 kgCO2eq
Laundry global warming
RU: 278 kgCO2eq
Natural resource energy
SU: 26289 MJ vs RU: 9396 MJ
Water consumption
SU: 1097 kg vs RU: 185 kg
Solid waste- SU: 265 kg vs RU 35.5–43.4 kg (depending on 100% or 0%
recycling)

SU: non-woven
polyester (non-criticalzone OR), PP (criticalzone OR);RU: woven PET in
non-critical zone andknit PET in criticalzone
SU: single-use; RU: reusable; HDPE: high-density polyethylene, PP: polypropylene, PET: polyester, SMMMS: spunbond, meltblown,
meltblown, meltblown, spunbond; OR: operating room

In summary, the studies demonstrated that reusable gowns/coveralls are more environmentallyfriendly than single-use equivalents.

Final report June 2023 – Study single-use materials in medicine and health care37

2.1.3.9 Laryngeal mask airway
A laryngeal mask airway (LMA) is a supraglottic airway device which is used temporarily to maintain an open
airway during anaesthesia or as an urgent life-saving measure in a patient with a difficult or obstructed airway.
An LMA consists of an airway tube and an elliptical mask cuff and is designed to sit in the patient’s
hypopharynx and cover the supraglottic structure (Liang 2019; Simon and Torp 2023).
The environmental impact of single-use and reusable LMA’s was compared in two cradle-to-grave LCA’s
using a similar methodology (See Table 13 and Appendices 9.1 & 9.2) (Eckelman et al. 2012; Liang 2019).
The results of both studies showed that reusable LMA’s had fewer negative environmental effects. In the
study by Eckelman et al. (2012), the production of PVC (polyvinylchloride), the main component of singleuse LMA’s, accounted for the largest source of GHG emissions (23%). For reusable LMA’s, natural gas
production and incineration for steam generation in the autoclave constituted the largest source of emissions(77%). Similarly, Liang (2019) concluded that for the single-use LMA’s, PVC production was the major
contributor to the environmental burden, while for reusable LMA’s, the use phase, specifically the manual
cleaning and soaking process (before automated cleaning), was the main source of environmental impact.

Example of a laryngeal mask airway

Table 12: Summary LCA's on laryngeal mask airways
Reference
Eckelman etal (2012,
US)

Objective LCA
To compare theenvironmental andhuman health impactof SU and RU
laryngeal mask airway

Functional unit
40 uses of a laryngeal
mask airway

Results
Global warming potential
SU: 11.3 kgCO2eq
oProduction + polymerisation PVC: 23%oPolycarbonate production: 14%oTransportation via truck: 15%oThermoforming: 13%oWaste disposal: 11%
RU: 7.4 kgCO2eqoNatural gas production + combustion to
produce steam for the autoclave: 77%
Scenario analyses
RU: fully loaded autoclave (10 pieces): 5.6 kgCO2eq
RU: individual autoclave: 37 kgCO2eq
RU: autoclave efficiency +10%: 6.8 kgCO2eq
RU: 10 reuses: 11.4 kgCO2e
SU: transport by air: 20.5 kgCO2eq
Liang (2019,
To compare the
40 uses of a laryngeal
No absolute figures are given, only graphs.
Sweden)environmental impact
mask airway
Comparative analysis of the single-use and reusable LMA forof SU and RU
3 endpoints (human health, ecosystems and resources):laryngeal mask airway
reusable LMA has less than 40% impact burdens compared tothe single-use LMA
SU: single-use, RU: reusable, LMA: laryngeal mask airway; PVC: polyvinyl chloride

In summary, the findings of both studies indicate that reusable laryngeal mask airway are moreenvironmentally friendly compared to single-use laryngeal mask airway.

Final report June 2023 – Study single-use materials in medicine and health care

38

3

STAKEHOLDERS

3.1

Goal

By consulting stakeholders, information on current (best) practices and challenges in reducing, reusing andrecycling of medical items and devices was collected.

3.2

Overview consulted stakeholders

Hospitals, departments-

Purchase departments-

Companies

-

-

-

-

Sustainability coordinators (Ghent University Hospital, AZ
Maria Middelares)
Working group single-use Ghent University Hospital
Central sterilisation Ghent University Hospital
Infection Prevention and Control Department Ghent University
Hospital
Surgery Ghent University HospitalBest practices hospitals from hospital websites
Procurement central Charleroi MercurHosp - Mutualisation
Hospitalière
Purchase department Ghent University HospitalGreenCycl (https://greencycl.org)
o Circular and economically sustainable solutions forhealthcare: consulting, collection, sterilisation, design,
production and recycling.
Vanguard (https://www.vanguard.de)o Medical remanufacturing: restores a used medical
device to “as new” functional and safety standard withmatching warranty.
Sterima (https://www.sterima.be/nl)o Sterilisation services for hospitals and medical
companies in the Benelux
Renewi (https://www.renewi.com)
o Waste management and recycling

Relevant information from the stakeholder interviews and visits was included in the analysis of the items,
LCA and recommendations (See Chapters 5, 6 and 7).

Final report June 2023 – Study single-use materials in medicine and health care

39

4

HOSPITAL SURVEY: CONSUMPTION AND COST OF SINGLE-USE
MATERIALS

4.1

Goal

The goal of the hospital survey was to identify the five most relevant single-use medical devices with possible
environmentally sustainable and/or circular alternatives based on consumption rates and/or cost rates in
Belgian hospitals.

4.2

Methods

4.2.1

DesignA cross-sectional multi-centre study was performed. Data were collected between August and November
2022.

4.2.2

Setting

Hospital participation was requested on behalf of the Directorate-General for the Environment of the Federal
Public Service (FPS) Health, Food Chain Safety and Environment. An email invite was sent by the FPS to
the CEO of the Belgian hospitals requesting participation (See Appendix 9.3: Invitation letter French-language
and Invitation letter Dutch-language). The study was also announced during a national meeting of the BVZDABDH (Belgian Association of Hospital Managers) on circularity and sustainability in healthcare on June 21thof 2022. All Belgian hospitals, including general and university hospitals (N=103), and psychiatric hospitals(N = 59), were invited to share information about the procurement of single-use medical items and devices.
No reminders were sent by the FPS, but requests for further information were replied by the FPS or by the
researchers of Ghent University Hospital. Hospitals that responded positively were given further instructions
for participation and a template to encourage uniformity of data entry. Hospitals who responded positively tothe initial call, but did not provided procurement data by the end of September, received two reminders (oneby telephone and one by mail).

4.2.3

Data collection: hospital survey procurement lists

To gain insight into the type of single-use medical devices most frequently used or with the highest cost per
item, a hospital survey requesting procurement lists was conducted. Following data were requested for all
medical single-use devices purchased by pharmacy and procurement department of the participating
hospitals:-

Name of the medical device purchased by pharmacy and procurement department
Manufacturer
Number of packing units ordered per year
Number of items per packing unit
Purchase price per packing unit (excl. VAT)
Optional parameters, if available, such as weight/volume.

Procurement data of the year 2019, the last full year before the COVID-19 pandemic, were requested. The
hospital situation during the COVID-19 pandemic was considered not representative for the study.
Participants obtained the certainty of anonymisation when analysing their data (See also 4.2.5: Ethicalconsiderations).

Final report June 2023 – Study single-use materials in medicine and health care40

4.2.4

Processing procurement lists

4.2.4.1 Consumption of single-use medical items and devices
Data were processed uniformly for each hospital separately: 1) sorted by consumption (amount), 2) related
items were added up (e.g. same item but from different companies, different size) and 3) consumption per
item per bed (licensed beds) per hospital per year was calculated.
Medical devices indicated by the FAMHP (Federal Agency for Medicines and Health Products) during the
COVID-19 crisis that they should not be reused (due to their complexity) were excluded (See Appendix 9.4).
In conjunction with this, items beyond the scope of the project due to safety (for example needles), complexity(for example glucose sticks), availability of alternatives (for example blood tubes) were excluded. The FPS
steering committees with delegates of several departments of the FPS monitored the project and advised thefocus on items with the potential of more sustainable alternatives. A non-limitative list of excluded items isprovided in Appendix 9.5.
The selection process from all items to the final five items for further research is detailed in the result section.
4.2.4.2 Cost of single-use medical devices
Similar to the list of items with high consumption rates, we aimed to compose a list of high cost items. Since
hospitals were not eager to share their prices, and the most expensive items were rarely included in theprovided lists, cost data could not be similarly processed.
For a selected amount of items, purchase costs were based on publicly available pricelists of three suppliers.

4.2.5

Ethical considerations

A data transfer protocol between the participating hospitals and Ghent University Hospital was developed toensure confidentiality. All data provided by the hospitals will only be used for data processing within thisresearch project and will be handled confidential. In processed and aggregated form, the data may be partof future scientific publications.

4.3

Results

4.3.1

Participating hospitals

Twenty-three hospitals responded to the initial call of the FPS to participate in the study. Eleven hospitals
provided procurement data lists. Upon completion of the initial data collection period, one additional hospitalprovided purchasing amounts based on a shortlist of items. In total, data from 12 hospitals were synthetised,of which four Walloon hospitals, six Flemish hospitals and two hospitals from Brussels-Capital region. Eighthospitals were general hospitals, the remaining four were university hospitals.
Of these twelve hospitals, nine provided procurement data lists from the requested year 2019, one provided
data from 2021 and two from a part (nine or ten months) of 2022. For the latter group, the data wererecalculated to full-year amounts.
Five hospitals were willing to report purchase cost in addition to consumption figures, of which one provided
cost data from 2022. All hospitals provided partial procurement data, with missing data on procurement
figures on regularly used single-use medical devices (See Table 13). An overview of the type of provided
data of the participating hospitals can be found in Appendix 9.6.
None of the participating hospitals provided data on the optional parameters, as weight or volume of thesingle-use medical items and devices.

Final report June 2023 – Study single-use materials in medicine and health care

41

Table 13: Overview of type of provided data of the participating hospitals
RegionNumber ofparticipating hospitals

Hospitals providing
procurement data/with cost data

% (n)% (n) – Cost %(n)Hospitals
providingpharmacy data/with cost data
# % (n) – Cost%(n)Brussels
Wallonia
Flanders

4.3.2

16.7 (2)33.3 (4)50.0 (6)8.3 (1) / 0.0 (0)33.3 (4)/ 25.0 (3)50.0 (6)/ 16.7 (2)8.3 (1) / 0.0 (0)25.0 (3) /16.7(2)50.0 (6)/ 16.7 (2)Hospitals providing
surgery equipment data(laparoscopic
devices/catheters…)/with costdata
# % (n) – Cost %(n)0.0 (0)/ 0.0 (0)0.0 (0)/ 0.0 (0)16.7 (2)/8.3 (1)Procurement data

4.3.2.1 Longlist of single-use medical devices
The twenty highest-scoring items in terms of consumption for each hospital were included in a list (hereafterreferred to as “longlist”). Consumption rate of items emerging in one hospital’s procurement top 20, but notin another hospital’s procurement top 20 were specifically searched for and, if available, completed in thelonglist. The longlist ended up containing a total of 78 medical single-use materials.
Categories were created based on the process needed for reuse. Following categories were identified:• Sterilisation or high level disinfectiono Small medical devices
o Operating room (OR) equipment, such as laparoscopic and other surgical equipment• Thermal disinfection (TD) or low level disinfection (LLD)• Laundry process• Change of item/device (alternative needed)/ Change of composition (/ Change of behaviour) 1
Each item was assigned one of these categories. The full longlist of items with categories is included inAppendix 9.7.
A more complete list consisting of the highest-scoring items per hospital based on cost per item expressed
as cost per bed per year could not be compiled due to missing cost data (>50% of hospitals), and missing
data on single-use surgical equipment (>90% of hospitals).
For illustrative purposes only, graphs of consumption in relation to cost (catalogue price and/or real hospital
prices) were added to the report. An example of a hospital was included where amounts and costs of singleuse medical devices including all departments (central purchase department, pharmacy and surgicalequipment) were available (Appendix 9.8). Due to the limitations of the data collection, results including cost
data should be interpreted with caution.
4.3.2.2 From longlist to shortlist
Pragmatically, in light of available project time and budget, the five most relevant items for further researchwere chosen, using following steps (See Figure 1). Firstly, a shortlist was created by selecting 28 items fromthe longlist. Secondly, items were sorted based on reprocessing categories and finally for each reprocessing
category, one item was selected. A detailed description of those three steps is provided below.
The first step was creating a shortlist of 28 items (See Table 14), compiled from the longlist, and based onfollowing criteria (and listed in Figure 1):• Consumption rate/bed/year (thermometer caps, kidney trays)• Cost/item (vessel sealer)• Feasibility (such as countering shift from reusable to single-use alternative) (vaginal speculum,
patient blanket)• Volume/item (patient blanket)• Safety (kidney tray, vaginal speculum, patient blanket)• Sustainability (high ecological impact when disposed as waste) (vessel sealer)• Literature/Stakeholders input/Focus of project
Items in the category “Change of behavior” were not included as this was not the scope of the study (more sustainable
alternatives for single-use medical devices)1

Final report June 2023 – Study single-use materials in medicine and health care42

High-disinfection (HLD) or
sterilisation (CSA)- Small medical devices- OR equipment

Thermal disinfection (TD) or
low level disinfection (LLD)

28 items
Selected based on
Consumption rate/bed/year
Cost/item
Feasability (such as countering
shift from reusable to single-use,
alternative)

5 ITEMS

Categorised by process

SHORTLISTLONGLIST

78 items

Kidney tray
Speculum

Thermometer covercaps
Vessel sealer
Patient blanket

Volume/item

Laundry process

Safety issues (such as patient
identification issues)

Other item/device(alternative needed)/ Changeof composition

Sustainability (high ecologicalimpact when disposed as waste)
Literature/stakeholders input/
Focus of project

Figure 1: Steps followed to identify the five single-use items for further research

Secondly, items were sorted based on the circular process needed for reuse as reflected in Table 14.
Table 14: Shortlist of items
ITEM

CIRCULAR PROCESS NEEDEDMEDICATION CUPSTD

BASINS/KIDNEY TRAYTD

NEEDLE BINS

TD/ CHANGE OF ITEM OR DEVICEGARROT

TD/ CHANGE OF ITEM OR DEVICEDENTAL JAR

TD/HLD

LID FOR DRINKING CUPTD

COVERCAPS FOR TEMPERATURE MEASUREMENTCHANGE OF ITEM OR DEVICESTERILISATION DRAPES
ABSROBERENDE VELLEN/LINERLAUNDRY/ STERILISATIONSURGICAL AND OTHER CAPSLAUNDRY

BREAST(FEEDING) COMPRESSLAUNDRYSHEETS EXAMINATION TABLESLAUNDRY

GOWN (NS) (ISOLATION)LAUNDRYSURGICAL GOWN (S)LAUNDRY/ STERILISATIONBIBLAUNDRYPROTECTIVE COVER MATRESSLAUNDRYWASH CLOTH

LAUNDRY

DIAPERS (BABY)LAUNDRY

INCONTINENCE SHEETSLAUNDRY

TROLLEY COVERSLAUNDRYBLANKETLAUNDRYMILK BOTTLESSTERILISATION

BRUSH ENDOSCOPIC VALVESSTERILISATIONSPECULUM

STERILISATIONSCISSORS (STERILE)

STERILISATIONLARYNGOSCOOPBLADESSTERILISATIONTROCARSTERILISATION (OR EQUIPMENT)VESSEL SEALINGSTERILISATION (OR EQUIPMENT)BLOODPRESSURE CUFS

CHANGE OF ITEM OR DEVICE

Final report June 2023 – Study single-use materials in medicine and health care

43

The large variations in consumption between hospitals and the lack of data on certain items is illustrated inAppendix 9.9 (each hospital is represented by another colour). Data on some of the items were only provided
by one or two hospitals, whereas, from logical reasoning in care provision, it is used by (almost) all hospitals,
for example incontinence materials.
Because of this limitation, it was not deemed appropriate to rely solely on the quantities received from thehospitals, but other criteria were also considered (as listed to compile the shortlist and in Figure 2). For
illustrative purposes only, a graphic overview of the median consumption-rates (amount/bed/year for 2019)of the 28 highest scoring items was provided in Figure 2.

Median Amounts (#/bed/year)
450,00400,00350,00300,00250,00200,00150,00100,0050,00
0,00

Figure 2: Median consumption rates (Amounts/bed/year)

Cost/amount rates of shortlist items based on hospital prices and catalogue prices were included in Figure
3 (below), and Appendix 9.10, respectively.

Final report June 2023 – Study single-use materials in medicine and health care

44

Cost (hospital prices)/Amount of participating hospitals - rate 2019

VESSEL SEALING(TYPE 1)

Cost - hospital prices (€/bed/year)

SHARPS CONTAINERS;VESSEL SEALING(TYPE 2)

TROCARS;GOWN (NS);BLOOD PRESSURE CUFFS;
SURGERY GOWNS;*for item blanket no amount vs cost data were available

KIDNEY TRAY;

STERILISATION DRAPES;GOWN (NS);STERILISATION DRAPES;STERILISATION DRAPES;NEEDLE BINS; 49,27
GOWN (S);MILK BOTTLES;PROTECTIVE
COVER MATRESS;INCONTINENCE PADS;PROTECTIVE
COVER
MATRESS;ANAESTHESIAMASKS;
36 SHEET/TRAYLINER;
ABSORBING
PROTECTIVE
COVER
MATRESS;
32,78203051
SCISSORS(STERILE);
MILK
BOTTLES;23
SURGICAL
AND
OTHER
CAPS;
27,17
27,05
ABSORBING
NEEDLEBINS;
20
SURGICALAND
OTHERSHEET/TRAYLINER;CAPS;19SCISSORS(STERILE);
16 (BABY);STERILISATION
BAG;
16 12,46
16
DIAPERS
15
TABLE
COVER;
13,6291236
STERILISATIONBAG;
KIDNEYTRAY;
ANAESTHESIAMASKS;
17,50
SURGICAL
AND
OTHER
CAPS;
BIB;BIB;
11,68
SCISSORS(STERILE);
9,99
15,17635844
SPECULUM;GARROT
LATEX
FREE
STRECH
SPECULUM;
7,944765045
WASH
7 DRINKING CUP; 5
KIDNEY
TRAY;
6 FOR
TROLLEY
COVERS;
5,46CLOTH;
LID
7,17716551
ANAESTHESIAMASKS;
1,78
6,879088206
CUPS;
BREAST(FEEDING)COMPRESS;
1MEDICATIONKIDNEYTRAY;
0,646274209
BLEU;
2,89

0,00

200,00400,00600,00

COVERCAPS FORTEMPERATURE
MEASUREMENT;

COVERCAPS FORTEMPERATURE
MEASUREMENT;WASH CLOTH;MEDICATION CUPS;

800,001000,00

Amount (#/bed/year)
Figure 3: Cost (hospital prices)/Amount of participating hospitals – rate 2019

Final report June 2023 – Study single-use materials in medicine and health care

45

1200,00

4.3.2.3 Selection of items
The last step was selecting five items from the shortlist of 28 items. The selection was based on 1) one item
was selected for each reuse process; and 2) the selection criteria listed in Figure 1 (and identical to the criteria
used to compose the shortlist from the longlist). The five items were summarised in Table 15. For example
kidney trays were included because of the high consumption rate, because possible alternatives would notraise additional safety concerns, and because several types of single-use and reusable trays exist (paper
pulp, plastic, metal), where indications on which type of kidney tray is most sustainable can be of added
value. For the speculum, the added value lies in preventing an ongoing shift from reusable to single-use,there are no additional safety issues, and limited results from studies are available on previous LCA’s, tosupport conclusions. Thermometer cover caps were chosen because of their surprisingly but systematicallyhigh consumption in Belgian hospitals. Vessel sealers had, beside their high cost, also suspected large
sustainability impact per device. The patient blanket has been included as example for a high amount oflaundry items. A blanket is eminently an item with a very high volume per item, and alternatives do not pose
any additional safety problems. The use of single-use blankets is not (yet) standard, therefore prevention ofshifting from reusable to single-use may be possible.

Kidney tray
Speculum
Thermometer cover
caps
Vessel sealer
Patient blanket

THERMALDISINFECTIONSTERILISATIONx

CHANGE OF
ITEM/DEVICExSTERILISATION(OR EQUIPMENT)LAUNDRY

x
x

x

x

x

x

x
x

x

Stakeholders
input

Literature

Sustainability/item

SafetyVolume/item

Feasibility

Cost/item

Consumption

Category

Table 15: Overview of the five items with selection criteriaxx

Furthermore, each item was selected for its potential to serve as an example for other items that belong to
the same category.

Final report June 2023 – Study single-use materials in medicine and health care46

5

FIVE SINGLE-USE MEDICAL ITEMS AND ALTERNATIVES

5.1

Goal

In this chapter, the five selected single-use medical items and their reusable alternatives were studied inorder to identify the most sustainable and feasible option.

5.2

Methods

Four parameters of each item were studied: sustainability, safety, costs and efficiency (Kwakye et al. 2010;
Siu et al. 2017). These criteria are also commonly used when purchasing medical material (Sherman et al.
2018; Klaske 2020).
To evaluate and compare the environmental burdens of medical devices (sustainability), conducting a life
cycle assessment (LCA) is a well-known and established method (Schulte et al. 2021; Sørensen et al. 2022).
However, conducting an LCA is a complex and time-consuming process. Therefore, it was decided to carryout an LCA of one item, namely a reusable and single-use vaginal speculum. The LCA is discussed in thenext chapter. For the other four items, available information according to the life cycle stages of an LCA wascollected (Hauschild et al. 2018; International Organization for Standardization 2022), but no full-level LCA
was performed.
Relevant information included:- Environmental sustainability:o The items were elaborated based on the frame of an LCA, namely raw materials,
manufacturing, distribution, (re-) use, and end of life (disposal/recycling) (Hauschild et al.
2018; International Organization for Standardization 2022). As data on end-of-life were
frequently not available in the ecoInvent Database, we focus on raw materials.
o The carbon footprint or global warming was used, since it was the most used and developed
parameter. Data from the ecoinvent Database 3.8 were used to quantify global warming,
expressed in kg CO2/kg raw material.
- Safety:o Focus on infection prevention (patient safety) and occupational safety (medical personnel).
- Costs:o Focus on purchase cost, reuse cost, and waste or recycling cost.
▪ Purchase costs were based on price lists of 3 commercial suppliers (catalogue
prices).
▪ Reuse cost based on a theoretical estimation including labour cost
▪ Waste or recycling cost based on average prices for healthcare institutions.
- Efficiency:o Focus on availability, handling, and time consumption to (re)use.

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47

5.3

Results

5.3.1

Kidney tray

5.3.1.1 Description and Specification
Kidney trays (synonym: kidney dish, emesis basin) are often used for holding and transporting small medical
devices (syringes, instruments, swabs, dressings, …) and for holding waste (e.g. soiled dressings, blood orother body fluids or other medical waste) arising from medical or nursing procedures. Sterile, as well as nonsterile kidney trays are used, the latter are widely consumed. We focus on both reusable and disposable nonsterile kidney trays. In practice, however, disposable kidney dishes are generally used (outside the operatingroom).
Kidney trays can be made of different materials (See Table 16).
Table 16: Most commonly used materials for kidney trays

Disposable
Paper pulp
with varying % recycled paper

Reusable
Stainless steel / inox

Plastic
polyethylene (PE)Plastic
polypropylene (PP)

5.3.1.2 Sustainability
Very little to no literature can be found on the sustainability of disposable and reusable kidney trays (Gabriel
et al. 2018). Gabriel et al. (2018) studied four scenario’s: Scenario 1: conventional kidney tray in high-density
polyethylene (HDPE), Scenario 2: combination of selected bio-ethanol based (made from sugarcane)
ethylene alternative with existing supply chain features to generate ecological impact estimates for a kidney
tray made from bioplastic, Scenario 3: green supply chain management and improvements (productstewardship) and Scenario 4: combination bioplastic and green supply chain management and improvements(Gabriel et al. 2018). The results showed that scenario 2 switching to a bioplastic product has the lowest
environmental impacts. Unexpectedly though, the product stewardship option had a more negative impact
on the natural environment than the conventional HDPE option (See Table 17). The authors suggest there
may be greater environmental gains to be obtained by focusing on one's core business (changing raw
materials/manufacturing), than by extending influence across the supply chain (more sustainable supply
chain options, e.g. transport) (Gabriel et al. 2018). Concerns regarding (bio)plastics were addressed inAppendix 9.11.
McGain et al. (2010) compared a single-use polyurethane with a reusable nylon drug tray, which is not
identical to a kidney tray, however sufficiently similar to be included in this overview. The reusable drug tray
was cleaned and thermally disinfected in a common washing machine (See Table 17). The single-use tray
produced 15% more CO2 and consumed three times the amount of water. Consequently, the authors
concluded from their LCA that the environmental and financial benefits of a hospital switching to reusable
drug trays are important. Producing the tray had a huge environmental impact for single-use trays, while forreusable trays, the thermal disinfection had the largest impact (McGain et al. 2010).
Final report June 2023 – Study single-use materials in medicine and health care48

Table 17: Summary LCA’s on trays
Reference
Gabriel et al(2018,
Australia)

McGain (2010,
Australia)

Objective LCA
To assess how the new
business model might affectthe overall life cycle impacts
of a reusable kidney dish4 scenarios were compared:(1) HDPE tray, (2) bioplastic
basin, (3) HDPE tray +green supply chain
management andimprovements, (4) bioplastic
tray + green supply chain
management andimprovements
To model the financial andenvironmental costs ofreusable and single-use
drug trays.

Functional unit
Use of one plastic kidney dish(100g)

Results
Global warming: no absolute figures are
given, only graphs

Use of one plastic anaesthetic
drug tray(RU: assuming 300 uses)

Global warming
SU: 126g CO2eq vs.RU: 110g CO2eq
SU: polyurethane tray: 111g CO2eq ,polyethylene wrap: 8g CO2eq paper
wrap: 3g CO2eq , trucking: 3g CO2eq ,shipping: 1g CO2eq
RU: nylon tray: 2 g CO2eq , tray
washing 99g CO2eq ,, tray drying 9g
CO2eq
Water use
SU: 3.1l vs RU: 10.3l

SU: single-use; RU: reusable; HDPE: high density polyethylene

Raw materials
The composition of the different types of kidney trays was extracted from the technical datasheets. In Table
18, the carbon footprint of each type of raw material is presented. The data sheets of the kidney trays do notalways state the exact composition of the kidney tray e.g. what percentage of recycled paper the kidney dishconsists of or what type of polyethylene. Properties and concerns about raw materials and its impact onsustainability are discussed in Appendix 9.11.
Table 18: CO2 emissions of the raw materials of different types of kidney trays

ReusableSingle-use

Raw material

Paper pulp
≥ 50% recycled paper
Polyethylene (PE)**High density (HDPE)
Low density (LDPE)
Inox /
stainless steel
Polypropylene (PP)CO2 emission(kg CO2 eq/ kg
raw material) *Weight/kidney
tray (g)CO2 emission/kidney
tray (kg CO2 eq/
kidney dish)0,52

17 - 190,009 - 0.01

2,29
2,45

9

0,021
0,022

4,73

130 - 250

2,27

92

0,62 - 1,18-> per use 0,0006 –0.001***
0,21->per use 0,0002****Ecoinvent 3.8; **on the data sheet of the kidney tray type PE was not mentioned; *** based on 1000 uses

Based on 1000 uses, a reusable kidney tray in stainless steel or polypropylene generates obviously thelowest carbon footprint according to the CO2 emissions of the raw materials.
Manufacturing
The production of kidney trays includes energy consumption during the manufacturing process (e.g. for plastic
kidney trays: polymerisation, extrusion and injection moulding process), package manufacturing, the use ofhazardous substances/chemicals e.g.,…(Gabriel et al. 2018).
Based on the Eionet Report regarding plastics, converting polypropylene and polyethylene in product causes
a generally GHG emission of respectively, 0.94 kgCO2eq/kg polypropylene and 1.13 kgCO2eq/kg
polyethylene (both HDPE or LDPE) (ETC/WMGE 2021).

Final report June 2023 – Study single-use materials in medicine and health care49

Transport
The environmental impact of transport depends on fuel type (electricity, fuel, biofuel,… ), the mode oftransport (road, rail, shipping,...), vehicle type (size of truck,…) and the distance (Rondaij and Spreen 2020).
The environmental impact is mainly due to the use of fossil fuels. This is not further explored because of thelack of data.
Use/Reuse
To reuse a kidney tray, it must be disinfected (See Safety – Infection prevention). According to the data sheet,a reusable plastic kidney tray is guaranteed to be autoclavable for 1000 cycles. Since sterilisation is not
required in our application, they can last longer. Stainless steel materials are known to last a lifetime.
The environmental impact of thermal disinfection mainly includes the energy consumption and water
consumption of the thermal washing machine. Rizan et al (2022b) calculated, that the carbon footprint of thesubprocess of disinfecting a surgical instrument in a washer/disinfector was 0,016 kgCO2eq per instrument(Rizan et al. 2022b).
When the kidney tray is disinfected with a disinfection wipe, the environmental impact of the life cycle of adisinfection wipe needs to be taken into account. Based on the LCA study of Sanchez et al. (2020), thecarbon footprint of manufacturing a disinfection wipe consisting of 1g of cotton substrate with active ingredientn-alkyl dimethyl ethylbenzyl ammonium chloride and isopropyl alcohol, was calculated to be 0.16 kgCO2eq
per wipe, and the disposal (incineration) impact was calculated to be at 0.039 kgCO2eq per wipe. This results
in a total emission of 0.20 kgCO2eq emission per wipe (Sanchez et al. 2020). This is a relatively high impact.
End of life / Waste
Depending on the soiling of the single-use kidney tray, it is sorted differently. If the kidney tray is filled withblood or body fluids, it must be sorted as Hazardous Medical Wase (HMW); if not, it can be sorted as NonHazardous Medical Waste (NHMW) (OVAM 2021) (See Figure 4).
Another possible option for specific paper pulp kidney trays is the use of a macerator, which disposes ofhuman waste along with pulp based single-use containers such as bedpans, urinals and bowls. Cutter blades
break the waste down into a fine slurry. This slurry is then deposited into the existing sewerage system.
Depending on the type of macerator, there is a maximum load capacity of about 3 to 6 pulp products. Theenergy and water consumption of the macerator has to be taken into account.

Figure 4: Waste sorting of single-use kidney dish
Final report June 2023 – Study single-use materials in medicine and health care50

End-of-life reusable plastic kidney tray will also be discarded with the medical waste. The end-of life stainlesssteel kidney tray can be recycled. When incinerated, bottom ashes can be reused (Indaver 2022).
In summary, reusable kidney trays are more environmentally friendly than single-use kidney trays.
However, the method of disinfection has also a considerable environmental impact.
5.3.1.3

SafetyInfection prevention
Single-use
The use of a new single-use kidney tray contains no risk of transmission of microorganisms.
Reusable
To reuse a plastic or inox kidney tray, disinfection is required. According to the Spaulding classification, akidney tray is ranked as a non-critical item meaning that it comes at most in contact with intact skin but notwith mucous membranes, hence, the sterility of items is ‘not critical’ (Rutala et al. 2008). Depending on thepossibility of contact with blood or other body fluids: low-level disinfection is minimally advised. If (visibly)
soiled with blood or body fluids, the kidney tray must be cleaned before disinfection, preferably consisting ofthermal disinfection by an automatic washer (See Figure 5). To ensure the correct operation of the automaticwasher, it is necessary to validate and monitor the automated disinfection process in accordance with theguidelines provided by the Belgian Superior Health Council (Hoge Gezondheidsraad 2023).

Figure 5: Disinfection options of a reusable kidney dishSince a kidney tray is a non-critical item, the risk of transmission of micro-organism after disinfection of areusable tray, is comparable of the risk using a single-use kidney tray.
Patient safety is ensured with both options.
Occupational safety
Commonly, handling a kidney tray involves no risk to the healthcare professional. When blood or body fluids
are involved, there is biological risk. Further, disinfection of the kidney tray may involve a minor chemical risk
(See Table 19).
Biological risk
When the kidney tray is filled with blood or body fluids, there is an occupational risk and must be handled as
if it is infectious. Therefore, gloves are advised (European Commission. Directorate-General for Employment,
Social Affairs and Inclusion 2011; Hoge Gezondheidsraad 2014). Attention should be paid when the kidney
tray filled with body fluids is discarded as accidental splashing is possible. Personal protective equipment
such as eye protection is advised. There is no difference between single-use or reusable trays.
Chemical risk
There is a possible chemical risk when using disinfectants. To reduce this risk, the use of thermal proceduresis preferable to chemical disinfection and automated procedures are preferable to manual disinfection. In
case of manual disinfection, gloves are indicated (European Commission. Directorate-General for
Employment, Social Affairs and Inclusion 2011).

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Table 19: Occupational risks associated with the use of single-use or reusable kidney tray.

No blood or body fluids
Transport and handling kidney tray filled with blood or body
fluidsPouring out body fluids
Possible overturning
Patient with known infection/MDROManual disinfection
Thermal disinfection

Single-use
No risk
Risk

Reusable
No risk
Risk

Risk
Risk
Risk
NA
NA

Risk
No risk
Risk
Risk
No riskIn summary, the patient safety and occupational safety of using a single-use or a reusable kidney
tray is comparable.

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5.3.1.4

Cost

The total cost of a single-use kidney tray includes the purchase and waste cost. The total cost of a reusable
kidney tray includes purchase cost/total uses, and disinfection cost (Overview see Table 20).
Purchase cost
The range of purchase cost per type of kidney dish is presented in Table 20.
Table 20: Purchase cost (including VAT) per type of kidney tray

Single-use

Reusable
Per piece

Paper pulp

€0.12 - €0.26

Plastic€0.17 - €0.20

Inox / stainlesssteel
Plastic

Per piece

Per use *€7.49 - €11.15€0.0075 –€0.0112€0.0026 –€0.0103€2.55 - €10.25*based on 1000 uses (data sheet reusable plastic kidney tray )Reuse cost
The reuse cost may comprise manual or thermal disinfection (See Infection prevention above).
Manual disinfection cost
The cost estimation includes the cost of the disinfection product and labour cost (See Table 21):
- Disinfection wipes: ± €0.06 – 0.16 per wipe
- Disinfection spray (750ml) + cloth:o Spray: ± €10 (estimated 3ml / spray) -> €0.08 (based on 2 sprays)o Cloth: ± €0.013 - 0.2 (disposable – reusable cloth)- Labour cost:• Calculated for a logistic assistant and a nurse based on data from the KCE study Manual forcost-based pricing of hospital interventions (Swartenbroekx et al. 2012). As these data were from2012, results have been indexed by a factor of 1.3076 (wage index March 2012= 1.5769, wage
index June 2022 1.8845) resulting in a cost per hour of €37.50 - €47.46• Labour time: 30 seconds
Thermal disinfection cost
The cost of thermal disinfection was calculated on the basis of a simulation costing from the Central
Sterilisation Department of het Ghent University Hospital. The cost was estimated at € 0.40 including direct
labour cost, energy, capital goods and building infrastructure, and auxiliary materials.
Waste cost
Depending on how waste has to be sorted, the cost varies. If the kidney tray is filled with blood or body fluids,
it must be sorted as HMW; if not, than it is sorted as NHMW (OVAM 2021).
Based on an average cost of waste treatment, the cost for- NHMW is €202 per ton- HMW is €780 per ton
Another possible option for specific paper kidney tray is the use of a macerator, which disposes of humanwaste along with pulp based single-use containers such as bedpans, urinals and bowls. Cutter blades break
the waste down into a fine slurry. This slurry is then deposited into the existing sewerage system. Costs
associated with using the macerator are mainly electricity and water.
Based on a consumption of 1000 kidney trays, the total cost of reusables is higher than the single-use tray,
due to disinfection and labour cost. McGain et al. (2010) modelled the financial costs of a reusable and singleuse plastic anaesthetic drug trays based on an LCA. Their results indicated that the total cost of one singleuse tray (Australian $0.47) was twice as much as a reusable one including thermal disinfection (Australian$0.23).
The total waste cost calculation per piece is stated in Table 21.

Final report June 2023 – Study single-use materials in medicine and health care53

Table 21: Overview of the costs related to the use of a single-use or reusable kidney tray

Single-use
Paper pulp
€0.12 - 0.26

Purchasecost / pieceType ofdisinfection
Disinfection
cost / piece
Labour cost *Type ofwaste
Waste cost /piece
Waste cost
bag orbarrel/piece**
TOTAL

Plastic€0.17 - 0.20

NHMW

HMW

NHMW

HMW

€0,0034 0,0038€ 0.0015€0,0133 0,0148€0.070.09€0,0018€0,0064€0.0015€0.070.09€0.13 0.27

€0.200.37€0.170.20€0.280.30

Reusable
Inox
Plastic€ 0.0075 – 0.0112 € 0.0026 – 0.0103
ManualThermalManualThermal€0.060.16€0.310.40€0.40***€0.060.16€0.310.40€0.40***€0.38 0.57

€0.41

€0.370.57€0.400.41* based on a labour time om 30 seconds of a logistic assistant and a nurse , **based on 100 kidney trays per bag or barrel*** Estimation Central Sterilisation Department of het Ghent University Hospital

In summary, the overall cost of using a reusable kidney tray is generally higher than that of asingle-use kidney tray, mainly due to the cost associated with disinfecting the kidney tray.
5.3.1.5

Efficiency

Availability
There should be sufficient stock on the ward. The single-use kidney tray requires multiple steps for orderingand delivery which are largely administrative: place order, arrival order, items move to storage warehouse,
ward places order, order delivered to ward (Conrardy et al. 2010). In contrast, using reusable kidney trays
demands no supply purchase and inventory process. Either way, sufficient stock space is needed.
Additionally, there should also be sufficient disinfectant material either disinfectant or an automated washingmachine. A consideration regarding thermal disinfection is that a standard nursing unit is not equipped with
an automated washing machine. The most practical and logistically feasible is to have a washing machineon the ward. It is imperative not to charge central sterilisation with supplementary thermal disinfection ofmaterial.
Handling
Handling of a reusable or a disposable kidney dish is fairly identical (See Table 22). The main difference isthe handling after use as already discussed above for single-use (See Sustainability – End of Life) andreusable (see Safety – Infection prevention). This has implication towards time consumption (See below).
A risk associated with using a disposable paper pulp kidney tray is the potential for leakage if moistureremains in the paper pulp kidney dish for an extended period of time (>4 hours).
In general, it is obvious that single-use kidney trays are less robust in comparison to their reusable
alternatives.
Time consumption
Using reusable kidney trays demands addition labour time of the healthcare professional to decontaminate
manually, this is less the case with thermal disinfection. Considering the consumption of kidney trays is high,this will require an extra time investment of approximately 30 seconds per kidney tray.

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54

Table 22: Overview on efficiency of using a reusable and single-use kidney tray

Availability

Single-use
Sufficient stock: supply ordering

Handling

Disposed:- Plastic: NHMW or HMW- Paper pulp: NHMW or HMW or inmacerator

Time-consumption

Time disposal<

Reusable
Sufficient stock
Need for disinfection equipment
Disinfection:- Manual - chemical- Automated thermalTime disinfection
Manual disinfection is more time
consuming for healthcare
professionals than thermal
disinfection

In summary, the efficiency of a single-use kidney tray is advantageous compared to a reusable
kidney tray, primarily due to the time-consuming process of disinfection.

5.3.1.6

Conclusion on kidney trays

Based on the available data, it seems that reusable kidney trays are more environmentally friendly.
However, the method of disinfection has also an environmental impact as well as a large impact on
cost. The safety is comparable, whereas the efficiency might be in favour of the single-use kidney
tray based on the time consumption.

Final report June 2023 – Study single-use materials in medicine and health care55

5.3.2

Blanket5.3.2.1

Description and specification

The Textile Institute defines medical textiles as textile structures designed and produced for use in any of avariety of medical applications, including implantable applications (implantable medical textiles) (The Textile
Institute 2023). Medical textiles can be woven, knitted, braided, or non-woven structures, depending on theapplication and can include both natural and synthetic fibres. Synthetic fibres are predominant in medical
textiles – including 100% synthetic fibres such as polyester and polypropylene – whilst cotton is the mostpopular natural fibre. The type of fibre depends on the specific end-use properties (Health Care Without Harm
Europe 2021b; Martínez-Barbosa and Moreno-Corral 2022). In disposable textiles, often several layers ofdifferent nonwoven fibres are thermally bonded, e.g. SMS (Spunbond/Meltblown/Spunbond) or SMMS
(Spunbond/ Meltblown/Meltblown/Spunbond).
Medical textiles are divided into several categories. Blankets (bedding) are included in the group of healthcare
and hygiene products (Health Care Without Harm Europe 2021b; Martínez-Barbosa and Moreno-Corral2022).
Disposable blankets are generally made from a combination of polypropylene and polyester and reusableblankets from polyester and/or cotton (See Table 23).
Table 23: Most commonly used materials for blankets

Disposable
Polypropylene + Polyester

Reusable
Cotton + Polyester

Cotton5.3.2.2

Sustainability

LCA’s that studied the environmental impact of single-use and reusable blankets were not found. However,there are several LCA’s on other medical textiles such as surgical gowns and isolation gowns (See
Chapter 2). These studies found that reusable textiles gave significant environmental benefits compared tosingle-use textiles (Vozzola et al. 2018a, b, 2020).
Raw materials
The composition of the different types of blankets was extracted from the technical datasheets. In Table 24,
the carbon footprint of each type of raw material is presented. Properties and concerns about medical textiles
and its impact on sustainability are discussed in Appendix 9.11.

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Table 24: CO2 emissions of raw materials of different types of blankets

ReusableSingleuse

Raw material

Polypropylene (50%)
Polyester (50%)
Polypropylene (25%)
Polyester (75%)
Cotton (50%)
Polyester (50%)
Cotton (100%)

CO2 emission(kg CO2 eq/ kg
raw material)
2,27
4,01
2,27
4,01
4,37
4,01
4,37

Weight/blanket(g)

CO2emission/blanket(kg CO2 eq /blanket)

300 g

0,34 + 0,60 = 0,94

332 g

0,19 + 1,00 = 1,19

1950 g4,26 + 3,91= 8,17

1568 g6,85

CO2emission/use(kg CO2 eq/use)
0,94
1,19
0,09**
0,08*** EconInvent 3.8, ** Based on 90 reuses (data from laundry)

Per use, the carbon footprint of the raw materials of a reusable blanket is about one tenth of that ofa single-use blanket.
Manufacturing
The production of blankets (and its packaging) includes- Energy consumption (fabric and blanket manufacturing)- Use of hazardous substances/chemicals e.g. dyes, bleach, flame retardants, …
Based on LCA’s on other medical textiles such as surgical or isolation gowns (Vozzola et al. 2018b, 2020),
manufacturing reusable blankets requires an increased energy consumption due to the weight difference andthe increased energy requirement of woven textile processes. However, the number of times the blanket canbe reused must be taken into account.
Transport
The environmental impact of transport depends on fuel type (electricity, fuel, biofuel,… ), the mode oftransport (road, rail, shipping,...), vehicle type (size of truck,…) and the distance (Rondaij and Spreen 2020).
The environmental impact of transport is not further explored because of the lack of data.
Use / Reuse
The major difference in the life cycle of reusable and disposable blankets is that reusable blankets arelaundered after each patient use. The laundry process consists generally of a prewash, main wash, rinse,
spin or pressing, drying and packaging. This process must be sufficiently disinfecting so that all pathogenic
microorganisms responsible for healthcare-associated infections are eradicated (Hoge Gezondheidsraad2018) (See Safety – Infection prevention).
The Belgian Superior Health Council defined physical criteria for reusable linen. Namely, the mechanicalwear is compatible with an average lifetime of the textile of at least 100 washes. A maximum of no more than
15% of the textile is lost at the end of use (Hoge Gezondheidsraad 2018).
According to Martinez-Barbosa and Mereno-Corral (2022), reusable garments generally can be used for 50
or more washing and drying cycles (Martínez-Barbosa and Moreno-Corral 2022). The number oflaundering/drying cycles is sometimes suggested by the manufacturer, e.g. for the cotton (50%) and polyester
blanket (50%) it is 90 times. Some fibres are more durable than others: polyester or a polyester/cotton mix
can survive more laundry cycles than 100% cotton (Watson and Fisher-Bogason 2017).
The laundry process of reusable blankets has the largest environmental impact of its life cycle (Kofoworola
et al. 2020) due to following processes:- Energy consumption (electricity, gas, …) / GHG emissions• The weight of the blanket differentiate the overall energy consumption.
• Type of energy- Water consumption- Chemical consumption (laundry products: e.g. phosphate-free surfactants, enzymes, oxidants,
optical brighteners, solvents and disinfectants): emissions to water.

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-

Washing may release microplastics when using synthetic fibres into wastewater (Health Care Without
Harm Europe 2021b).
Transport (external laundry)

Waste
A single-use blanket and its plastic packaging will normally be disposed of as NHMW and is incinerated(OVAM 2021). The size of the blanket determines the volume of waste.
Since single-use blankets consist of different types of material (PP, polyester), recycling is not possible.
In summary, the environmental impact of single-use textiles will be the highest during the production
and disposal phase, while for reusable the impacts will be towards the (re)use phase (= laundry). As
with reusable gowns, the environmental savings reached from producing fewer blankets compensate
the additional burden of the laundry process.
5.3.2.3

SafetyInfection prevention
Single-use
The use of a new single-use blanket contains no risk of transmission of microorganisms.
Reusable
Blankets are replaced and washed after every patient discharge and, in case of long-term admission, e.g.
weekly. All textiles visibly soiled with body fluids or blood are replaced immediately. Good practice for proper
linen handling, such as the frequency of replacement has been described before (Hoge Gezondheidsraad2018).
The laundry is preferably done by the use of thermal decontamination. An A0 value, which is a physicalparameter denoting the inactivation of microorganisms (Röhm-Rodowald et al. 2013), of at least 600 is
required . If the value is not met, chemical disinfection during the washing process is necessary in order toachieve this requirement (Hoge Gezondheidsraad 2018).
The Belgian Superior Health Council advises the laundry management to function according to the European
RABC standard NBN EN 14065 which describes how the laundry can guarantee the microbiological quality
and safety of the linen. The total number of microorganisms on the ready-to-use textile must be less than 12
CFU (colony forming unit) per 25 cm2 (AFNOR standard - France; NBN EN 14065) (Hoge Gezondheidsraad2018).
Occupational safety
Commonly, handling a blanket involves no or minimal risk to the healthcare professional. Though, when bloodor body fluids are involved, there is biological risk. These risks are identical when using reusable as well as
disposable blankets.
Biological risk
When a blanket is soiled with blood or body fluids, there is a well-known occupational risk and must be
handled accordingly. Therefore, gloves are advised (European Commission. Directorate-General for
Employment, Social Affairs and Inclusion 2011; Hoge Gezondheidsraad 2014).
Chemical risk
Professionals working in a laundry must be careful with laundry disinfectants which often have corrosive or
irritant properties, and in addition they may act to sensitise skin or respiratory tracts (European Commission.
Directorate-General for Employment, Social Affairs and Inclusion 2011). When in contact with these
disinfectants protective personal equipment is advised (gloves, respiratory mask, goggles).
In summary, the patient safety and occupational safety of a single-use and a reusable blanket are
similar.

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5.3.2.4

Cost

Purchase cost
Depending on size, composition and supplier, the purchase cost of disposable blankets may vary (SeeTable 25).
Reuse cost
Because of the strict regulations and conditions for a laundry, most hospitals outsource their laundry processfor (bed) linen. In practice, a lease is often agreed with a rental price per item for the hospital (See Table 25).
Table 25: Purchase/rental cost (including VAT) per type of blanket (per piece/use)

Polypropylene +polyesterSingle-use
Per piece€2.50 - €7

Reusable
Per useCotton + polyester€ 2.30 - €3.50

If a hospital itself has a laundry the reuse cost includes energy, water use, cost of the employees, andassociated costs. Then, the purchase cost of a blanket needs to be divided by the number of uses during the
lifetime of a blanket.
Waste cost
A single-use blanket will normally be disposed of as NHMW. Since blankets are very bulky, they take up a
lot of space in the waste bag. The waste cost is presented in Table 26.
Table 26: Overview total cost (including VAT)

Purchase cost / pieceLaundry cost / piece
Waste cost / piece
Cost bag / piece
TOTAL

Single-use€2.50 - €7

Reusable€ 2.30 - € 3.50

€0.06
€ 0.08*€2.64- €7.14€2.30 – 3.50

*based on 2 blankets per waste bag

Reusable blankets are packaged in plastic (e.g. per 5, 10 or 20), while single-use blankets are packaged inplastic per blanket and in cardboard (e.g. per 20, 50 or 100 blankets). As this depends on the laundry(reusable blankets) or company (single-use blankets) no uniform data were available. In general, thepackaging waste will be more for single-use compared to reusable blankets. The cost to discard the
packaging materials is not taken into consideration.
The total cost to the hospital is more expensive for a single-use blanket than for a reusable one.
5.3.2.5

Efficiency

Availability
Both types of blankets require an ordering and delivery procedure from either a laundry or medical equipment
supplier. In both cases, sufficient stock space is needed. Note that reusable blankets take up more spacethan disposable blankets, considering their volume and packaging method (See Table 27).
Handling
The ease of use of blankets is similar. When comparing reusable versus single-use medical garments,
reusable healthcare garments come out on top because reusable medical textiles meet the same safety
standards and are more comfortable than their disposable counterparts (Martínez-Barbosa and MorenoCorral 2022).
The handling of the blankets is quite identical. After use, a reusable blanket is thrown into the linen bag, whilea single-use is discarded with the medical waste (NHMW). Both are picked up by logistic staff.

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Time consumption
If the laundry process is outsourced, there will be similar time consumption for both options. Namely, a
reusable blanket is thrown into the linen bag and then picked up by the logistics service, while a single-use
is discarded with the medical waste (NHMW).
If the hospital has its own in-house laundry, a large time investment has to be taken into account. Then, allsteps of the laundry process are done by the hospital itself: sorting, prewash, main wash, rinse, spin orpressing, drying and packaging.
Table 27: Overview on practical matters of using a reusable and single-use blanket

Single-use
Availability
Handling
Time consumption

Reusable
Sufficient stock: supply ordering
Disposed as waste
Disposed in linen bag - and washed in(external) laundry
Time disposal waste bag = or <Time disposal linen bag
Hospital in-house laundry: large time
investment

In summary, the efficiency of a single-use or a reusable blanket is comparable. If a hospital has its
in-house laundry, then the time investment required for the laundry process must be taken into
account.
5.3.2.6

Conclusion on blankets

In summary, sustainability and cost favour the use of reusable blankets. Safety and efficiency are
similar, unless the hospital has its own laundry. If the hospital has its own laundry, the efficiency isless favourable.

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5.3.3Vessel sealing device

5.3.3.1

Description and Specification

Laparoscopic surgery, as a minimally invasive treatment, has experienced rapid growth. Accurate
haemostasis, the process of preventing and stopping bleeding, is of utmost importance in laparoscopy, as
bleeding can quickly compromise the working environment conditions. The sealing of blood vessels is
effected by application of, for example, controlled radiofrequency energy while the vessel is compressed, andthe vessel is cut via movement of a knife under a consistent shear. The most frequently employed vessel
sealing devices are bipolar devices (consisting of an active electrode and a return electrode into a single
electrosurgical instrument with two small poles) or ultrasonic devices. Bipolar vessel sealing devices typicallyutilise electric current (occasional a battery), while ultrasonic devices employ high-frequency vibrations(Hasanov et al. 2018; Kawaguchi et al. 2020).

Examples of a single-use vessel sealing devices
The surgical devices are complex and diverse. Various sealing devices are available with differences inparameters such as shaft length, shaft rotation, seal plat length, cut length, seal plate width, etc. A reusabledevice comes often with disposable blades.
Two studies compared a new reusable vessel sealing device with a conventional standard single-use device.
The studies were not LCA’s, but rather focused on efficacy and costs. In an older study, Klar et al (2011)
conducted a prospective animal study to compare the efficacy of sealing time, failure rate, and burst pressure
between a new reusable vessel sealing device and a conventional standard disposable vessel sealing device(Klar et al. 2011). Kawaguchi et al. (2020) compared in a retrospective study a single-use and a reusable
vessel sealing device in modified total neck dissections at a Japanese hospital, with focus on haemostasis,
surgical time and medical expenses. No LCA’s comparing the environmental sustainability of single-use andreusable vessel sealing devices were available.
5.3.3.2

Sustainability

Raw materials
Vessel sealing devices are complex and primarily composed of a combination of metals (e.g. titanium,
stainless steel) and plastics (e.g. poly(phenyl sulfone, poly(tetra fluoro-ethylene (PTFE), polycarbonate,polyamide) as depicted in the figure below (Yung et al. 2010). Some single-use devices have single-use
transducer cables, while other cables are sterilisable. Due to the lack of information provided in data sheets
and companies’ reluctance to disclose the exact composition of these devices, it was not possible to provide
a comprehensive overview of all the raw materials included and their associated CO2 emissions .

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61

Example of various parts ofa vessel sealer/cutter (Vanguard 2023)
From studies conducted on analogue medical devices, such as surgical staplers and clip appliers, it is highly
probable that reusable vessel sealers devices are more sustainable (Meissner et al. 2021; Rizan and Bhutta2022) (See Chapter 2).
Transport
The environmental impact of transportation is influenced by factors such as the fuel type used (electricity,
fuel, biofuel, etc.), the mode of transport (road, rail, shipping, etc.), the type of vehicle type (size of truck, etc.)
and the distance travelled (Rondaij and Spreen 2020). The primary contributor to the environmental impact
is the use of fossil fuels.
Exploration of the environmental impact of transportation is limited due to a lack of available data.
Use/reuse
A reusable vessel sealer can generally be reused 50 times, as warranted by the manufacturer (Kawaguchi
et al. 2020). The device requires a sterilisation process including cleaning, thermal washing/disinfection, andsterilisation (See Safety – Infection prevention).
Another option is to remanufacture the single-use vessel sealer. Medical remanufacturing can restore a usedsingle-use medical device to its original functional and safety standards, with a matching warranty (Vanguard2023). This process involves disassembly and assembly steps, cleaning, decontamination, testing andsterilisation (Schulte et al. 2021; Rizan et al. 2022a). After remanufacturing, the vessel sealer can be reused
for a limited number of cycles.
In Europe, remanufactured medical devices must comply with CE certification and meet the requirements of
the Medical Device Directive 93/42/EEC (Schulte et al. 2021).
Remanufacturing electrophysiology catheters is a well-established process that ensures equal quality
compared to newly produced catheters. An LCA study revealed that using remanufactured catheters reduced
the global warming impact by 50.4% compared to single-use catheters (Schulte et al. 2021). Similarly, in their
LCA Meister et al (2023) calculated a reduction of 60% (Meister et al. 2023).
Remanufacturing requires cleaning, disinfection and sterilisation before reusing (ethylene oxide sterilisation
for remanufactured and steam sterilisation for reusable vessel sealers). No data were available in theliterature on the ecological impact of this sterilisation process for reusing vessel sealers.
Remanufacturing of these medical devices takes place outside Belgium. It is allowed to transport used vessel
sealers to the company provided the devices are correctly packed and labelled according to the conditions
mentioned in the European Agreement concerning the International carriage of Dangerous Goods by Road
(ADR) (United Nations Economic Commission for Europe 2022).

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WasteSingle-use vascular sealing devices are disposed as hazardous medical waste, requiring high-temperatureincineration.
Both single-use and remanufactured vessel sealers involve significant packaging, including hard plastic
protection and a cardboard box. Unger and Landis (2016) concluded that the high levels of polyethylene in
the single-use vessel sealing device and its packaging contribute significant to environmental impacts (Unger
and Landis 2016).
In summary, using reusable or remanufactured vessel sealers is more beneficial for the environment
than using single-use vessel sealers.
5.3.3.3

SafetyInfection prevention
Since a vessel sealing devices comes into contact with sterile body tissues or the vascular system, it isconsidered a critical item according to the Spaulding classification and needs to be sterile (Rutala et al. 2008).
Single-use
The use of a single-use sealing device carries no risk of microorganisms transmission as the device issterilised by the manufacturer, often using ethylene oxide.
Reusable
To reuse a vessel sealer, the device requires a sterilisation process. In the central sterilisation department,
the reusable vessel sealing device undergoes cleaning including an ultrasonic bath, thermal disinfection in
the washing machine, and steam sterilisation. However, the complex structure and multiple parts of thevessels sealer make cleaning challenging. Additional auxiliary tools, such as single-use cleaning brushes,
may be necessary. Moreover, the cleaning process is performed manually because the use of a washingmachine may not provide sufficient contact between the water, disinfecting products, and the device as
demonstrated by Chivukal (2021) (Chivukula et al. 2021).
As a rule, the reprocessing of reusable and the remanufacturing of devices occurs under highly controlled
strict standard conditions in the central sterilisation departments or in the medical remanufacturers
compagnies. Consequently, if the reprocessing process is caried out properly, there is no risk of microorganism transmission.
Occupational safety
Biological risk
As the vessel sealing device comes into contact with blood during the surgical procedure, there is a potential
occupational risk associate with its handling. This risk applies for the different types of vessel sealers.
This risk persist for a longer duration with reusable devices, as they need to be transported to andmanipulated in the central sterilisation department. Transportation process itself involves no risk, as thedevice needs to be collected in a closed transportation box. For the manipulation in the central sterilisation
department, the professionals need to wear PPE (protection gown, gloves, goggles, mask) when manualdisassemble and clean the device to protect them from splash accidents (European Commission. DirectorateGeneral for Employment, Social Affairs and Inclusion 2011).
Chemical risk
There is a possible chemical risk when using disinfectants. Instrument disinfection may lead to inadmissibleindoor air concentrations if manual disinfection is applied, and also with ultrasonic baths cleaning. Therefore,
the use personal protective equipment, such as respiratory mask, is indicated (European Commission.
Directorate-General for Employment, Social Affairs and Inclusion 2011).
In summary, if the cleaning and sterilisation process is performed properly. the patient safety of using
single-use, reusable or remanufactured vessels sealers is comparable. Regarding occupationalsafety, personal protective equipment is required for the sterilisation process.

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5.3.3.4 Cost
Klar et al. (2011) found that the cost for a single-use vessel-sealing device was $500, while the cost for areusable instrument was $130. Another study on small vessel sealing devices compared a reusable, costing$240 per operation, to a single-use costing $1000 (Kawaguchi et al. 2020). However, both studies did notinclude the cost of cleaning and sterilisation of the reusable vessel sealing device, but did include the cost of
single-use blades in the reusable device.
Hasanov et al. (2018) calculated a cost of approximately €420 for a single-use and €182 for a reusable vessel
sealer, including the cost of disposable blades (€98 per blade) and the cost of cleaning and sterilisation (€10
per procedure).
Yung et al (2010) compared the costs of a reusable ultrasonic shear (including purchase price of 4 shears,
number of uses, manual cleaning, sterilisation costs) to a single-use ultrasonic shear (including purchaseprice of 85 shear and reprocessing cost transducer cable). Based on their data (using a shear for 85 cases),the cost for one use of the reusable ultrasonic shear was $280, while the cost for the single-use was $384.
Purchase cost
The cost data are presented in Table 28.
Remanufactured medical devices are estimated to be up to 50% cheaper than new single-use ones.
Additionally, the hospital receives compensation for each collected functioning vessel sealer that can beremanufactured (Vanguard 2023).
Reuse cost
The cost of reuse includes sterilisation expenses (See Table 28), which can vary depending on the study andmay encompass labour costs (disassembly, cleaning, reassembly) as well as energy costs. In certain studies,
additional costs associated with reuse, such as repair and maintaining expenses, are also taken into account.
Waste cost
Single-use vascular sealing devices are discarded as HMW. Based on an average cost for HMW (€ 780 perton), the waste cost related to one device (+/- 300 gr) is €0.21 (waste barrel not included). The waste cost
per piece is stated in Table 28. It should be noted that a single-use vessel sealing device involves
considerable packaging: cardboard box and hard plastic protection (Unger and Landis 2016). The cost to
discard the latter is not taken into consideration.
Table 28: Overview total cost

Purchase cost

Single-use€500 - €700

Reusable€120-170 €**Remanufactured€250-350(including disposable blades)

Waste cost (HMW)/piece€0.21

Cost waste barrel/piece*€0.7-€0.9€10-€30 ***Total sterilisation cost
TOTAL

- € 5-€10+€501-701€130–200**€240-345* Based on 10 vessel sealers per barrel**Reusable vessel sealers (€3700 - €4900 per device and €33 - €100 per disposable blade) can be used (minimum) 50 times(Hasanov, 2018; Klar, 2011) -> +/- €120 - €170 per use*** Based on Hasanov, 2018, Rizan et al. 2022 and calculation Ghent University Hospital+ The hospital receives an amount of money per functioning devices (estimation €5-10)

It can be concluded that reusing a vessel sealer generally results in cost savings compared to using
a single-use vessel sealer. However, it is important to ensure that when comparing two devices, thatthey are of the same type and have the same functions.

Final report June 2023 – Study single-use materials in medicine and health care64

5.3.3.5

Efficiency

Availability
Both types of vessel sealing devices require an ordering and delivery procedure from either the central
sterilisation department or medical equipment supplier. However, the single-use and remanufactured device
require a few more steps than the reusable device such as placing order to supplier, arrival order, items moveto the storage operating room (Conrardy et al. 2010). Either way, sufficient stock space is needed. A sufficientnumber of reusable instruments, transducers (or loaded batteries) are needed so that the required ready-touse vessel sealers are available (Conrardy et al. 2010).
Handling
After use, the reusable vessel sealing devices is collected in a washable container and transported to thecentral sterilisation department, while a single-use device is discarded as HMW. Single-use devices that will
be remanufactured are also collected separately and undergo a separate logistic process.
Time consumption
A single-use vessel sealer is discarded as HMW, while a reusable is collected into a container and thenpicked up by the logistics service. Using a reusable vessel sealing device requires thorough washing,disinfection, packaging and sterilisation which implies additional labour time of the hospital (Kawaguchi et al.
2020). This demands an extra time investment from the central sterilisation department.
A vessel sealer used for remanufacturing should to be collected and labelled separately and is send to thecompany.

Table 29: Overview on practical matters of using a reusable and single-use vessel sealing device

Availability

HandlingTime
consumption

Single-use
Sufficient stock: supply
ordering- More administration- More space needed
Disposed as hazardous
medical waste
Time disposal waste bag <Reusable
Sufficient stock: supply
ordering- More space needed
Collected in transport
container
Time sterilisation process

Remanufactured
Sufficient stock: supply
ordering- More administration- More space needed
Collected and labelled inseparate transport container
Time to collect, label andsend

In summary, the most efficient alternative is the single-use vessel sealer due to its disposal afteruse, eliminating the need for disinfection.
5.3.3.6

Conclusion

Using reusable vessel sealers or remanufactured is more beneficial for the environment. Patient
safety is comparable if cleaning and sterilisation is adequately completed. Using reusable andremanufactured vessel sealers is cost saving. The efficiency is in favour of the single-use sealer
because of the time investment for sterilisation and the separate collecting process forremanufactured devices.

Final report June 2023 – Study single-use materials in medicine and health care65

5.3.4

Cover caps for thermometers

5.3.4.1 Description and Specification
The use of cover caps is standard when non-invasive tympanic (ear) thermometers are used. These covercaps were found to account for a large proportion of single-use material consumption in Belgian hospitals(See Chapter 4). Although some of the cover caps are made from rigid plastic and could allow multiple use
in the same patient, no reusable cover cap alternatives are available on the market for use between different
patients.
Therefore, searching for more sustainable alternatives for single-use cover caps in tympanic thermometersneeds to include the comparison with other thermometers available on the market. For this item we will focus
on the additional material needed to use several types of thermometers in different patients.
In addition to tympanic thermometers, axillary thermometers, temporal thermometers, and frontal non-contact
thermometers are available (Cutuli et al. 2018). In this section, we will focus on non-invasive temperature
measurement and the additional materials needed to use them in different patients (See Table 30).

Example of a cover cap

Table 30: Overview of types of thermometers for non-invasive measurement

Ear/tympanic

Axillary thermometer

Temporal scanner

Frontal non-contact

Remote ear thermometers,also called tympanic
thermometers, use an
infrared ray to measure thetemperature inside the ear
canalTemperature measurementin the armpit, or rectal. The
latter is the most usedmethod for temperature
measurement in infants andchildren.

Remote forehead
thermometers use an
infrared scanner to measure
the temperature of thetemporal artery in theforehead.

Remote thermometer basedon infrared energy radiatedfrom the forehead as well as
objects, to measure bodytemperature and surface
temperature.

5.3.4.2

Sustainability

No LCA’s on the environmental impact of the use of cover caps in the measurement of body temperature,
nor a comparison of the environmental impact of different thermometers were available. We will focus on theuse of extra materials needed for using the different systems (see overview below - Table 31), rather than on
the different types of thermometers itself.

Final report June 2023 – Study single-use materials in medicine and health care66

Table 31: Materials needed to (re)use thermometers

Ear/tympanic

Materials
neededfor reuse

Axillary thermometer

Temporal scanner

Frontal noncontact

Cover cap for every
use.

Disinfection (wipe)
between two patients

Disinfection (wipe) afteruse

No additional
materials are needed
for general use(Patient- specific useof cover cap may bepossible for some
types of cover caps)(Plastic cover is available,
but rarely used)(Patient – specific use ispossible)

The raw materials of the supplementary items needed when using the various thermometers with different
patients are shown in Table 31 above.
Raw materials
Table 32: CO2 emissions of raw materials of different types materials needed to (re)use thermometers
Raw material

CO2 emission (kg CO2
eq/ kg raw
material) *Weight/cover cap orwipe (g)CO2 emission/use(kg CO2 eq/ kg raw
material) *

2,45

0.40g

0.001

2,29

1.42g

0.003

Cotton4,37

1.00g **

n-alkyl dimethyl ethylbenzyl
ammonium chloride

Not available

0.02 g**Wipe

Cover cap

Type 1: low
densitypolyethylene(LDPE)
Type 2:polyethylene (PE)

Isopropanol Isopropanol

0.16**

2.3 g*** EconInvent 3.8; ** Based on (Sanchez et al. 2020)
LDPE: Low density polyethylene; PE: Polyethylene

From Table 32, the use of a wipe gives a carbon footprint more than 53 times the carbon footprint of the raw
materials needed for a cover cap. When using a non-contact thermometer no additional materials are needed.
Manufacturing
The production of cover caps and wipes should include the manufacturing of the caps and wipes, as well as
the manufacturing packaging. Energy consumption during manufacturing, and use of hazardous
substances/chemicals e.g. disinfectant, flame retardants,…
Transport
The environmental impact of transport depends on fuel type (electricity, fuel, biofuel,… ), the mode oftransport (road, rail, shipping,...), vehicle type (size of truck,…) and the distance (Rondaij and Spreen 2020).
The environmental impact is mainly due to the use of fossil fuels. This is not further explored because of thelack of data.
Use / Reuse
See item raw materials where the reuse of the items was included.
When a disinfection wipe is used to disinfect the thermometer between two patients, the environmental impactof the life cycle of a disinfection wipe needs to be taken into account. Based on the LCA study of Sanchez etFinal report June 2023 – Study single-use materials in medicine and health care67al. (2020), the carbon footprint of manufacturing a disinfection wipe consisting of 1g of cotton substrate withactive ingredient n-alkyl dimethyl ethylbenzyl ammonium chloride and isopropyl alcohol, was calculated to be
0.16 kgCO2eq per wipe, and the disposal (incineration) impact was calculated to be at 0.039 kgCO 2eq per
wipe. This results in a total emission of 0.20 kgCO2eq emission per wipe (Sanchez et al. 2020).
Waste
A cover cap and wipe can both be disposed of as NHMW.
Although not the focus of this item (the use of cover caps), an additional concern when using thermometersis that they all contain batteries. The batteries need to be removed and the thermometers need to be disposed
as electronic device. Manufacturers need to pay attention to the design of the thermometers so batteries caneasily be removed before disposal.
In summary, the most sustainable option is when additional materials or items can be avoided toreuse a thermometer for different patients.
5.3.4.3

SafetyInfection prevention
To reuse a thermometer for different patients, low level disinfection can be needed, depending on the type ofthermometer. According to the Spaulding classification, a thermometer is ranked as a non-critical item,
meaning that it comes into contact with intact skin. Normally, it is not soiled with body fluids. Potential infection
prevention risks and handling is summarised in the overview below (See Table 33).
Table 33: Overview infection prevention risks and handlingContact

Handling&
DisinfectionneededEar/tympanic

Axillary thermometer

Temporal scanner

Frontal non-contact

Contact with intact skinContact with intact skin

Disinfection wipe after use

No contact with body
fluids, nor intact skin.

Can be soiled by earwax

When used in the groin area:
contact with body fluids suchas sweat, urine and faeces ispossible
Disinfect between patients(regardless of use of sleeve)

Can be soiled by sweat

Use over cover cap

Only regular disinfectionneeded in accordance withhospital guidelines (every
shift/daily/weekly)*not included in analysis

Disinfect between patients

Sleeves available (PE film, PE
laminated paper)*Only regular disinfectionneeded in accordance withhospital guidelines (every
shift/daily/weekly)

Occupational safety
Biological risk
For healthcare professionals, no additional risks were associated with the use of thermometers, cover caps
or wipes. When contact with body fluids (urine, faeces) is possible for example when axillary thermometers
were used in the groin area, gloves are indicated (Hoge Gezondheidsraad 2014).
Chemical risk
As stated in the other items, there is a possible chemical risk when using disinfectants, such as wipes.

In summary, thermometers that do not come into contact with the patient pose the least risk
concerning infection prevention. There are no significant occupation safety issues.
5.3.4.4 Cost
The total cost consists of the purchase cost of the thermometer, divided by the number of uses, and summed
up with the reuse cost. The latter consisting of the purchase cost of additional materials and the labour costneeded for reuse.

Final report June 2023 – Study single-use materials in medicine and health care

68

Purchase cost
Depending on size, composition and supplier, the purchase cost of thermometers may vary (See Table 35).
The cost per use will depend on the lifetime of the device, which depends on how long it functions and how
quickly it is lost. The latter, is a common issue for axillary thermometers.
Reuse cost
The reuse cost consists of use of cover caps or disinfection needed between use. In the interests ofcomparability, we assumed disinfection after every use, if needed by the type of thermometer or a new covercap after every use. Periodic disinfection, aside from disinfection between patients, was not included.
Table 34: Purchase and use cost (including VAT) per type of thermometer

Purchase costof thermometer
Material
needed toreuse
Cost per use
Labour time(seconds)
Labour cost $Total purchaseand use cost

Ear/tympanic

Axillary thermometer

Temporal scanner

Frontal non-contact€217.4 – €313.4**€5.37 - €10.64€251 - €437**€61.4 – €112.5**

Cover cap
€0.17 - €0.23

Wipe€0.06 – €0.16

Wipe€0.06 – €0.16-€ 0.176 – € 0.239
10€ 0,061 – € 0.162
30€ 0.067 - € 0.1730

€ 0.002 – € 0.003-€ 0.13€ 0.31 – € 0.37

€ 0.40€ 0,46 – € 0.56

€ 0.40€0,47 – € 0.57

€ 0.002 – € 0.003*Based on 7120 uses/1 year (1 years of guarantee * 365 days * 2 measurements per day * 10 patients) **Based on 35600 uses/5 year
(5 years of guarantee * 365 days * 2 measurements per day * 10 patients)$ As data were from 2012, results have been indexed by a factor of 1.3076 (wage index March 2012= 1.5769, wage index June 2022
1.8845) or €47.46 /h

Waste cost
A cover cap and wipe can be disposed of as NHMW. Despite new waste directives, caps will not be able tobe recycled because medical devices that came into contact with the patient, are not allowed in PMD.
Table 35: Waste cost (including VAT) related to materials needed for reuse

Type of waste
Weight per piece
Cost waste weight per piece
Cost per bag (100L)
Cost bag per piece
Total waste cost

Cover cap
NHMW
PMD
0.40-1.42g
0.40-1.42g
0.000080.000080.0003
0.0003€ 0.15€ 0.3<0.00001<0.00001
0.000080.000080.0003
0.0003

Wipe
NHMW
1g*
0.0002€ 0.150.000075
0.00028* Based on (Sanchez et al. 2020); ** 2000 wipes per bag

The overall cost per use was lowest for non-contact thermometers, the overall cost per use was highest forthermometers using cover caps, due to the high cost of the caps which was almost four times higher than theuse of wipes (Table 35). Waste cost per piece/per proved negligible (<0.001) due to the low weight andvolume of cover caps and wipes.
In summary, from a financial perspective the most interesting option is when additional materials or
items can be avoided to reuse a thermometer for different patients.

Final report June 2023 – Study single-use materials in medicine and health care69

5.3.4.5

Efficiency

Availability
Cover caps and wipes require an ordering and delivery procedure from either the medical equipment supplieror the pharmacy department, respectively. Stock space needed for cover caps is less than for disinfection
wipes.
Handling and comfort of use
Axillary and temporal measurements require disinfection after every use (every patient), therefore wipes orother disinfection materials need to be available and discarded. Tympanic measurement requires the discardof a used cover cap and availability of a new one. The use of non-contact thermometers require no materials
for reuse.
The handling of the thermometers is quite identical, only no touch thermometers require no contact with thepatient (less disturbing for patient when e.g. sleeping).
Time consumption
Options where disinfection is needed, are the most time consuming followed by the use of cover caps.
Thermometers where no additional actions are needed are the least time consuming, but differences arelimited.
In summary, the most efficient alternative is when additional materials or items can be avoided toreuse a thermometer for different patients.
5.3.4.6

Conclusion on cover caps

The use of cover caps for tympanic temperature measurement was found to be less costly and moresustainable than when disinfection (one wipe/use) was needed between patients (axillary andtemporal scanner). Temperature measurement requiring no disinfection or additional equipment to
be used in different patients, such as non-contact thermometers, proved to be the cheapest, mostsustainable, safest and most efficient alternative.

Final report June 2023 – Study single-use materials in medicine and health care70

5.3.5

Vaginal speculum

The parameters safety, costs and efficiency of a vaginal speculum were described hereafter to beconsistent with the other items. The item sustainability was studied through a life cycle analysis andpresented in a separate chapter (Chapter 6).
5.3.5.1

Description and Specification

A vaginal speculum is a semi-critical medical instrument for insertion into the vagina, used to perform agynaecological examination, for the removal of smears, and further introduction of instruments into the uterus.
Reusable and disposable specula are frequently used in healthcare. Hospitals as well as outpatient clinics
and general practitioners are performing pelvic examinations.

Example of a reusable vaginal speculum

Example of a single-use speculum

5.3.5.2 Sustainability
An LCA was performed to evaluate the environmental impact of the use of reusable compared to single-use
vaginal specula during a pelvic examination. This is reported in detail in Chapter 6: Life Cycle Analysis of avaginal speculum.
5.3.5.3

SafetyInfection prevention
Single-use
The use of a new single-use speculum contains no risk of transmission of microorganisms.
The single-use specula used by the Belgian hospitals that participated in our hospital survey (See Chapter 4)
were sterilised with ethylene oxide by the manufacturer. Sterilisation by ethylene oxide is an alternative forsteam sterilisation if materials are not resistant to high temperature. In addition, there are specula on themarket that meet cleanroom criteria, which is sufficient for contact with mucous membranes. Those specula
are also commonly used in hospitals in Belgium and The Netherlands.
Reusable
To reuse a stainless steel vaginal speculum, cleaning and subsequent high level disinfection is required.
According to the Spaulding classification, a vaginal speculum is ranked as a semi-critical item since it comesin contact with mucous membranes (Rutala et al. 2008). Furthermore it is contaminated with body fluids afteruse. Therefore vaginal specula undergo a thermal disinfection, and are subsequently sterilised. Although
high-level disinfection is theoretically sufficient, sterilisation is mostly done in daily practice.
Occupational safety
Vaginal specula are soiled with blood and/or body fluids after use. Therefore, they pose a biological risk.
Further, disinfection and sterilisation of a speculum may involve a minor chemical risk for central sterilisation
department staff.
Biological risk
A used speculum must be handled as if it is infectious. Therefore, wearing gloves is advised during use until
they are discarded as waste or collected for transport to the central sterilisation department (European
Commission. Directorate-General for Employment, Social Affairs and Inclusion 2011; Hoge Gezondheidsraad2014).

Final report June 2023 – Study single-use materials in medicine and health care71Chemical risk
There is a possible chemical risk when using disinfectants. To reduce the chemical risk, the use of thermal
procedures is preferable to chemical disinfection and automated procedures are preferable to manual
disinfection. In case of manual disinfection, gloves are indicated (European Commission. Directorate-Generalfor Employment, Social Affairs and Inclusion 2011).
There is a possible chemical risk when using disinfectants (see item kidney tray), but procedures in the central
sterilisation unit are already in place to avoid a chemical risk.
In summary, no relevant differences between both alternatives concerning safety (patient andoccupational) were present.
5.3.5.4

Cost

Purchase cost
Depending on size, composition and supplier, the purchase cost of disposable and reusable specula mayvary (See Table 36).
The cost per use of reusable specula will depend on the lifetime of the device. This will be further discussed
in the LCA (see Chapter 6). Items in stainless steel are, in principle, almost impossible to break down, but
for reasons of uniformity with the LCA (See Chapter 6) a lifetime of 500 uses is taken into account tocalculate cost per use.
Reuse cost
The reuse cost consists of the cost to clean, thermal disinfect, package, and sterilise the speculum.
Table 36: Purchase and reuse cost (including VAT) per type of speculum (per piece/use)

Purchase cost per piece
Purchase cost per use
Packaging (double)

Single-use€0.74 - €1.33€0.74 - €1.33-

Reusable€ 15.00 - € 49.69€ 0.03 - €0.10€ 0.10 - € 0.28

Labour cost of reuse
Total cost

€ 0.74 - €1.33€ 0.78*€ 0.91 - € 1.16

*based on measurements staff central sterilisation department Ghent University Hospital

Waste cost
A single-use speculum can be disposed of as NHMW. Reusable specula could be recycled, but in practice
it is disposed of as HMW.
Table 37:Waste cost (including VAT) per type of speculum

Type of waste
Weight per piece
Waste cost per piece
Waste cost per use
Cost per container(100L)
Cost per piece/use
Cost per bag (100L)
Weight of paper
packaging/piece
Cost of paper packaging/piece
Weight of plastic
Cost of plastic
TOTAL waste cost per use

Single-use
NHMW
34.4-39.9 g€ 0.007 – € 0.008€ 0.156.08 gReusable
HMW
179.0 g
€ 0.14€ 0.00028€7-€9€ 0.00007 - € 0.00009*€ 0.1510 g

0.23 g< € 0.0001€ 0.007 – € 0.008

8g€ 0.001€ 0.00135 - € 0.00137-*Based on 200/container or bag and a lifespan of 500 uses for a speculum

The waste cost is higher for single-use compared to reusable, due to the long lifespan of these reusable
materials (Table 37).

Final report June 2023 – Study single-use materials in medicine and health care72

Table 38: Total cost (including VAT) per type of speculum per use

Purchase & reuse
Waste
TOTAL

Single-use€ 0.74 - €1.33€ 0.007 – € 0.008€ 0.75 – € 1.34

Reusable€ 0.91 - € 1.16
€ 0.0014€ 0.91 – € 1.16

In summary, the cost of a single-use and reusable speculum are similar, and can be more or lesscostly compared to reusable depending on how competitively priced the single-use specula are(Table 38).
5.3.5.5 Efficiency
Availability
Both types of vaginal specula require an ordering and delivery procedure from either the central sterilisation
department or medical equipment supplier. Either way, sufficient stock space is needed. Note that reusable
specula take up more space than single-use specula, due to their packaging.
Handling and comfort of use
The handling is quite identical, with small differences . Reusable specula are more robust to use and no parts
will break off, furthermore they are available in more different types and shapes. On the other hand, singleuse specula are more comfortable for the patient (less cold), often transparent which facilitates observation,and the different types are easily recognisable (different colours).
After use, a reusable speculum is collected in a washable container and transported to the central sterilisation
department, while a single-use speculum is discarded as NHMW, or by some practitioners as HMW. Bothare picked up by logistic staff.
Time consumption
In both options, there is an equal time consumption in use. A reusable speculum is collected into a container
and then picked up by the logistics service, while a single-use is discarded with the medical waste(NHMW/NHMW). Time consumption of hospital personnel to clean, disinfect, package and sterilize reusable
specula is included in the cost part of this item.

5.3.5.6

Conclusion for vaginal specula

In summary, cost and safety of single-use versus reusable specula were comparable, whereas
efficiency may be in favour of single-use devices due to the time investment for sterilisation.

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6

LIFE CYCLE ANALYSIS (LCA) OF VAGINAL SPECULUM

6.1

Background literature

A vaginal speculum is a semi-critical medical instrument for insertion into the vagina, used to perform agynaecological examination, for the removal of smears, and further introduction of instruments into the uterus.
Reusable and disposable specula are frequently used in healthcare. Hospitals as well as outpatient clinics
and general practitioners are performing pelvic examinations.

Example of single-use speculum

Example of reusable speculum

The environmental impact of single-use and reusable vaginal specula was compared in three studies(Donahue et al. 2020; Rodriguez Morris and Hicks 2022; Snijder and Broeren 2022), of which only two were
published in a peer reviewed journal (Donahue et al. 2020; Rodriguez Morris and Hicks 2022) (See Table 39
and Appendices 9.1 & 9.2).
In the study of Donahou et al. (2020) three types of specula were compared; two reusable stainless steel,and one acrylic single-use speculum. The reusable specula had a robust favourable carbon footprintcompared to the single-use acrylic specula. Compared to single-use acrylic specula, the reusable speculum
has a lower carbon footprint after 2 or 3 completed examinations. The material production and manufacturingphase contributed for more than 90% to the carbon footprint of the acrylic speculum, whereas the use andreprocessing phase contributed between 65-74% to the carbon footprints of the two stainless steel specula(Donahue et al. 2020). Similarly, the findings of Snijder and Broeren (2022) comparing stainless steel speculawith two types of single-use specula, one of fossil plastic and one of biobased plastic, estimated that after
500 uses the environmental impact of reusable specula was about 50% lower, compared to a single-use
speculum from fossil plastic. The estimated impact of reusable specula was also slightly better than that ofbiobased plastic (Snijder and Broeren 2022).
Finally, the study of Rodriguez Morris and Hicks (2022) compared a reusable stainless steel speculum andan acrylic single-use speculum. The authors concluded that no speculum outperforms the other consistently
across all impact categories. The reusable speculum outperformed the single-use alternative in five impact
categories (global warming, acidification, respiratory effects, smog formation, and fossil fuel depletion), but
not for ozone depletion. The authors referred to the use of personal protective equipment (PPE), and more
specifically the use of gloves, during the disinfection process of reusable specula. Furthermore, the impactof hard coal sourced electricity was dominant in almost all impact categories (Rodriguez Morris and Hicks
2022).

Final report June 2023 – Study single-use materials in medicine and health care74

Table 39: Summary LCA’s on vaginal speculum
Reference
Donahue et al.
(2020, US)

Objective LCA
Environmental impact of
three vaginal specula: one
SU acrylic and two RU
stainless steel specula

Functional unit
20 gynaecologic examinations byeither type of speculum

Rodriguez
Morris andHicks (2022,
US)

Environmental impact of SU
acrylic and RU stainlesssteel specula

5000 pelvic exams, equivalent for
one year of clinic operation

Snijder andBroeren(2022, The
Netherlands)

Environmental impact of SU
fossil plastic, SU biobased
plastic and RU stainlesssteel specula

One gynaecologic examination
using a vaginal speculum

Results
Global warming
RU stainless steel 304 (lifespan 20 ex.): 5.72
kg CO2eq
RU stainless steel 316 (lifespan 20 ex.): 6.51
kg CO2eq
SU acrylic:17.54 kg CO2eq
Global warming
RU stainless steel (lifespan 5 years): 326 kg
CO2eq
SU acrylic: 2220 kg CO2eq
Ozone depletion:
RU stainless steel (lifespan 5 years):
0.00033 kg CFC-11e
SU acrylic: 0.000042 kg CFC-11e
Global warming
RU stainless steel (lifespan 500 uses): 0.13
kg CO2eq
SU fossil plastic: 0.30 kg CO2eq
SU biobased plastic: 0.14 kg CO2eq

RU: reusable, SU: single-use

In summary of these studies, the majority of the results indicate a benefit for reusable specula. The
findings were not fully conclusive, as the use of nitril gloves and energy mix significantly impacted
specific impact categories in one study.

Supplementing the selection process described in Chapter 4, we conducted this LCA on vaginal specula
because of 1) the limitations of the available studies and because 2) data applicable to the Belgian context
were lacking.
The two published studies on vaginal specula were conducted outside of Europe (Donahue et al. 2020;
Rodriguez Morris and Hicks 2022). In the UK or other European countries the power mix is principally sourced
from renewables, whereas in the US natural gas is the most important source, and in Australia the power mix
is mostly based on coal (McGain et al. 2017). Therefore it would be interesting to identify the impact of
renewable energy on the reuse process of medical equipment, such as vaginal specula. The Ghent University
Hospital uses a power mix based on 100% renewable energy and consumes steam created as a wasteproduct by a nearby waste disposal plant.
Currently, environmental implications are seldomly included in the procurement of medical materials anddevices, but the attention is growing. Manufactures are also becoming more aware of their role and theecological impact of the production and use of their products. In this process the use of bioplastics is put
forward by manufactures as a more ecological alternative. Single-use specula made from biobased plastics
have a smaller carbon footprint compared to single-use made from fossil based plastic (Snijder and Broeren2022). At first glance, this could be the preferred option for single-use specula, but Snijder & Boeren (2022)
performed a scoping LCA, only including the midpoint impact category global warming. A comprehensive
overview ecological impact categories is currently lacking.

6.2

Goal

The goal of the study was to evaluate the potential environmental impact of the use of reusable compared tosingle-use vaginal specula based on rational, scientifically solid grounds using the method of life cycle
analysis (LCA).

Final report June 2023 – Study single-use materials in medicine and health care

75

6.3

Methods

The LCA followed the ISO 14040/14044 guidelines (International Organization for Standardization), and wasmodelled using SimaPro 9.4.0.2. Primary data was used whenever possible. Secondary data was retrieved
from the ecoinvent database (version 3.8).

6.3.1

Functional unit

The functional unit was one pelvic examination by either a sterile stainless steel reusable, or a single-use
speculum of three different types: one containing fossil plastics acrylonitrile butadiene styrene (SU ABS), one
containing biobased plastic polylactic acid (SU PLA), and one consisting of polystyrene blades andpolyethylene bolt and sterilised with ethylene oxide (EO SU). The reusable speculum was an uneven-bladed
stainless steel speculum (90x80x30 mm) manufactured in Germany and most commonly used in the Ghent
University Hospital. Reusable specula were assumed to be used a minimal of 500 times based on Snijder
and Broeren (2022) and expert opinion (head of the central sterilisation department and materials manager
OR of the Ghent University Hospital). An additional decontamination and sterilisation (steam sterilisation)
cycle of the reusable speculum was required before the first use and included in the modelling (See Appendix
9.12).
The single-use specula were all three medium size (26 mm) specula. The SU ABS and SU PLA specula wereboth manufactured in The Netherlands and did not undergo a sterilisation process. The EO SU speculum
was manufactured in Poland and sterilised using ethylene oxide. A single-use speculum was not commonlyused to perform pelvic examinations in the Ghent University Hospital. Therefore, the use of a medium sized
single-use speculum was based on figures from the survey of consumption of single-use materials of Belgian
hospitals (See Chapter 4).

6.3.2

System boundary

A cradle-to-grave approach was used, including the production of the specula and packaging materials(consisting of raw materials and manufacturing), as well as distribution, (pre-) use phase, and end-of-life of
specula and packaging materials.
The systems studied can be separated into foreground and background subsystems and are detailed in
Figure 6 and Figure 7 for reusable and single-use specula, respectively. The foreground subsystem consistsof all processes, assessments, and flows for which primary data were collected. The background subsystem
includes the other processes that are linked through mass or energy exchanges with the foregroundprocesses. The production of electricity is an example of a background process. For the background systemsecondary data from databases and literature were used.
For the (re-)use phase, energy, water, and materials used for decontamination and sterilisation of thereusable specula were included (See Appendix 9.12). Waste treatment of specula, all packaging materials,
and waste water used throughout one life cycle were included, as well as emissions to air, soil and water for
all processes retrieved from the life cycle inventory database. Capital goods and building infrastructure forthe decontamination and sterilisation (foreground system) were excluded, as well as infrastructure fromsecondary data (background system) retrieved from the ecoinvent database to be consistent with the primarydata collected. PPE used by personnel during cleaning and disinfection of the specula were not included, as
this is used while working in the dirty zone of the central sterilisation department, where the specula aremanipulated together with other instruments. Details of the system boundaries were outlined in Figure 6 forreusable and Figure 7 for single-use specula. The use of specula in outpatient clinics related to the university
hospital, was excluded.

Final report June 2023 – Study single-use materials in medicine and health care76

Figure 6: System boundary reusable specula

Figure 7: System boundary single-use specula

6.3.3

Life cycle inventory

Parameters for raw materials and manufacture of vaginal specula and packaging were included in Table 40.
Manufacturer information was used to determine the composition, or expert knowledge where suchinformation was not available. Each component and packaging material was weighed using the same balancescale. Associated primary and secondary packaging were included in the model, up to the packing unit
supplied to the hospital. One-time packaging of the reusable specula present at the time of purchase wasassumed to be identical as packaging of single-use specula. The inventory was developed through matching
Final report June 2023 – Study single-use materials in medicine and health care77the materials (from specula and packaging) with closest materials included within the ecoinvent database
version 3.8. A summary of the used datasets from the ecoinvent database was included in Appendix 9.13.
An overview of the assumptions used was included in Appendix 9.14.
Table 40: Speculum and packaging composition data
Product

Material

Weight, g

Weight, g/piece

Reusable speculum (RU)

179g

179.0gSterilisation bag reusable speculum

Speculum Stainless Steel (18/8)(uneven-bladed 90x80x30 mm)
Laminate plastic

8.0g

Sterilisation bag reusable speculum

Paper

Secondary packaging for distribution frommanufacturer to hospital
Cardboard packaging for distribution frommanufacturer to hospital (small box)
Disposable speculum 1 (SU ABS)

Plastic (LDPE & LLDPE)

4g (x2 - double
packed)5g (x2 - double
packed)4g/10pieces

Cardboard (small box)

200g/10pieces

20.0g

Speculum from fossil plastic (= ABS or
Acrylonitrile butadiene styrene)
Medium size (26 mm)
Speculum from biobased plastic (= PLA
made from sugarcane)
Medium size (26 mm)
Plastic (LDPE & LLDPE)

34.4g

34.4g

39.9g

39.9g

45g/200 pieces

0.2g

Cardboard (large box)

1215g/200 pieces

6.1g

Speculum from fossil plastic (=polystyrene
blades and polyethylene bolt)
Sterilised with ethylene oxide (EO)
Medium size (26 mm)
Plastic LDPE & LLDPE
Plastic (LDPE & LLDPE)

31g

31 g
(29g blades and2g bolt)

Disposable speculum 2 (SU PLA)

Packaging for distribution from manufacturer tohospital
Carton packaging for distribution frommanufacturer to hospital (secondary packaging)
Disposable speculum 3 (EO SU)

10.0g
0.4g

Plastic packaging per speculum
4g
4g
Packaging for distribution from manufacturer to
45g/200 pieces
0.2g
hospital
Carton packaging for distribution from
Cardboard (large box)
1215g/200 pieces
6.1g
manufacturer to hospital (secondary packaging)
RU: reusable; SU: single-use; LDPE: Low density polyethylene; LLDPE: Linear low-density polyethylene; ABS: Acrylonitrile butadienestyrene; PLA: Polylactic acid; EO: ethylene oxide

Distribution was included in foreground and background subsystems, represented as “T”, and detailed in
Figure 6 and Figure 7. Distribution was modelled using estimates of travel distances of the wrapped speculum
between the manufacturer and Ghent University Hospital by Google maps, and assuming average size oftrucks if land transport was used. Details of modelled transport necessary for the use of reusable and singleuse specula were summarised in Appendix 9.13 and Appendix 9.15.
Reusable specula can be separately packaged in a sterilisation bag consisting of paper on one side andplastic laminate on the other side, or integrated into a reusable instrument set together with other instruments
wrapped in polypropylene sterilisation sheets (blue wrap). The plastic laminate of the sterilisation bag iscomposed of five layers: one layer of PET, 3 layers of PP and one layer of glue. The composition of thesepackaging bags, although technically possible, makes it currently not feasible to recycle the plastic sides.
Since single-use specula are individually packaged, the comparison was made with individually packaged
reusable specula. Sterilised specula are double packed, so for each reusable speculum the packing materialof two sterilisation bags was used.
A detailed overview of the different steps of the reuse phase of reusable specula was included inAppendix 9.12. Sterilisation was conducted in an in-house sterilisation department using steam sterilisation,
which is most common in Belgian hospitals. Input and output data were collected through direct observation,
own measurement, and data from the manufacturers of machines and materials used in Ghent University
Hospital. Where not available, data were based on expert opinion (from staff of the central sterilisation
department or biomedical department).
Steam derived from waste-heat of a nearby waste incinerator was used as steam for the cart wash and theheating of osmose water to clean steam. This waste heat was modelled as a burden-free input. The energy
mix used in the Ghent University Hospital is 100% renewable energy mix (mainly from wind) from a Belgianenergy provider. Waste (specula and laminate plastics from sterilisation bags) was assumed to beincinerated, aside from the (initial) packaging materials (cardboard, paper and plastics – double packaged)
which were recycled. It is assumed that the reusable speculum will be disposed of, after 500 uses as HMW,
Final report June 2023 – Study single-use materials in medicine and health care78

and that the majority (92%) of the metal is recovered from the resulting bottom ash (Rigamonti et al. 2010;
Indaver 2022). An overview of the assumptions used was included in Appendix 9.14. Reusable specula weredouble packaged in laminate bags consisting of paper and laminate plastic. The paper side was recycled, theplastic laminate side was disposed of as NHMW and sent to waste incinerators after use. Benefits fromincineration (recovered energy) and recycling (recycled materials substituting virgin materials) were taken
into account as avoided impacts.

6.3.4

Outcome measures

The primary outcome was global warming impact, with total GHG expressed as carbon dioxide equivalents(kgCO2eq). Global warming was selected because of the high awareness about this challenge in today’ssociety and the urgency to mitigate our global warming impact. Seventeen additional midpoint impact
indicators were calculated using ReCiPe 2016 Midpoint (H) V1.07 / World (2010) H. Of those seventeen
midpoints, four were selected due to their relevance for this item. Fossil resource scarcity was selected toreflect the difference between the use of fossil-based and bio-based materials. Mineral resource scarcity waschosen because the reusable specula are made of steel. Due to water and steam consumption in the
reprocessing phase of reusable specula, water consumption was selected as the fourth midpoint impact
category. Only the midpoint global warming is discussed in the text, for the four most relevant midpoints
described above, graphs were included in Appendices 9.17. For all midpoints, the estimates were includedin Appendix 9.16.
The secondary outcome was the environmental impact evaluated by the associated damage to human health(measured in disability-adjusted life years [DALYs]), ecosystems (loss of local species) and resource scarcity(financial cost involved in future mineral and fossil resource extraction). Estimates of damages and graphs
for all endpoints were included in Appendix 9.16 and Appendix 9.17, respectively. Those endpoint estimates
were obtained through ReCiPe 2016 Endpoint (H) V1.07 / World (2010) H/A (Huijbregts et al. 2017).

6.3.5

Scenario analyses

To evaluate the generalisability of the findings, following alternative scenarios were modelled, changing justone parameter in the scenario:- Scenario 1 modelled the energy mix used for the disinfection and sterilisation process of a reusable
vaginal speculum using the average Belgian energy mix provided by the ecoinvent database.
- Scenario 2 modelled the steam used for the disinfection and sterilisation process of a reusable
vaginal speculum and cart wash using steam generated by Ghent University Hospital itself (using an
ecoinvent dataset for industrially produced steam mainly based on the incineration of natural gas)
- Scenario 3 modelled the impact of the number of reuseso Scenario 3A: increasing the number of reuses of reusable specula to 1000 times. The
manufacturer stated that no defined limit can be set for the maximum number of reprocessing
cycles that can be performed. Based on expert opinion a use of 1000 times seems easily
achievable.
o Scenario 3B: decreasing the number of reuses of reusable specula to 50 times, as specula can
be available on infrequently used places or in infrequently instrument sets.
- Scenario 4 modelled the impact of using one sterilisation bag instead of two for reusable specula- Scenario 5 modelled the impact of the waste treatment process of the packaging materials. In this
scenario all waste was incinerated (using ecoinvent datasets for waste incineration). Scenario 5 isstill a common practice in many Belgian hospitals.

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79

6.4

Results

6.4.1

Life cycle assessment

An overview of all midpoint and endpoint estimates for the reusable (RU) and three single-use (SU) specula
were presented in Appendix 9.16. Global warming (kgCO2eq) was provided in Figure 8 for the four types ofspecula, and details were given in Table 41 (for global warming) and Appendix 9.17 (for other midpoints).
Life cycle GHG emissions from reusables were largely due to packaging production (used during treatment
on-site) and end-of-life treatment of that packaging, and the on-site reprocessing (treatment) of the specula,whereas life cycle GHG emissions from single-use alternatives were mainly due to raw material production
and manufacturing, incineration of the speculum at the end of life, and packaging (first purchase) production.

Figure 8: Life cycle greenhouse gas emissions (kgCO2eq) of one use of a speculum for the four types of specula

The most favourable option, from global warming perspective, is the use of a sterile stainless steel RU
speculum producing 78% less GHG emissions than a single-use speculum from fossil plastic (SU ABS), 65%
less emissions than a single-use biobased plastic speculum (SU PLA), and 74% less emissions than an
ethylene oxide sterilised single-use speculum consisting of two types of fossil plastic (EO SU).
None of the specula scored best across all midpoint estimates. For water consumption SU specula madefrom biobased plastics were the least favourable, for fossil resource scarcity a SU ABS speculum was theleast good, whereas for mineral resource scarcity RU specula were worst. Across all three endpoint
estimates, the use of RU specula was most favourable (See Appendix 9.16 and 9.17).
6.4.1.1 Reusable specula (RU)
For global warming, the packaging used during treatment on site proved to have the greatest impact (76% of
the total burdens of GHG emissions) for RU specula, including packaging for sterilisation and end-of-life
treatment of the packaging after use. In addition, the treatment phase (cleaning, disinfection and sterilisation)
has the second largest impact (21% of the total burdens of GHG emissions for RU specula) (See Table 41
for overview of the GHG emissions per phase). The limited impact of the treatment phase is related to theuse of renewable energy and the use of steam from a nearby waste incinerator. The impact of raw materials
and manufacturing of the reusable speculum was highest for the midpoint mineral resource scarcity (61%).
For the endpoint estimates, the impact of raw materials and manufacturing was lower or negligible (Appendix
9.17).
Final report June 2023 – Study single-use materials in medicine and health care80

6.4.1.2 Single-use specula from fossil plastic (SU ABS)
Throughout the four midpoint impact categories and three endpoint damage categories, raw materials andmanufacturing proved to have the greatest impact, or 57% of the total burdens of GHG emissions for SU ABS
specula. In addition, handling waste from end-of-life specula has the second largest impact (31% of the total
burdens of GHG emissions on SU ABS specula) (See Table 41). SU ABS specula were only the least
favourable of the four types of specula for the endpoint resource scarcity. An overview of the secondary
outcome measures was included in Appendix 9.16 and 9.17.
6.4.1.3 Single-use specula from biobased plastic (SU PLA)
Throughout the four midpoint impact categories and three endpoint damage categories, raw materials andmanufacturing proved to have the greatest impact, or 72% of the total burdens of GHG emissions for SU PLA
specula. In addition, packaging production and end-of-life treatment had the second largest impact (16% of
the total burdens of GHG emissions on SU PLA specula) (See Table 41). For the endpoints ecosystem quality
and human health, SU PLA specula were the least favourable of the four types of specula. An overview ofthe secondary outcome measures was included in Appendix 9.16 and 9.17.
6.4.1.4

Ethylene oxide sterilised single-use specula composed of two types of fossil plastic (EOSU)
Throughout the four midpoint impact categories and three endpoint damage categories, raw materials andmanufacturing proved to have the greatest impact, or 58% of the total burdens of GHG emissions of EO SU
specula. In addition, handling waste from end-of-life specula has the second largest impact (32% of the total
burdens of GHG emissions on EO SU specula) (See Table 41). An overview of the secondary outcome
measures was included in Appendix 9.16 and 9.17.
Table 41: Overview of the global warming impact (kg CO2eq) per phase for the four types of specula
Reusable specula
SU ABS specula SU PLA specula SU sterile specula
NET IMPACT
7,13E-02
3,25E-01
2,03E-01
2,80E-01
BENEFITS-1,10E-02-3,88E-02-2,94E-02-2,74E-02
Benefits end-of-life speculum-5,30E-04-1,97E-02-1,06E-02-1,76E02
Benefits end-of-life packaging (treatment on-site)-1,04E-02
Benefits end-of-life packaging (first purchase)-2,73E-05-1,91E-02-1,88E-02-9,73E-03
BURDENS
8,23E-02
3,64E-01
2,33E-01
3,07E-01
End-of-life treatment speculum
1,33E-06
1,11E-01
1,95E-02
9,88E-02
End-of-life treatment packaging (treatment on-site)
2,94E-02
End-of-life treatment packaging (first purchase)
3,66E-05
8.12E-03
7,67E-03
5,94E-03
Packaging (used after treatment on-site)
3,33E-02(Pre-)treatment on-site
1,70E-02
Distribution to treatment on-site
5.16E-08
1.25E-03
1,39E-03
5,29E-03
Packaging (first purchase)
4,94E-05
3,67E-02
3,67E-02
1,85E-02
Raw materials and manufacturing speculum
2,53E-03
2,07E-01
1,68E-01
1,79E-01
SU ABS: single-use fossil based plastic; SU PLA: Single-use biobased plastic; SU sterile specula: Ethylene oxide sterilised single-use
specula from fossil based plastics
Figures are expressed according to LCA-standards; E-01= x 0.1;E-02= x 0.01; E-03= x 0.001; E-04= x 0.0001; …

6.4.2

Scenario analysis

6.4.2.1 Scenario 1: energy mix
The Ghent University Hospital uses an energy mix based on 100% renewable energy sources, which may
not be the case for other Belgian hospitals. Therefore, scenario 1 modelled the energy mix used for thedisinfection and sterilisation process of a reusable vaginal speculum using the average Belgian energy mix.
The most favourable option, from global warming perspective, remained the use of a reusable speculum
producing 61% less GHG emissions than a SU ABS, 37% less emissions than a SU PLA speculum, and 54%
less than an EO SU speculum (See Appendix 9.18). The treatment process (cleaning, disinfection andsterilisation) gained impact compared to the baseline scenario, and became responsible for most of theemissions when using reusable specula.
6.4.2.2 Scenario 2: steam
Steam derived from waste-heat of a nearby waste incinerator is used in Ghent University Hospital as steam
for the cart wash and the heating of osmosis water to clean steam. In scenario 2 the steam used for theseapplications was modelled using average steam production (which is based on an ecoinvent dataset for
average steam production in the chemical industry, mainly produced from natural gas incineration). In that
scenario SU PLA specula became the most favourable option from global warming perspective, directly
Final report June 2023 – Study single-use materials in medicine and health care81followed by the reusable with 11% more emissions, EO SU specula with 28% more emissions, and SU ABS
with 38% more emissions compared to SU PLA specula. On the other hand, reusable specula remained thebest option for two of the three endpoint estimates (human health and ecosystem quality) (See Appendix
9.18).
6.4.2.3 Scenario 3: Number of uses
Lifespan of a reusable speculum was based on an assumption of 500 uses (Snijder and Broeren 2022),
therefore the impact of the number of reuses was included in the scenario analysis. In scenario 3A the numberof reuses was increased to 1000, and decreased to 50 reuses in scenario 3B. The results are included inAppendix 9.18. Although the relative impact of raw materials and manufacturing was highest in scenario 3B(for 50 uses), compared to the baseline scenario and scenario 3A, no substantial differences were foundbetween the three scenarios. RU specula remained the most favourable concerning global warming andthroughout the three endpoint estimates (See Appendix 9.18).
From five reuses, a RU speculum became more sustainable than a SU ABS, from eight reuses it became
more sustainable than a SU PLA speculum, and from six reuses it became more sustainable than a EO SU
speculum from a global warming perspective.
6.4.2.4 Scenario 4: Packaging
Reusable specula were double packaged, for each speculum two sterilisation bags were used. When this
could be reduced to one sterilisation bag, as proposed in scenario 4, the results became even morefavourable for reusable specula (See Appendix 9.18). The most favourable option, from global warming
perspective, remained the use of a RU speculum producing 86% less GHG emissions than a SU ABS, 78%
less emissions than a SU PLA speculum, and 84% less than an EO SU speculum (See Appendix 9.18).
6.4.2.5 Scenario 5: Waste treatment
When all the packaging materials were not recycled but sent to incineration with energy recovery, a common
practice in many Belgian hospitals, RU specula remain the most favourable option. The net global warming
impact (including burdens and benefits), however, was more favourable in this scenario (packaging sent toincineration) than the baseline scenario (recycling packaging). This is due to a higher net global warming
impact for recycling of paper and cardboard compared to their incineration with energy recovery (Gradus etal. 2017). On the contrary, the recycling of the (fossil-based) plastic packaging was better from a global
warming perspective compared to their incineration with energy recovery. This can be explained by the factthat CO2 emissions from biogenic origin (biomass), which is the case for paper and cardboard, are notcounted by the global warming impact assessment method because CO 2 was taken up when the biomass(trees to produce paper) was growing. Whether recycling of paper and cardboard is better than theirincineration also depends on the electricity dataset used to model the benefits from recovered energy. The
more carbon-intensive the avoided electricity, the more favourable the incineration with energy recovery(Arena et al. 2004). However, it should be noted that our study only considered one recycling cycle, while
paper can be recycled up to 7 times and so ensures that CO 2 stays longer stored. A review of the European
Environment Agency on LCA studies of paper and cardboard waste management concluded that for mostenvironmental impact categories recycling of paper and cardboard is better than incineration with energy
recovery, where there is a strong influence of the assumptions used in the LCA (such as the carbon-intensityof the avoided energy) (European Environment Agency 2005).
6.4.2.6 Best case scenario
The best case of all the above scenarios on reusable specula included the combination of an energy mix
based on 100% renewable energy sources, the use of steam derived from waste-heat, 1000 reuses, andminimal packaging. These assumptions combined with the assumption of recycling of all packaging materials
because of current circularity targets within Europe is presented in Appendix 9.18.

6.5

Conclusion on LCA of vaginal speculum

In summary, the use of reusable vaginal specula was environmentally the most favourable
alternative compared to three types of single-use specula. The best case scenario includes the useof reusable specula combined with using an electricity mix based on 100% renewable energy
sources, the use of steam derived from waste-heat, 1000 reuses, and minimal (single) packaging.

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7

DISCUSSION

7.1

Main findings

The initiative for this project has been taken by the Directorate-General for the Environment of the Federal
Public Service Health, Food Chain Safety and Environment. The underlying question is how to manage
medical waste in hospitals, in particular investigate whether it is possible to replace single-use medical
devices by reusable items. If this replacement would be successful, it could result in a significant reductionof the amount of solid medical waste, and a reduction of the extraction of raw materials.
The background for this project is double. There is at first, the urge to comply with the sustainable
development goals in particular with SDG 12: ensure responsible consumption and production patterns,
including waste reduction. The commitment for every country joining the declaration was pronounced after
its publication in 2015 (United Nations 2015). Second and not less important is the recent highly unwantedpressure on the medical health system due to the COVID-19 pandemic and more precisely, about theuncontrollable high pile of waste from hospitals. It became very clear that the management of the waste –and in particular the medical waste – had to be reconsidered. The WHO is even calling for reforms
surrounding the disposal of medical waste (WHO 2018, 2022). It is clear that the question of the WHO tocompletely revise the management of medical waste went far beyond the exceptional situation during the
pandemic but referred to the whole of considerations related to medical waste.
Concerns about the environment and the role of healthcare organisations are already present in many
hospitals and e.g. within the Ghent University Hospital, several concrete actions in order to fulfil theobligations linked to SDG 12 to reduce the amount of waste and establishing within the organization a cultureof sustainability are ongoing: selective collection of different waste streams whenever possible followed byrecycling (paper, plastics…), raising awareness for environmental issues, etc.
All this was the fertile ground for the project to start. Together with 12 collaborating hospitals, the Ghent
University Hospital took the challenge to investigate the option to reduce the amount of waste throughconsidering the dichotomy of single-use and reuse medical equipment and the Governmental project was thepossibility to study this point.
Old common sense dictates that the best way for reducing the amount of medical waste is producing lesswaste. However, medical waste production is inevitable in the actual Western World healthcare environment
and the amount of waste is to a large extend proportionate to the perfectionated high level of medical care.
One of the important aspects of reducing the amount of waste is to reduce the single-use medical material
which is, by definition, thrown away after one action in the context of diagnosis, treatment or regular care ofpatients. Actual healthcare has a preference for single-use material for a number of reasons: safety of thepatients certified by the producer of the material, easiness of use, on time delivery, logistic simplicity on thepositive side. However, on the negative side are the effects on the environment since the amount of waste
increases significantly and the costs are frequently high. Hence, any decision on the possibilities for replacing
SUD’s by reusable material need to be evidence-based.
The project evolved in four subsequent steps.
Step 1: inventory of the medical material used in hospitals. The collaboration with 12 hospitals was obtained
and based on that information, a “long list” of 78 devices was constructed. These devices were used in mostof the collaborating hospitals;
Seemingly simple, this turned out to be a very difficult exercise due to the differences in names anddescriptions proper to multiple companies delivering the material. The collaborating hospitals,
although very willing to share data, frequently did not had the time to deliver their informationaccording to a preformed layout. It required a lot of efforts and time and frequent re-consultation of
the partners to get this information correct.
Step 2: reduce the number of items in this long list into a “short list” of 28 devices. This selection process
was based on a number of criteria including the possibility to gather enough information that would eventuallylead to a conclusion. At the same time, the selection was also guided by the advice of experienced employees
Final report June 2023 – Study single-use materials in medicine and health care83within the hospitals. Among these experts are nurses in general healthcare function, nurses working in theoperation theatre, responsible employees in the sterilisation department, etc.
The authors of this document are well aware of the fact that the feasibility of this selection process
can be discussed. It is clear that personal experience of employees within a hospital is variable andthe selection presented in this project could be biased. However, in favour of our choices, the coworkers were thoroughly informed on the background of the study and the consulting employees
were aware of the importance of their contribution. They participated in a number of meetings on thesubject, choices were discussed among the employees and there was agreement on the importanceof these choices. In spite of the drawbacks, we are confident that most of these selected items in the
short list are valuable within the scope of the project, and any result could lead to valid conclusions.
Step 3: regrouping items of the short list into five representative categories according to the criteria:
sterilisation or high level disinfection of small medical devices, sterilisation of operating room equipment,
thermal disinfection or low level disinfection, laundry process and change of item or device. One item for eachtype was selected from the short list as a representative.
In view of the ultimate goal, i.e. how to take decisions whether to use single-use or reusable devices,a further narrowing of the number of items was needed. Therefore, a second selection was carriedout based on some characteristics of the items within hospital care. This resulted in a list of fivecategories of devices and each item from the short list was attributed to one of the five categories. In
contrast to the selection process described in step 2, this second selection is less subject todiscussion. Indeed, we retain the items of the short list and the regrouping into the categories is logic
and rational. The final result is a list of 5 medical devices.
Step 4: select one out of the five items to perform a detailed study, i.e. one life cycle analysis and four items
for analysis on safety, cost, efficiency, and different aspects related to environmental sustainability based onliterature data and document study, meeting with relevant stakeholders, and working visits.
The least disputable conclusions on the feasibility of choosing single-use or reusable devices should
be based on a life cycle analysis. However, in view of the time and efforts needed to execute an LCA,
one item was selected for the LCA while for the four other items, conclusions based on literature data
and a limited number of observations are presented. It is clear that the latter are not LCA’s according
to the definition but, based on carefully studied literature data, we are confident that the conclusions
are valid and contribute to the general conclusion.
As the purpose of this study was to identify for five single-use medical devices the most sustainable and/or
circular alternatives, we discuss these items from the point of view of the circularity principles. The results
are summarized in Table 42 and Table 43.
Kidney trays
Based on the available data, reusable kidney trays are apparently more environmentally friendly.
However, the method of disinfection has an environmental impact as well as a large impact on cost.
The safety is comparable, whereas the efficiency might be in favour of the single-use kidney tray
based on the time consumption. Since date are lacking, no more firm conclusions are possible. Thisshould be further explored, for instance, through an LCA and LCC comparing single-use and reusable
kidney trays, including the various disposal and disinfection methods.
Blankets
Based on this study, sustainability and cost are in favour of reusable blankets. Safety and efficiency
are similar, unless the hospital has its own laundry. Generally, extending the life cycle of textile
products mitigates their environmental impact. As hospitals consume huge amounts of disposabletextiles, such as surgical or isolation gowns, surgical caps, surgical drapes, warm-up jackets, wascloths, napkins,… there is a great potential for reducing environmental impact (Health Care Without
Harm Europe 2021b). Hospitals or laundries could use sustainable procurement criteria including
e.g.: fibre source (percentage recycled source), GHG footprints, hazardous substances, ecolabel
certifications related to textiles, design for reuse or recycling (Watson and Fisher-Bogason 2017;
Kofoworola et al. 2020; Health Care Without Harm Europe 2021b).

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84

Thermometer
The use of single-use cover caps for tympanic temperature measurement was found to be less costly
and more sustainable than when disinfection with a wipe was needed between patients. Temperature
measurement by a non-contact thermometer requiring no disinfection or additional equipment (covercaps) to be used in different patients proved to be the cheapest, most sustainable, and most efficient
alternative. Avoiding waste is the basis of Lansink’s ladder (Lansink 2018). The simple principle ofpreventing the use of or using fewer materials was clearly illustrated in this item in favour of noncontact thermometers.
Vessel sealer
Using reusable vessel sealers or remanufactured ones is more beneficial for the environment. Patient
safety is comparable if cleaning and sterilisation is adequate. Using reusable and remanufactured
vessel sealers is cost saving. The efficiency is in favour of the single-use sealer because of the time
investment for sterilisation and the separate collecting process for remanufactured devices .
To remanufacture single-use vessel sealers in accordance with legislation, it is required that the
reprocessor re-validates the vessel sealer as a new product. This is a time-consuming process forthe remanufacturer to bring the product to the market with the required stringent regulatory
certifications, and also required to ensure the safety of the patient.
Vaginal speculum:
Based on the LCA, using reusable vaginal specula was environmental most favourable alternative
compared to single-use specula. Cost and safety were comparable, whereas efficiency may be infavour of single-use devices due to the time investment for sterilisation.
To investigate the environmental sustainability of reusable and single-use specula, a cradle-to-grave
LCA was performed to compare reusable stainless steel specula (RU) and single-use specula madeof fossil-based ABS (SU ABS), bio-based PLA (SU PLA), or ethylene oxide sterilised single-use
specula consisting of two types of fossil based plastic (EO SU). Packaging (production and waste
managing of double sterilisation bag) and to a lesser extent cleaning, disinfection, and sterilisationaccount for most of the ecological footprint of reusable specula. One could question whether
sterilisation of specula is always necessary (Rodriguez Morris and Hicks 2022; Snijder and Broeren2022). During surgical procedures, this is evident, in other conditions (ambulant care, outpatient
clinics), this is less necessary, and washing at high temperatures may be sufficient, to achieve a highlevel disinfection as specula come in contact with mucous membranes (Snijder and Broeren 2022).
The use of (double) packaging of reusable specula in sterilisation bags should also be questioned(Rodriguez Morris and Hicks 2022).
Single-use specula made from biobased plastics have a smaller carbon footprint compared to singleuse made from fossil based plastic. At first glance, this could be the preferred option for single-use
specula. However, biobased plastics are perceived as more environmentally friendly thanconventional fossil plastics, but this is questionable. Bio-based plastics might increase plastic
pollution, exaggerate climate change such as ecosystem degradation, deforestation, water scarcity,and harm biodiversity, and create competition with crops intended for human consumption. In the EU
policy framework on biobased, biodegradable and compostable plastics (European Commission
2022a), the European Commission states that producers should minimize use of primary biomass
and prioritise the use of organic waste and by-products as feedstock. If nevertheless biobased
plastics are used, producers should ensure it does not cause harm to biodiversity or the ecosystem,
for example by ensuring that they contribute to the circular economy (European Commission 2022a).

Final report June 2023 – Study single-use materials in medicine and health care85

Table 42: Comparison of single-use and reusable medical material based on exploratory literature searchComparing SINGLE-USE vs. REUSABLE
based on exploratory literature search
Aspect ENVIRONMENTSURU
Instrument/device
Laryngoscope

Aspect COSTS
SU
RU

-

~

Flexible endoscope~

Trocar

+

~

~

-

+

Depending on sterilisation process

Laparoscopic stapler, cutter,scissors, clip applier
Surgical scissors
Reusable solid containers vssingle-use blue wrap
Sharp container
Gowns/coverall
Laryngeal mask airway

nd

-

+

-

+

-

+

-

+

-

+

-

+
+
+

nd
nd
nd

SU: single- use; RU: reusable; nd: no data found; ~: no clear difference is found; +: in favour of; -: not in favour ofTable 43: Comparison of single-use and reusable medical material based on the studied items

Comparing SINGLE vs. REUSABLE
based on studied items
Aspect
ENVIRONMENTSURU
Instrument/device
Kidney tray+-

Impact disinfection

Blanket+-AspectCOSTS*SU
RU+-

AspectSAFETYSURU=

Disinfection/labour+-

AspectEFFICIENCY
SU
RU
+

-

Labour/time==
Depending laundryexternal/internal

Vessel sealer

+

-

+

-

=

+

-

=

-

+

=

+

-

If adequately cleaned
and sterilised

Cover cap
thermometer**

+

-

+

-

LCA
Vaginal speculum

-

+

=

SU: single-use; RU: reusable; LCA: life cycle analysis; *Cost is based on catalogue prices; **In case of the thermometer cover caps:
RU stands for the absence of the need of cover caps or wipe for use in multiple patients; and SU includes the use of cover caps foruse in multiple patients

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86

Conclusion:
Taken together, the overall conclusion is that as far as the environment is concerned, the reusable
equivalents of the devices are favourable, except for laryngoscopes, flexible endoscopes and trocars. The
emerging picture as far as costs and efficiency is concerned is mixed although in most cases, using thesingle-use device is more expensive. The conclusions are less evidence/literature based because in mostcases data on the impact of costs for labour and/or time for e.g. re-sterilisation of reusable items are lacking
or are unknown. In terms of safety, there is equivalence between the 5 studied single-use and reusabledevices.
The authors are aware of the limitation being the shortness of data, which prevents unequivocal conclusions.
However, we are convinced that the main findings are mentioned, allowing the most balanced conclusions
possible.

7.2

Limitations

In this study, we encountered challenges in analysing and comparing the medical items due to context
specificity, data incompleteness, underrepresentation of actual costs and reliance on assumed information.
Firstly, the literature overview was exploratory, rather than conducting a systematic review. The authors
chose to elaborate on items of which at least two LCA’s were available in the literature and to focus onsustainability. As a consequence, other themes such as efficiency, cost, safety were not (fully) addressed,
and only a limited number of single-use devices were included in the literature overview. Furthermore, theresult of an LCA was always connected to a specific location and working method. Therefore, not all resultsfrom the literature review concerning the level of sustainability can blindly be copied to the Belgian healthcare
system. However, this overview did offer valuable insights into the various medical devices that have been
the subject of sustainability research, and their results.
Secondly, some limitations on amount and cost of medical materials need to be addressed. Because of the
COVID-19 pandemic, purchase data of 2019 were requested since it was assumed that the hospital activities
during the pandemic were not representative for normal hospital activities. However, it is likely that a further
shift has occurred from reusable to single-use in recent years which might have led to an underrepresentationof real consumption and costs of medical items. Interviews with stakeholders mentioned, for example, singleuse blood pressure cuffs and single-use bedpans which were not fully captured by this survey. The use ofisolation gowns and masks was not prominent in 2019, yet exploded during the pandemic, and will possibly
remain high in the coming years.
Furthermore, data from 2019 were used for hospital prices, and 2023 data for catalogue (list) prices. The
2019 prices were not indexed in the study. However, given the limitations of data collection of the hospitalsurvey, the prices collected were used for illustrative purposes only.
The purchase cost was based on the publicly available catalogue prices since the hospitals were reluctant toshare their individual prices. Consequently, the purchase costs overestimates the price paid by hospitals
which biased the cost results in chapter 5. In this study, the costs of single-use and cost of reusable items
often seemed comparable or in favour of reusables. However, it should be noted that hospitals (often)
negotiate better prices than the catalogue prices. Due to the limited response regarding the cost part of thehospital survey, this aspect could not sufficiently be addressed.
Thirdly, considering that the sustainability of the items included in chapter 5 was not examined by an LCA(and only emissions of the raw materials could be included), the conclusions on environmental sustainability
should therefore be interpreted with caution. As conducting an LCA is a complex and time-consuming
process, it was not feasible to perform it for the other items within the scope of this project.
Fourthly, an assumption was made for the lifespan of the items and devices included. For example,
concerning the reusable specula, the manufacturer did not specify an instrument lifetime on its technical data
sheet or instrument information. Reusable specula were more sustainable compared to their single-use
alternatives, in literature even after two, three or seven uses (Rodriguez Morris and Hicks 2022, Snijder andBroeren 2022), a correct lifespan of reusable specula may therefore be less crucial for the interpretation of
the results.

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A life cycle analysis is context specific. For example, the source of energy (coal, oil fuel, solar power, nuclear)influences the carbon footprint. For this reason scenario analyses were performed to enhance
generalisability.
Finally, the goal of this exploratory research was to identify medical items with a high consumption or cost in
Belgian hospitals, and to provide insights in possible environmental more sustainable alternatives, including
also safety issues, cost, and efficiency of use. This resulted in the description of five items as provided above,and the recommendations below. To elaborate on concrete proposals to existing legislations at the different
levels (federal and regional), as well as the definition of competences needed to implement certain
recommendations are beyond the scope of the study and the area of expertise of the researchers and(nonetheless widely) consulted stakeholders. Nevertheless, the research conducted does allow following
cautious recommendations to be made and listed (See 7.3 and Table 44).

7.3

Recommendations

From the hospital survey, the findings related to the items studied (including the LCA) and the stakeholders
consultations, the following recommendations emerged. The recommendations are listed in order of priority
based on circular strategies. Therefore, we employ the waste management hierarchy, originally introducedby Lansink’s ladder in 1979. The original waste management hierarchy consisted of five steps fromprevention, preparing for re-use, recycling, recover to disposal (Lansink 2018).
In the boxes, we identified practice requirements and proposed corresponding recommendation to stimulate
sustainability. Table 44 summarises a gap analysis and recommendations to improve environmental
sustainability in the use of medical items.

1. PURCHASE OF MEDICAL DEVICES AND ITEMS-

Need for information on sustainability of medical devices and items in the procurement process
Need for integrating reusable options in the procurement process

IT IS RECOMMENDED TO:
Integrate following elements in the procurement process:- Let sustainability criteria weigh on purchase decisions- Involve a sustainability coordinator/team
Implement the principles of the digital product passport (EU) for medical devices, but also broader for all
medical items or materials used in healthcare
Include also the reusable option a procurement file
- Adapt (public) procurement legislation accordingly- Adapt public tender EU legislation accordingly
Encourage the use of reusable materials and/or discourage single-use materials- Prioritise on single-use medical items with high volume, weight, environmental impact per item, cost
- Make cost of reusable more attractive than of single-use- Financing (pilot) projects on studying reusing medical items and disinfection methods
Encourage hospitals or hospital networks to have a sustainability coordinator and green teams who promote
environmentally sustainable healthcare and advocate for changes at various levels. This could be
implemented comparable to the Hospital Outbreak Support Teams (HOST) pilot projects
Provide training of sustainability coordinator in healthcare

Several reasons, such as low purchase cost, ease of use, patient safety, time savings, past disease
outbreaks, and recently, the COVID-19 pandemic, have driven hospital’s procurement decisions to shift tosingle-use materials, resulting in a higher ecological footprint of global healthcare, and more specifically
hospitals . This shift towards using single-use materials instead of reusables is still ongoing in healthcare.
The COVID-19 pandemic has further intensified and accelerated this process, despite temporary market

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shortages for all types of single-use materials and devices (Rizan et al. 2021). This situation has led to theimplementation of creative solutions, the exploration of (reusable) alternatives within hospitals, and methods
to safely reuse available materials. Although these challenges have demonstrated that reusable alternatives
were possible and feasible, and that materials could often be used for longer periods than initially indicatedby manufacturers, many of these solutions were temporary contingencies rather than well-designed andthoroughly tested sustainable alternatives. The legislative framework and significant personnel shortages
were strong drivers in the choices to abandon most, if not all, of these contingency solutions as soon as theusual materials were available again. Environmental implications were seldomly considered in thesepurchase discussions.
The purchase department has a crucial role in optimising circular strategies in the hospital and can stimulate
an environmental awareness. However, there is no legal requirement to include sustainability criteria or asustainability coordinator in the procurement process (award criteria). Currently, there is no requirement for
procurement of medical devices to ask information on raw materials, production process, packaging,transport, recycling/remanufacturing, sustainability efforts of compagnies. Hospitals are in no way
encouraged to use reusables; and there are no incentives to promote the preference to reusable medical
items, except reduction of the costs for hospitals.
Moreover, there is no mandatory requirement for hospitals to designate a sustainability coordinator. Hence,
it is essential to appoint a sustainability coordinator, ensure their adequate training, and involve them in the
procurement process to effectively address sustainability concerns. This coordinator can be part of a green
team in the hospital, some Belgian hospitals have established dedicated green teams to enhancesustainability efforts. In several countries, these teams are already well-developed (f.i. the Netherlands:
https://milieuplatformzorg.nl, Canada: https://greenhealthcare.ca/,UK: https://sustainablehealthcare.org.uk).
A limited number of hospitals have a sustainability coordinator, but a specific training for sustainability
coordinators (in healthcare) is lacking. Furthermore, sustainability is not, and if so, only to a very limited
extent, included in healthcare training programmes (Visser et al. 2022). However, having knowledge ofsustainability, the impact of materials, and the lifecycle impact of medical devices, etc. is crucial in making
environmentally friendly choices, also in terms of purchasing materials. Moreover, a lack of knowledge canpotentially result in greenwashing (European Commission 2022b). From the LCA in this study, a biobased
plastic polylactic acid (PLA) specula was evaluated which at first looks good, but the LCA proves the opposite.
For hospitals, other institutions, and researchers it is crucial to have access to detailed information on thematerials used in medical devices (specific composition and type of chemicals used, weight, transportation
method, mining location of raw materials, and manufacturing process) as well as the processes involved(water and energy use, detergent composition and usage), in some cases also costs. Moreover, theavailability of this information is necessary to study the sustainability of medical devices, including LCA’s and
LCC’s.
Each hospital could decide which specific single-use items they wish to prioritise, considering factors suchas purchase volume and cost, similar to the approach adopted in this study. Additionally, environmental
impact per item and weight of the device could be taken into account as may indicate high consumption of
raw material; and it is essential to take safety issues into consideration.
Consequently, it is advisable to consider the following possible criteria in a procurement process:a) Comparability of reusable devices with single-use itemsb) Detailed information on the raw materials used: exact composition and weight. Further considerations:• E.g. where mined• E.g. paper: recycled paper (instead of virgin paper), ecolabel certification, chlorine free paper• E.g. textiles: type of fibre (e.g. recycled fibres instead of cotton), free of hazardous chemicals• Avoid disposable stainless steel, and other high-grade materials for single-use purposesc) Transparency regarding the production process (location, type of process(es), use of chemicals)d) Detailed information on packaging (exact composition and weight)e) Consideration of transportation factors (type and distance)f) Guidelines for recycling, remanufacturing and waste treatment (including advice and possibilities)g) For medical devices with batteries: manufacturers need to add an instruction sheet including information
whether the batteries are rechargeable or removable, if they can either be reused or recycled, so waste
containing batteries can be avoidedh) Evaluation of the sustainability efforts made by the company

Final report June 2023 – Study single-use materials in medicine and health care89

European law mandates that all listed companies (except listed micro-enterprises) must provide information
on what they see as environmental risks and opportunities and on the impact of their activities on theenvironment. This must also be done for their social impact. European companies (including hospitals)
meeting the criteria will be required for the Corporate Sustainability Reporting Directive (CSRD) according toscope 3 for their reporting in 2026 (on 2025) (Europese Commissie 2022). This will oblige suppliers to reportand reduce their environmental impacts.
However, more legislation is needed to boost companies to include sustainability criteria as part of a (public)
tender. The principle of the European commission's digital product passport proposal (Ecodesign for
Sustainable Products Regulation) could potentially help, as well as for the medical device as for its packaging(European Commission 2022b).
Ideally, based on the aforementioned information, it would be advantageous for medical devices to be
assigned an environmental sustainability rating or code. This would assist hospitals in making informed andsustainable choices. However, we acknowledge that due to the complexity of this matter, implementing sucha system is not straightforward.

2. SUSTAINABILITY OF ADDITIONAL MEDICAL ITEMS AND DEVICES- Need for more sustainability information on other high volume and high cost single-use items- Attention to correct and rational use of single-use medical items that cannot be replaced by moresustainable options (e.g. gloves)
IT IS RECOMMENDED TO- Stimulate further research on* Sustainability of the other frequently used items of the shortlist* Sustainability of disinfection processes* Comparison between single-use surgical instruments with reusable instruments utilising in-housesterilisation or external sterilisation company by conducting an LCA in combination with an LCC- Further support the campaigns on hand hygiene with special attention to correct glove use, including
the perspective of environmental sustainability- Sensibilisation campaigns on environmental sustainability themes in health care

When literature was juxtaposed with the results of the hospital survey, it became apparent that for many of
the items with high consumption in Belgian hospitals, there has been little to no research yet on more circularalternatives. This study only investigated five items out of the 28 medical items with high consumption or witha high cost in Belgian hospitals. However, each of the selected items was intended to serve as an example
for a whole group or category of items. We hope this report succeeds in this endeavour. Nevertheless there
are certainly more items where further investigation would be of added value. Therefore, further research into
the sustainability of the remaining items is recommended. Evidence-based information from studies that are
well and thoroughly conducted can help healthcare professionals (ranging from people on the floor such as
physicians, cleaning staff, nurses and paramedics over hospital hygiene teams, purchase and financial
departments to hospital management) to enable changes in phasing out single-use materials in favour ofmore sustainable options.
There is often lack of or limited evidence-based information available on the environmental sustainability ofcommonly used single-use and reusable items and existing research does not always provides a clear
understanding. For example, we identified a potentially significant impact related to the cleaning anddisinfection process, especially in the case of kidney trays. Further research is needed, including anassessment of the environmental impact of single-use disinfection wipes versus disinfection sprays withreusable or disposable wipes, as well as thermal disinfection. In order to make well-founded statements about
the sustainability of medical devices, conducting an LCA specific to the device in question is necessary.
Additionally, conducting an LCA that specially compares disinfection methods is crucial in the context ofreusing medical devices and making informed decisions on the application of reusable materials.
A number of hospitals in Belgium work with single-use surgical instruments (scissors, tweezers, … ), otherswith reusables which are cleaned, disinfected and sterilised in an in-house sterilisation department or in an

Final report June 2023 – Study single-use materials in medicine and health care90

external sterilisation facility. Practitioners and stakeholders indicate the need for research comparing theenvironmental impact of these options, as evidence based information is currently lacking.
At the top of all purchase lists of the participating hospitals, gloves (non-sterile, followed by sterile) wereidentified. This item was not further addressed in this study, as it was not the focus of the study. A reusable
alternative is not (currently) available, and recycling is not (yet) an option. In order to address glove use, themain effort should be on behavioural change to discourage use outside the correct indications, and to address
overuse. Perhaps, it might be worth considering a reassessment of the indications for glove usage. The
correct use of gloves was the focus of the 10th national hand hygiene campaign (2022-2023). However, thefocus of the campaign “Use gloves rationally, this is essential” was only on infection prevention. A broader
view where cost and sustainability were considered alongside safety would certainly be appropriate.
Research into the ecological impact of correct use of gloves and the effect of sensitisation campaigns is
recommended.

3. PRACTICAL IMPLEMENTATION OF ENCOURAGING REUSE OF MEDICAL ITEMS AND DEVICES IN
NEED OF CLEANING, DISINFECTION AND/OR STERILISATIONa) Need for optimisation of the logistics process of cleaning and disinfectionb) Need for expansion of disinfection and sterilisation capacity
IT IS RECOMMENDED TO− (Pilot) study the practical issues related to augment the disinfection capacity for reusable devices,− Cost-benefit study on outsourcing the sterilisation of reusable medical items and devices− Encourage hospitals to use renewable energy and explore the possibilities of collaborations with otherindustries for example to use waste steam

Importantly, switching from a single-use to a reusable equivalent is not just a switch of materials, but mostly
a switch of logistics, habits, and procedures. Of utter importance is the possibility to clean, disinfect and/or
sterilise the reusable medical devices in a proper, safe, cost-effective, efficient and sustainable way.
Currently, most hospitals are not logistically ready to switch from single-use to reusable, especially with the
non-critical items. On the contrary, the transition from reusable to single-use is still in full swing. To reusenon-critical medical devices, the washing/cleaning and disinfection capacity needs to be expanded. As
mentioned above, the most sustainable way to disinfect has yet to be clarified.
If thermal disinfection is indicated, an automatic washer may be useful. However, not to burden the central
sterilisation department with cleaning and disinfecting material (not sterilising), an automatic washer on thenursing ward is needed. Comparable to the bedpan washer on the nursing units, but separately because ofhygienic reasons, may be an option. When a washing machine is available on the wards, the logistic process
will also be simplified. When the logistics of disinfecting and/or sterilising processes are optimised for one
medical device, it is often optimal for most other medical devices.
As indicated in this study, cleaning and disinfection of reusable non-critical material may require more timeand manpower. It should be examined for which healthcare professional this task is most suitable. For
instance, this could be included in the responsibilities of a logistic assistant or other healthcare support
workers.
The semi-critical and critical items can follow the logistic process of the central sterilisation department.
However, these additional material flows, separation of clean and dirty materials, need to be elaborated ineach hospital according to their infrastructure, bearing in mind that hospitals, for instance an outpatient clinic,
often have no suitable location to deposit their dirty items.
Additionally, if more items need to be processed by the central sterilisation department, the capacity needs
to be adjusted. Eventually, the central sterilisation department needs to be expanded or the possibility ofoutsourcing certain materials to external sterilisation companies can be investigated. The opportunities forregional collaborations or cooperation within hospital networks could offer opportunities. For this, a costbenefit study is needed.
Furthermore, hospitals should be encouraged to use renewable energy and where possible to explore
collaborations with surrounding companies to reuse, for example, residual heat/steam. Also, efficient water
recycling can be applied, for example by reusing cooling water from steam pipes, etc. (Hoge
Gezondheidsraad 2023). The results of the scenario analyses on the LCA on vaginal specula gave insight in
Final report June 2023 – Study single-use materials in medicine and health care91the importance of the use of an energy mix from renewable sources, and the use of steam generated as aby-product of other industry (here waste incineration). In the study of Snijder and Broeren (2022) acogeneration power plant was used to generate the steam used for sterilisation. The authors found that 40%of the carbon footprint of reusable specula was related to steam generation during sterilisation (Snijder andBroeren 2022). In our study the impact of treatment in the central sterilisation department (cleaning,
disinfection and sterilisation) increased by a factor of 10 by adjusting the method of generating steam.
Encouraging hospitals to use alternative ways of generating (a part of the) steam and relying on renewableenergy sources can reduce the climate impact of reusable devices in need of sterilisation, and thereby thefull sterilisation unit.

4. INTRODUCE MORE REUSABLE (MEDICAL) TEXTILES- Need for more reusable textile alternatives- Need for expanding the logistic process
IT IS RECOMMENDED TO- Include the reusable option in the procurement process- Encourage studies on the development of reusable alternatives in textile- Encourage financially the use of reusable textile alternatives

Because of the large volume, the blanket was chosen to elaborate on the category laundry. Since thepandemic, medical textiles such as isolations gowns are used in large amounts, and this is likely to continue
for the next years. Because of worldwide shortages, there was a switch to reusable alternatives due tonecessity. This use was again abandoned once single-use gowns were available. However, based onliterature (Vozzola et al. 2020; Bijleveld and Uijttewaal 2022; Vozzola et al. 2018a, b), as well as our findingson the item blanket (Chapter 5), the utilisation of reusable textile materials emerges as the most favourable
approach.
When using more reusable textiles, the logistics process should adapt accordingly comparable to the flow
process already used in hospitals for bedlinen. If a hospital collaborates with an external laundry service, thislaundry service could invest in reusable textiles that would be rented out to the hospital. Conversely, if thehospital has its own laundry, the hospital needs to invest in these textiles.
For some items a high quality alternative is (already) available (eg. bibs), but single-use alternatives are often
cheaper to purchase (per piece). Due to hospitals’ high financial pressure, efficiency exercises are indicated.
Making sustainability a criterium in the purchasing process, on top of the costs, with sufficient impact isindicated. We align with Health Care without Harm’s recommendation that, in situations where both reusable
and single-use options are available, preference should be given to the reusable alternatives, and the ongoingshift from reusable towards single-use textiles should be stopped (e.g. blankets, sheets, bibs, washing cloths).
When reintroducing reusable medical linen products, the procurement criteria for reusable textiles should to
be included in the purchase process (Health Care Without Harm Europe 2022).
Further research is required to clarify whether the use of reusable gowns and other linen is more interesting
than single-use alternatives. Similar challenges exist for other single-use medical textiles such as surgicalcaps which have also a high consumption, but have possibilities for reusable alternatives. However, thesupply of reusable textiles with the required standards in the market is limited (Hoge Gezondheidsraad 2018).
The Belgian government is currently stimulating research on ecodesign in the clothing textile industry aiming
at reducing the environmental and health impact of products and materials throughout the product life cycle(Belgium Builds Back Circular). This could be stimulated also for medical textiles. A Flemish project reCURE
on medical reusable surgical gowns and surgical drapes is ongoing. That study investigates the acceptability
and desirability of these items and also the optimisation in terms of functionality (reCURE | Reuse Lab |Universiteit Antwerpen (uantwerpen.be). This study is a good initiative, but much more research is needed
to develop and test alternatives for other items (e.g. for isolation gowns, surgical caps, …). Moreover, funding
for this type of studies on sustainability is limited or lacking.

Final report June 2023 – Study single-use materials in medicine and health care92

5. USE OF REMANUFACTURED MEDICAL DEVICES
Need for more use of remanufactured medical devices
IT IS RECOMMENDED TO- Review legal obligations/regulations necessary for reusing medical material after remanufacturing (withinsafety standards)- Increase the opportunities for medical device certification

The regulations around remanufacturing/refurbishment of medical devices are very stringent and hinder
companies to invest on this domain (Srivatsav et al. 2017).
The Medical Device Regulation (MDR) EU 2017/745 (05 May 2017) is a European regulation on medical
devices which has been in force since 26 May 2021. The aim of this European legislation is to ensure thesafe use of medical devices. Reprocessing of single-use devices (article 17) is part of this Medical Devices
Regulation. However, the topic “Single-use devices and their reprocessing” is reserved for the Member States
to regulate by their national law. Consequently, each Member state can decide to permit the reprocessing of
single-use devices. Thus, there are differences between countries.
Belgium has chosen to permit reprocessing provided that compliance with implementing regulation
2020/1207 and, consequently, regulation 2017/745 can be demonstrated to a notified body (Hoge
Gezondheidsraad 2023). This is described in section 6 article 12 of the law of 22 December 2020 on medical
devices and chapter 3 article 6 of the Royal Decree of 12 May 2021 implementing the law of 22 December
on medical devices. One can opt for reprocessing through an external reprocessor that complies with thecurrent regulation and legislation. Alternatively, one can also decide to perform reprocessing within their own
healthcare facility, following the guidelines outlined in Article 17 of MDR 2017/745 and implementing
regulation 2020/1207.
An external remanufacturer needs to be certified as a manufacturer which implies stringent regulations: CE
regulation. For remanufacturers, it is difficult to find a notified body that can certify for Common Specification.
Common specifications are detailed practical rules setting out how particular types of devices should comply
with certain requirements of Regulation (EU) (2017/746EN) EUR-Lex - 02017R0746-20230320 - NL - EURLex (europa.eu). Similarly, also for hospitals it is difficult to fulfil the requirements for remanufacturing.
Moreover, the control, maintenance, repair, and testing of functionality, as stipulated in Article 17 of MDR
2017/745 and implementing regulation 2020/1207, will certainly pose an additional challenge for hospitals.
Clearly, the remanufacturing of medical devices must be done within safety standards and strict regulations
are needed to ensure quality and safety.

6. OPTIMISING MEDICAL WASTE SORTING FOR RECYCLING- Need for sorting waste correctly according to the current regulations: NHMW, HMW, PMD, other waste
streams- Need for participation to additional existing alternatives to avoid waste and promote recycling
IT IS RECOMMENDED TO- Sensitise hospitals to sort optimally according to the authorised recycling streams e.g. plastic medical
packaging with PMD waste, (non-confidential) paper with paper/carton- Review the waste legislation of hazardous medical waste and non-hazardous medical waste to potentiallyrecycle more
- Encourage research aimed at rethinking the material and amount of material used for essential packaging- Stimulate manufactures to develop reusable medical devices instead of single-use medical devices toreduce medical waste

Currently, some authorised recycling streams are not (fully) practised in hospitals. For instance, since July
2022, plastic packaging of medical devices may be collected with PMD waste in Flanders (Plastic, Metal andFinal report June 2023 – Study single-use materials in medicine and health care

93

Drink packaging) (Fostplus 2023). Examples of these medical plastic packaging are the packaging of
disinfectant wipes, vial of hand alcohol, packaging of linen and packaging of sterilised material. Obviously,
packaging that poses a potential risk due to the presence of residues of hazardous active substances andpackaging from infectious patients that poses a possible contamination risk do not belong in the PMD bag.
By collecting these plastics with PMD, it is diverted from incineration and can be recycled. Sensitise hospitals
to sort waste correctly and according the current regulations is needed.
Furthermore, focus on collecting as much (non-confidential) paper and cardboard as possible separately andnot depositing it with the NHMW.
Correctly sorting NHMW and HMW remains also an area of concern. If NHMW is sorted as HMW this implies
unnecessary consumption of HMW plastic containers or cardboard boxes and unnecessary high temperatureincineration.
Hospitals have to adhere to the waste legislation of its region in Belgium (Flanders: VLAREMA - Flemish
Regulation on the Sustainable Management of Material Cycles and Waste; Wallonia: Décret relatif auxdéchets, Brussels-Capital Region: Ordinance on Waste).
In addition to the already existing waste streams, there are various initiatives and projects aimed at optimising
medical waste for recycling. These initiatives are sometimes funded by the region (f.i. Vlaanderen Circulair).
Also several waste and recycling companies have committed to implementing waste sorting practices.
Examples of already existing initiatives in Belgian hospitals to collect and recycle disposables are:- Single-use PVC medical devices, such as oxygen and anaesthetic masks, tubing, IV and dialysis bags,
are transformed into e.g. vinyl wall covering (VinylPlus Med)- Polypropylene blue wrap (sterilisation wrap)- Surgical staplers- Single-use steel instruments
Considering the aforementioned initiatives, it would be beneficial to review the current medical waste
legislation (both for NHMW and HMW), as there is potential for environmental benefits by reducing
incineration and increasing the recycling of medical waste. It is obvious, that this must be done within thelimits of safety.
The use of reusable materials can be encouraged by making the use of single-use more costly or penalise
the amount of waste, as is the case in Geneva (Peters 2022). Where governmental institutions are penalised
if less than 70% of all waste is recycled. The Hospital of Geneva also included in its sustainability strategy to“quantify the use of single-use equipment and identify ways of the most effective reduction or replacement”(Hôpitaux Universitaires Genève 2022).
An identified problem with disposal of packaging of medical devices is that it often composed of different
types of material. For instance, sterilisation bags are made from paper and laminated plastic. It is practicallypossible to separate these two materials manually when unpacking an dispose them separately as paper and
NHMW. The additional problem is the laminated plastic part, which is made of four layers of plastic and one
layer of glue, not can be recycled. Although it is currently already technically possible to separate these layers
for recycling, this is not yet standard practice in waste management and recycling plants (Ragaert et al. 2017).
Consumption of these bags is very high in hospitals. Rethinking the construction and composition of current
sterilisation bags to make them more suitable for recycling, is recommended.
Ideally, manufacturers should be made responsible for the disposal of single-use medical devices andconsider recycling or reprocessing the device. First of all, this requires notification of the exact material
composition of the device and the packaging. Further, in the instruction manual, the necessary actions tosafely collect the devices for recycling should be mentioned. For complex materials with a high environmental
impact per item, such as single-use laparoscopic devices (vessel sealer, clipper, scissors, trocars, …)
manufacturers could be stimulated or made (financially) co-responsible for the disposal of their device andpackaging materials. Subsequently, consideration should be given to finding effective ways to incentivise
manufacturers to prioritise the development of reusable systems, rather than persisting in investing in singleuse alternatives that have significant environmental impacts on both materials and packaging.

Final report June 2023 – Study single-use materials in medicine and health care94

Table 44: Overview gap analysis and recommendations to improve the environmental sustainability when using medical items

Recommendations forpractice

Gaps

Recommendation for government/policy Based on

Purchase department
Integrating in procurement
process:

The procurement process lacks
information on:
Reusable alternatives
Raw materials (exact composition
and weight)
Production process (location, type ofprocess(es), use of chemicals)
Packaging (exact composition andweight)Transport (type and distance)
Recycling (which items andhow)/remanufacturing (inclusion ofadvises and possibilities)/ waste
treatment (if the above is notpossible, see points 2 and 3)
Sustainability efforts of thecompagnies

Implement the principles of the digital productpassport (EU) for medical devices, but also broader
for all medical items or materials used in health
care.

-

Sustainability criteria
Sustainability
coördinator/team

No incentives to give preference toreusable medical items
No/limited evidence based information on
environmental sustainability of (frequently
used) single-use/reusable items.

-

-

LCA
Items
Stakeholder
involvement-

Hospital survey
Stakeholder
involvement-

Stakeholder
involvement-

Stakeholder
involvement

Public procurement legislation
Public tender: EU legislation
In a procurement file: include/compare also thereusable option

Encourage use of reusable materials
By making cost of reusable more attractive
Financing pilot projects
Encouraging waste avoidance

Introduce sustainability coordinator/team in
hospitals.
Provide professional training for sustainability
coordinator

No obligation to include sustainability
criteria and a sustainability coordinator inprocurement process (award criteria)
No specific training sustainability
coordinator (health care)
Risk of greenwashing
Final report June 2023 – Study single-use materials in medicine and health care95

Hospitals (need to) rely on firms'
subjective information and/or LCA’s
Sustainability information of othermedical items /devices:-

Need for more sustainability
information on other highvolume and high cost singleuse items.

-

Practical implementation of
encouraging reuse of medical
items and devices in need ofcleaning, disinfection andsterilisation.

-

Introduce more reusable textiles--

Use of remanufactured devices
e.g. vessel sealers, …
(extend the life cycle)-

Lacking information on sustainabilityof frequently used medical devices
No (or limited) financing for researchon sustainability.
Need for correct and rational use of
single-use medical items that cannot
be replaced by more sustainableoptions (e.g. gloves)
Need for optimisation of the logistics
process of cleaning and disinfection
Need for expansion of disinfection
and sterilisation capacity-

Stimulate further research on sustainability ofother items of the long list
Ensure funding for high-quality research on
sustainability (on alternatives for single-use
materials)
Further support the campaigns on handhygiene with special attention to correct glove
use.
Pilot study
On the practical issues related to augment thecapacity of disinfection of reusable devices
To compare environmental impact of several
cleaning and disinfection methods
Encourage hospitals to use of renewable energy
and the possibilities of collaborations with otherindustries (e.g. use of waste-steam)-

Hospital survey
Literature
Stakeholder
involvement-

Hospital survey
Literature
Stakeholder
involvement

Reusable textiles are not often usedin hospitals
Limited reusable alternatives on themarketNeed for expansion of the logistic
process
Reusables are not always financiallyattractive
Need for inclusion of reusables in the
procurement process
Limited supply of remanufactured
medical devices.
Strict MDR regulation impedes
reprocessing and remanufacturing of
medical devices.

-

Encourage development of (safe) reusable
alternatives in textile by studies
Financially encouraging the use of reusabletextile alternatives
Include reusable option in procurement process-

Hospital survey
Literature
Stakeholder
involvement

Adapt Medical Device Regulation (MDR) EU
2017/745 (05 May 2017) within safety
standards
Increase opportunities for medical devices
certification-

Hospital survey
Stakeholder
involvement

-

-

-

Final report June 2023 – Study single-use materials in medicine and health care

96

Optimising medical waste sortingfor recycling

-

-

-

Some recycling possibilities are notfully practiced in hospitals (e.g. plastic
packaging)More possibilities for recycling in
hospitals, currently individual andvoluntary initiatives e.g. single-use
PVC, polypropylene blue wrap,
surgical staplers, single-use steel
instruments,… These items arenormally collected as hazardous or
non-hazardous medical waste.
No information on the exact
material composition of medical
devices and packaging which isneeded correctly collect thedevices.
Some materials cannot be recycled.

-

-

-

Sensitise hospitals to sort optimally according
to the authorised recycling streams e.g. plastic
medical packaging with PMD waste, (nonconfidential) paper with paper/carton.
Review the waste legislation of hazardous
medical waste and non-hazardous medical
waste to potentially recycle more.
Introduce principles of digital product passport
for product and packaging (see before).
Encourage research aimed at rethinking thematerial used for essential packaging.

Final report June 2023 – Study single-use materials in medicine and health care

97-

Literature
Stakeholder
involvement

CONCLUSIONS
The results of this project demonstrate clearly that decisions on whether to use single-use or reusable medical
items within a hospital cannot be taken light heartedly. Remarkable was the evidence gap noted by the lackof existing studies on environmental impact (LCA’s) on many of the items on the longlist compiled from theprocurement data of the twelve participating hospitals. The exploratory literature review includes items forwhich at least two LCA’s were available.
For the five selected devices, the study evaluated their sustainability and circularity alternatives. Reusable
kidney trays appeared to be more environmentally friendly, but disinfection methods and costs played asignificant role. Reusable blankets were found to be more sustainable and cost-effective, for hospitals using
an external laundry. Single-use cover caps for thermometers were less costly and more sustainable thanwhen disinfection wipes were needed between patients, but non-contact thermometers turned out to be mostfavourable when looking at sustainability, cost and efficiency. Reusable or remanufactured vessel sealers
were environmentally beneficial with comparable safety if cleaning, disinfection and sterilisation can be done
properly, but single-use sealers were more efficient due to sterilisation time.
For the comparison of the environmental impact of single-use and reusable vaginal specula, an LCA was
conducted. Reusable vaginal specula were the most environmentally favourable option, with major impact ofthe packaging materials for reusable specula and raw materials and manufacturing for single-use specula.
The use a renewable energy, waste-steam and double sterilisation bags importantly impacted the results ofreusable specula.
Considering that we have to prevent waste and that raw materials are not inexhaustible, circularity is key. For
medical devices our data suggest that we will have to move towards reusing or, if that is not possible,
recycling, remanufacturing, … This shift will have major consequences for manufacturer, but also for
healthcare organisation and workers. Maybe one of the major obstacles in elaborating this shift is to adapt
entrenched habits. Our results deliver an instrument to convince people to change. Further high-quality
research, such as properly conducted life cycle assessments as well as implementation research, is
recommended to make conclusive decisions, support healthcare organisations in their procurement
discissions, and overcome practical obstacles.
Overall, the project provides valuable insights into the potential for replacing single-use medical devices withreusable alternatives. The findings contribute to the broader efforts of hospitals to reduce waste, promotesustainability, and align with the circular economy principles.

Final report June 2023 – Study single-use materials in medicine and health care98

8

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9

APPENDICES

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9.1

APPENDIX 1: Evidence table LCA’s Methodology

Laryngoscopes
Refence (year,
country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)DistributionUse
phase/reuse

EoL/Recycling

Inventory databases

McGain et al.
(2017, Australia)

ISO 14040
standards

Not specified

Not specified

Yes

Yes

Yes

Yes

Yes

LCI’s, Ecoinvent, Swiss
Centre for Life Cycle
Inventories, Zurich
Switzerland

1 handle and 1
blade for a single
patient encounter

Cradle to
grave

Yes

Yes

Yes

Yes

Yes

Ecoinvent adjusted for
US energy system (USEI database, Earthshift,
Huntington, VT)

Consequential

Sherman et al.
(2018, US)

Using Monte
Carlo analysis
ISO 14040-44
standards
Attributional

LCA & LCC
LCC: life cycle cost; EoL: end-of-life

Flexible endoscopes
Reference(year, country)
Badoudjian etal. (2022,
France)Bringier etal.(2023,
France)Davis et al.
(2018,
Austrialia)
Duijndam(2022, The
Netherlands)
Hogan etal.(2022,
Ireland)Kemble et al.
(2023, US)

Methodology
LCA
ISO 14040-44
standards

Systemboundary
Cradle-tograveRawmaterial
SU: Yes
RU: NoManufacturing(Packaging)
SU: Yes
RU: NoDistribution

Use/Reuse

SU: Yes
RU: No

RU: Yes

Cradle-tograve

Yes

Yes

Yes

Attributional
Not mentioned

2000 uses of a flexible
bronchoscope(200 tracheal intubations
per year for 10 years)
Use of one ureteroscope

Cradle-tograve

Yes

Yes

Attributional
ISO 14040-44
standards

450 uses of flexible
intubation scopes

Simplified
cradle-tograve

Yes

Attributional
Not mentioned

Use of one cystoscope

Cradle-tograve

Attributional
Not mentioned

One use of cystoscope

Cradle-tograve

Attributional
ISO 14040-44
standards

Functional unit
SU: one cystoscope
RU: reprocessing acystoscope one time

EoL/
Reclycing
SU: Yes
RU: NoInventory database

Yes

Yes

EcoinventNo

Yes (RU)

Yes

Not mentioned

Yes

Yes

Yes

Yest

Ecoinvent

Yes

Yes

Yes

Yes

Yes

Not mentioned

-

Yes

Yes

Yes

Yes

Not mentioned

Attributional

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107

EcoinventLe et al. (2022,
US)

Sørensen and
Grüttner (2018,
Danmark)

Not mentioned

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Ecoinvent

Exploratory
LCA

One endoscopic
retrograde
cholangiopancreatography(ERCP) procedure

Attributional
Simplified LCA

Use of one bronchoscope

Focus on use
and EoL

SU: Yes

SU: Yes

SU: No

SU: NoNot mentioned

RU: NoRU: NoRU: No

RU: Yes(using/washing/sterilisation
drying/storing)

SU: Yes(recycling all
recyclable
material andincineration
with energy
recovery ofscope + PPE
Packaging)

ISO 14040-44
standards

SU: Cradle-tograve
RU: Reuse-tograve

Attributional

RU: Yes(disposal
PPE)Notmentioned
SU: single-use, RU: reusable; PPE: personal protective equipment; EoL: end-of-life

Trocars
Refence (year,
country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)DistributionUse
phase/reuse

EoL/Recycling

Inventory databases

Boberg et al.
(2022, Sweden)

ISO 14040-44
standards

Cradle-tograve

Yes

Yes

Yes

Yes

Yes (disposal/
recycling)

Econinvent

Rizan and Bhutta(2022, UK)

Attributional
ISO 14040-44
standards

500 uses ofsingle-use, reusable,
and mixed (SU and
RU) trocar systems
Number of 3 types of
instruments required
to perform one
laparoscopic cholecystectomy (= 2small diameter ports,
2 large diameter
ports, 1 laparoscopic
scissor, and 1
laparoscopic clip
applier)
Seven medical
devices:
deep veinthrombosis
compression
sleevepulse oximeter
ligasure

Cradle-tograve

Yes

Yes

Yes

Yes

Yes (disposal)

EcoinventIndustry data

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Ecoinvent
ELCD (European
Reference Life Cycle
Database)

Attributional

Unger and Landis(2016, US)

ISO 14040-44
standards
Life Cycle
ImpactAssessment(LCIA)

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108

-

Attributional

harmonic
scalpelendoscopic
trocararthroscopic
shaverscissor tip(= the number of
medical devices
needed to fulfil the
reprocessed device
supply chain
requirements of thehospital)
SU: single-use; RU: reusable; EoL: end-of-life

Laparoscopic stapler, cutter, scissors and clip applier devices
Refence (year,
Country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)Distribution

Rizan and
Bhutta (2022,
UK)

ISO 14040-44
standards

Number of 3 typesof instruments
required to perform
one laparoscopiccholecystectomy(=2 small diameter
ports, 2 large
diameter ports, 1
laparoscopic
scissor, and 1
laparoscopic clip
applier)

Cradle-to-grave

Yes

Yes

Yes

AttributionalUse
phase/reuse
Yes

EoL/RecyclingInventory databases

Yes

EcoInventIndustry data

EoL: end-of-life

Surgical scissors
Refence (year,
country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)Distribution

Ibbotson et al.
(2013, Germany)

ISO 14040
standards

4 500 use cycles
of surgical scissors
during 18 years

Cradle-tograve

Yes

Yes

Yes

Use
phase/reuse
Yes

EoL/Recycling

Inventory databases

Yes

EcoinventAustralian data 2007
databases

Screening LCA
Attributional

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109

Rizan et al.
(2022, UK)

ISO 14040-44
standards
Attributional

One use of areusable surgicalscissor (type 17cm, straight Mayoreusable;manufactured inGermany and usedin the UK)

Cradle-tograve

Yes

Yes

Yes

Yes
(decontamination& repair if
relevant)

Yes (waste)

Ecoinvent
European Life Cycle
Database

EoL/Recycling

Inventory databases
Ecoinvent,U.S. LCI database,
Emissions & Generation
Resource Integrated
Database, the1994
Manufacturing
Consumption of Energy
SurveyPlasticsEurope,
PE International
The European ReferenceLife Cycle Database.
Ecoinvent

EoL: end-of-life

Medical blue wrap
Refence (year,
country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)Distribution

Babcock et al.
(2016, USA)Not mentioned

Sterilization
protection for 100
surgical toolsets
used 365 times per
year over 10 years

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Sterile packaging
of a standard
format instrument
tray for 5000
sterilization cycles

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Attributional

Friedericy et al.
(2021, The
Netherlands)

ISO 14040-44
standards
AttributionalUse
phase/reuse

EoL: end-of-life

Sharps containers
Refence (year,
Country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)DistributionUse
phase/reuse

EoL/Recycling

Inventory databases

Grimmond andReiner (2012,UK)

PAS 2050

Provision for 100
occupied hospitalbeds for one year

Cradle-tograve

Yes

Yes

Yes

Yes

Yes/NoGaBi (Ganzheitliche
Bilanz)
DEFRA (Department forEnvironment; Food andRural Affairs)
Warm (Waste Reduction
Model)

Attributional

Final report June 2023 – Study single-use materials in medicine and health care110

Grimmond et al.
(2021, UK)

BritishStandards
Institute PAS
2050
Attributional

McPherson et al.
(2019, US
California)

BritishStandards
Institute PAS
2050

Total fill line litres(FLL) of sharps
containers needed
to dispose of
sharps for 1-year
period in 40 trusts

Cradle-tograve

Yes

Yes

Yes

Yes

Yes/NoSupply of sharps
containers,
disposable andreusable, for a
one-year period

Cradle-tograve

Yes

Yes

Yes

Yes

Yes/NoUsephase/reuse

Plastic Europe
GaBi database2018/2019 UK
Department forEnvironment, Food andRural Affairs well-towheel GHG values forvehiclesWinPepi
American ChemistryCouncil, 2010,
USOE, 2010, DEFRA,
2010, NCASI,

Attributional
EoL: end-of-life

Surgery gown/isolation gown/coverall
Refence (year,
Country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)Distribution

EoL/Recycling

Inventory databases

Bijleveld andUijttewaal (2022
The Netherlands)
Vozzola et al.
(2018a, USA)ISO 14040-44
standards

One surgical gown

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

EcoinventISO 14040-44
standards

1000 uses of acleanroom coverall

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Environmental Clarity

Vozzola et al.
(2018b, USA)

Attributional
ISO 14040-44
standards

1000 uses ofisolation gown

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Environmental Clarity

Vozzola et al.
(2020, USA)

Attributional
ISO 14040-44
standards

1000 uses ofsurgical gown

Cradle-tograve

Yes

Yes

Yes

Yes

Yes

Environmental Clarity

EoL/Recycling

Inventory databases

Attributional
EoL: end-of-life

Laryngeal mask airway
Refence (year,
Country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)DistributionUse
phase/reuse

Eckelman et al.
(2012, USA)ISO 14040
standards

40 uses oflaryngeal mask
airwayCradle-tograve

Yes

Yes

Yes

Yes

Yes

Ecoinvent

Liang (2019,
Sweden)Attributional
ISO 14040-44
standards

40 uses oflaryngeal mask
airwayCradle-tograve

Yes

Yes

Yes

Yes

Yes

Ecoinvent
ELCD (European
Reference Life Cycle Data
System)Attributional

Final report June 2023 – Study single-use materials in medicine and health care111

Vaginal speculum
Refence (year,
Country)

Method LCA

Functional unit

Systemboundaries

Rawmaterials

Manufacturing(Packaging)Distribution

Donahue et al.
(2020, US)

ISO 14040-44
standards

5000 pelvic exams
with a vaginal
speculum

Cradle-tograve

Yes

Yes

Yes

20 pelvic exams
with a vaginal
speculum

Cradle-tograve

Yes

Yes

One pelvic examwith a vaginal
speculum

Cradle-tograve

Yes

Yes

Rodriguez Morrisand Hicks (2022,
US)

Attributional
ISO 14040-44
standards

Use
phase/reuse

EoL/Recycling

Inventory databases

Yes

Yes

Ecoinvent
WARM (Waste Reduction
Model)

No

Yes

Yes

Yes

Yes

Yes

Ecoinvent
ELCD (European
Reference Life Cycle Data
System)USLCI (United States Life
Cycle Inventory
Database)
EcoinventAttributional

Snijers et al.
(2022, The
Netherlands)

ISO 14040-44
standards
Attributional

EoL: end-of-life

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9.2

APPENDIX 2: Evidence table LCA’s Results

Laryngoscopes
Reference

Objective

Outcome

McGain etal. (2017,
Australia)

Environmental
impact ofdifferent
scenarios ofreplacing RU
anaesthetic
equipmentwith SUvariants

CO2 emissions(kgCO2eq)
Water use
(kilolitres)
Cost

Sherman etal. (2018,
US)

Providingquantitative
comparisonsofenvironmental
impacts andtotal cost ofownership
among
laryngoscope

Primary: GHG(CO2eq)Secondary:stratosphericozone
depletion,
PM2.5 which
contribute torespiratory
disease; cancer

ResultsRawmaterials
Not
specified

Manufacturing(Packaging)
Not specified

Distribution
Not
specifiedUsephase/reuse
Not
specified

EoL/Recycling

Total

Not specified

Climate change:
Scenario 1 (RUanaesthetic
equipment) –Scenario 5(replacement of RU
with SU anaesthetic
materials) = 5575 6763= - 1 188 kg
CO2eq
Water depletion:
82.2 (S1) -69.7 (S5)=
12.5 kilolitres
Eutrophication: 0.000.07: -0.07 kg P eq
Solid Waste: 250917= -667kg
Human Toxicity: 12491= -479 kg 1.4DBeq
Terrestrial
ecotoxicity: 0.0110.2=0.181 kg 1.4DBeq
Freshwater
ecotoxicity: 0.788.0= -87.3 kg 1.4DBeq
Marineecotoxicity:0.7-92.3=-91.6 kg 1.4-DBeq
Handles
RU with
HLD: 0.06 kg CO2eq
LLD: 0.08 kg (40%more than HLD)
CO2eq per use,
STZ (steam
sterilization): 0.23 kg
CO2eq (400% morethan HLD)

Final report June 2023 – Study single-use materials in medicine and health care

113

Sensitivity
analyses

RemarksNA
Scenario
based
consequential
LCA

In Australia
emissionsincreased byconvertingfrom SU to
RU due topower sourcemix.
Scenario’s
using
European and
US power
mixes lead to
reductions inCO2emissions forallanaesthetic
equipment
included inthis study.

1) 100%recycling
scenario
demonstrated
marginal
reductions inGHG
emissionsover thestandard

options forone hospitaland noncancer
disease throughchemical
exposure,ground-levelozone,
degradation ofwater quality
and ecosystem
health byacidification andeutrophication
aquatic
ecotoxicity anduse of nonrenewable fossil
resources

waste
disposalscenario for
SU and had
no significant
impact on RU
deviceemissionsand nosignificant
impact on
Bladescost
RU with2) calculate
HLD: 0.06 kg CO2eq
break-even
STZ: 0.22 kg CO2eq
scenarios(400% more thanbetween RU
HLD)and SU:SU
SU handles
plastic: 0.38 kg
becomeCO2eq
preferable if
metal: 0.44 kg
lifetime falls
CO2eq
below 5 for(approximately 40plastic and
50% more GHG
below 4 uses
emissions than thefor plastic.
reusable treated withBlades: SU
STZ)
becomepreferable if
lifetime of RU
falls below 5
for plastic
and below 3
for metal
blades
SU: single-use; RU: reusable; NA: not applicable; HLD: high level desinfection LDL: low level desinfecion; GHG: greenhouse gasses; STZ: steam sterilisation; EoL: end-of-life

Final report June 2023 – Study single-use materials in medicine and health careSU
plastic: 1.41 kg
CO2eq
metal: 1.60 kg
CO2eq(approximately 25
times more GHG
emissions than thereusable handle
treated with HLD)

114

Flexible endoscopes
Reference

Objective

Outcomes

ResultsRawmaterials

Badoudjian
et al. (2022,
France)To provide
the first LCAof flexible
cystoscopy
comparingthe LCA of
RU flexible
cystoscopes
and SUcystoscope

Globalwarming
potential(kgCO2eq),
Mineralresource
scarcity (MJ),
Ecotoxicity
potential(kg1.4-DBeq),
Acidification
potential (kgSO2 eq),Eutrophication potential(kg PO4eq)

Bringier et al(2023)

To compare
the potential
environmental
impact of RU
and SU
flexiblebronchoscopesGlobalwarming
potential(GWP)(kgCO2eq)
and11 otherenvironmenta
l categories
Abiotic
depletion (kgSbeq), abiotic
depletion(fossil fuels)(GJ), ozone
depletion

Production andmanufacturing:
SU: 86.1%
RU: 0.2%
Packaging:
SU: 5.3%
RU: 0%,

Sensitivity
analyses
Manufacturi
ng(packaging)Distribution

Transport:
SU: 3.1%
RU: 0.1%

Use phase/reuse

Use:
SU: 0%,
RU: 73.3%

EoL/Recycling

Waste:
SU: 5.4%
RU: 26.3%

Final report June 2023 – Study single-use materials in medicine and health care

Remarks

Total

Globalwarming:
SU: 2.06
kgCO2eq
RU: 3.08
kgCO2eq
Mineralresource
depletion:
SU: 25.03 MJ
RU: 49.92 MJ
Ecotoxicity
SU: 1.07
kg1.4-DBeq
RU: 2.20
kg1.4-DBeq
Acidification
SU: 0.0105 kg
SO2 eq
RU: 0.0369
kg SO2 eq
Eutrophication
SU: 0.0028 kg
PO4eq
RU: 0.0052
kg PO4eq
Globalwarming:
SU: 7.8 t
CO2eq vs RU:
5.8 t CO2eq
Abiotic
depletion
SU: 2.4 kg
Sbeq)
RU: 0.01 kg
Sbeq)
Abiotic
depletion(fossil fuel)SU:93 GJ
RU: 91.2 GJ

115

The
functional unit
and systemboundaries ofthe studied
products
differ.

-(gCFP-11eq), human
toxicity(t1.4DB eq),
fresh wateraquatic
ecotoxicity ,marineaquatic
ecotoxicity,terrestrial
ecotoxicity(kg 1.4DB
eq),
photochemical oxidation
acidification(kg SO2),
eutrophicitation (kg PO4eq), wateruse (m3)(in the life
stages GWP
is expressed
as % of thetotal life cycle
GWP of SU
or RU)

Davis etal.(2018,
Australia)

Compareenvironmental
impact of SU
with RU
flexible

Estimatedcarbonemissions(CO2)/Global
warming

SU: 3.83 + 0,3 kgCO2eq(sterilization
RU: 0.06 kgCO2eq

RU:3,95 kgCO2eq(washing
sterilisation) +<0.005 (repacking)+ 0,45 (kgCO2eq(repair)

SU: 0,3(kgCO2eq
RU: 0,005(kgCO2eq

Final report June 2023 – Study single-use materials in medicine and health careOzone
depletion
SU: 3.31
gCFP-11 eq
RU: 0.09
gCFP-11 eq
Humantoxicity
SU: 33.5
t1.4DB eq
RU: 6.7
Fresh wateraquatic
ecotoxicity
SU: 53.5 kg
1.4DB eq
RU: 29.6 kg
1.4DB eq
Marineaquatic
ecotoxicity:
SU: 253 kg
1.4DB eq
RU 162 kg
1.4DB eq
Terrestrial
ecotoxicity
SU: 64.6 kg
1.4DB eq
RU: 5.99 kg
1.4DB eq
Photochemical oxidation
SU: 1.76 kg
SO2
SU 0.92 kg
SO2
Eutrophication
SU: 80.5
RU: 4.43
Water use:
SU: 2.530 m3
SU: 3.920 m3
SU: 4.43
kgCO2eq
RU: 4.47
kgCO2eq116-

No validated
data.

Duijndam(2022, The
Netherlands)

Hogan et al(2022,
Danmark)Kemble etal. (2023,
US)

Le et al(2022, US)ureteroscopes
Investigate
environmental
impact of a
SU and a RU
flexible
intubation
scope.
Compare thecarbonfootprint of
SU with RU
cystoscopes

potential(kgCO2eq)
Climatechange(kgCO2eq) +9 midpoint
impactcategories
Global waste

Climatechange:SU: 1230
kgCO2eq
RU: 1120
kgCO2eq
SU: 1.34 kg C02eq
RU: 0,013kg C02eq

Estimatedcarbonemissions(CO2)/Global
warming
potential(kgCO2eq)

SU: 0,049 kg
C02eq
RU: -

Sterilisation
SU: 0,3 kg CO2eq
RU: 3,5 kg CO2eq

Incineration:
SU: 0,61 kg
CO2eq
RU: 0,52 kg
CO2eq
Landfill:
SU: 0,11 kg
CO2eq
RU: 0.22 kg
CO2eqCompare thecarbonfootprint of
SU and RU
flexible
cystoscopes

Estimatedcarbonemissions(CO2)/Global
warming
potential(kgCO2eq)

SU: 1.37 + 0.22 (packaging) +0.3 (sterilization) kgCO2eq
RU: 0.002 kgCO2eq

To compare
environmental
and human
health effects
of SU, RU
and RU withdisposable
endcapduodenoscopes.

Globalwarming
potential (kgCO2eq) + 22
midpoints

SU: 91-96% of total impact
GWP

SU: 0.20
kgCO2eq

No absolute
figures for thedifferent life
cycle phases,
only graphs.

Globalwarming
potential SU:
2.41 kgCO2eq
RU: 4.23
kgCO2eq(p>0.0001)-

New
reprocessor
wasintroduced:
RU: total
impact 1.04
kgCO2eq

RU: 0.20 kgCO2eq(reprocessing)
0.005 kgCO2eq(repackaging) + 0.3(PPE) + 0.02
(repair) kgCO2eq

SU: 0.31
kgCO2eq
RU: 0.0001
kgCO2eq

SU: 2.40
kgCO2eq

RU:
Electricity: 62% of
total impact GWP
Cleaning anddisinfection: 26% of
total impact GWP

SU: disposal 35% of total
impact GWP

SU 1*: 36.3
kg CO2eq
SU 2*: 71.5
kg CO2eq
RU: 1.53 kg
CO2eq
RU +
disposable
endcap: 1.54
kg CO2eq
Human health
SU1:1.7e-7
DALY
SU2: 3.42 e-4
DALY
RU: 1.31e-5
DALY
RU+: 1.29e-5
DALY

3 endpoints:
Human health(DALYs),ecosystem
quality(species.yr),
nonrenewabl
e resourceuse (US $)Final report June 2023 – Study single-use materials in medicine and health care

RU: 0.53
kgCO2eq

117

Range ofinfection rates

Short
duration
No validated
data
Estimated
impact data
Incomplete
LCA: only
carbonfootprint, notoverallenvironmenta
l impact.
Detergentswere notincluded

Compositionof theduodenoscop
e based on
an available
data or aureteroscope
Severalauthors
disclosed
financialrelationships

Ecosystem
quality
SU1: 2.58e-7
species.yr
SU2: 4.67e-7
species.yr
RU: 6.22 e-8
species.yr
RU+: 6.12e-8
species.yr

Sørensenand Grüttner(2018,
Danmark)CompareCO2equivalentemissionsand resource
consumption
from a SU toa RU
bronchoscope

GHG
emissions as
CO2equivalent (kgCO2eq)
Primaryenergyconsumption(MJ)

SU: scope

SU: scope

RU: PPE

RU: PPE

RU: using/washing/sterilization/drying/storing

Recycling all
recyclable
materials andincineration withenergy recoveryofauxiliarymaterials
SU: scope

Resource
consumption
SU1: 2.24
US$
SU2: 4.28
US$
RU: 8.5e-2
US$
RU+: 8.53-2
US$GHG
emissions
SU: 1.6
kgCO2eq
RU: 2.9
kgCO2eq
Energyconsumption
SU: 29 MJ
RU: 48 MJ

Different
standards
cleaning &disinfection
Different usesof PPE
1 PPE/ ≥ 2cleanings

Partial LCA
Producer SU
scope
involved indatacollection andfundingDifferent
Estimatedequipment
impact data,
Scarcecleaning &only graphs
resources
disinfection
are showed.
consumption(energy
SU: 2,1 DKK
consumption
RU: 2,9 DKK
washing/drying)
Different waste
treatments(disposals of
PPE or SU
scopes)
SU: single-use; RU: reusable; DALYs: disability-adjusted life years; GWP: global warming potential; GHG: greenhouse gas; PPE: personal protective equipment; DKK Danish krone*because of lack of data on the composition of SU, the authors modelled a lower bound SU scenario (scenario 1 = same % of electronics as the RU) and an upper bound scenario (scenario 2 =same mass of electronics as the RU).
Scarceresources
consumption(DKK)

RU: PPE +materials forcleaning

Final report June 2023 – Study single-use materials in medicine and health care118

Trocars
Reference

Unger andLandis(2016, US)

Boberg etal. (2022,
Sweden)Rizan and
Bhutta(2022, UK)

Objective

OutcomeResultsRawmaterials

Manufacturing(Packaging)DistributionUse
phase/reuse

EoL/Recyclin
g

Total

Sensitivity
analyses

Remarks

No absolutenor relative
figures on
outcomemeasureswere
included inthemanuscript
Mixed trocar
system: useof SU andRU trocars.

To modelenvironmenta
l impacts ofvarying levelsofreprocessing
at a hospitalin Phoenix,
Arizona
To compare
environmenta
l impacts of asingle-use, amixed, and areusable
trocar systemforlaparoscopiccholecystectomy

Global warming,
carcinogenic,
non-carcinogenic,
and respiratory
effects

Graph

Graph

Graph

Graph

Graph

Not specified

Varying quantities of
ETO consumed by
the commercial gas
sterilizer

Global warming(kgCO₂eq) +15
midpoint
categories & 4
endpoint
categories:
resources,
climate change,
ecosystem
quality, andhuman healthGraph (perendpoint)

Graph (perendpoint)

Graph (perendpoint)

Graph (perendpoint)

Graph (perendpoint)

Differences between
SU and RU trocars
were found to besensitive to lower
filling of machines inthe sterilization
process (forresource use andecosystem quality),
50% decrease in
number of uses, andusing a fossil fuelelectricity mix(ecosystem quality).

To compare
theenvironmenta
l life cycle
cost of hybrid
and SU
instruments(trocar) for
laparoscopiccholecystectomy

Global warming(CO2eq) + 17
midpoints
and 3 endpoint
categories:
damage to humanhealth (DALY),
naturalenvironment(species.yr),
resource scarcity(US $)

Graph

Graph

Graph

Graph

Graph

SU trocars
182%
higherimpact on
resources379%
higherimpact on
climatechange83% higher
impact on
ecosystemcompared
to reusable
trocars
Hybrid933g CO2eq /4
trocars
Human health
1.67e−6. DALY
Ecosystem
3.67e−9 species.
yrResources
0.0853 US $Final report June 2023 – Study single-use materials in medicine and health careSU
3495g CO2eq/4
trocars
Human health
6.13e−6 DALY

119

Five alternative
scenarios examining
impact of number ofuses, separate clip
applier, impact ofenergy mix,changing
transportation, typeof trocars used:performance ofhybrid instruments
was better evenwith lownumber ofreuses of
instruments,

Work wasfunded by
SurgicalInnovations
Ltd. who
manufacture
hybridlaparoscopic
instruments

Ecosystem
1.36e−9species.yr
Resources
0.344473 US $

-

-

-

decontaminatio
n with separate
packagingdecontaminatio
n using fossilfuel-rich energy
sources,changing
carbon intensityof instrumenttransportation

Laparosopic surgical stapler, cutter scissors, clip appliers
Reference

Rizan and
Bhutta(2022, UK)

Objective

To compare theenvironmental
life cycle cost
impact of hybrid
and single-use
laparoscopic
instruments(scissors andclip applier)used for alaparoscopiccholecystectomy

Outcomes

Globalwarming(gCO2eq) +17 midpoints
and 3
endpoint
categories:
damage tohuman health(DALY),
naturalenvironment(species.yr),
resource
scarcity (US$)

Results
Raw
Manufacturing
materials (packaging)
Global warming
SU: 660 gCO2eq vs Hybrid
232 gCO2eq (SU parts),
1.27 gCO2eq (RU parts)

Distribution
Globalwarming
SU: 324gCO2eqUsephase/reuse
Global warming
Decontamination
Hybrid: 79
gCO2eq

EoL/Recycling

Total

Globalwarming:
SU: 154gCO2eqGlobalwarming
SU 1138gCO2eqHybrid378 gCO2eq
Human health
SU: 2.90.e−6.
DALY
Hybrid: 1.28
e−6. DALY
Ecosystem
SU: 5.22 e−9
species.yr
Hybrid:1.84 e−9species.yr

Scissors

Resources
SU: US $0.1176
Hybrid: US$0.0314
Clip applier

Global warming
SU: 112 gCO2eq
Hybrid 112 gCO2eq (SUparts), 4,37 gCO2eq (RU
parts)

Globalwarming
SU: 923
gCO2eqGlobal warming
Decontamination
Hybrid: 247
gCO2eqGlobalwarming:
SU: 294gCO2eqFinal report June 2023 – Study single-use materials in medicine and health care

Sensitivity analyses

Remarks

Five alternative
scenarios examining
impact of number ofuses, separate clip
applier, impact ofenergy mix, changing
transportation, typeof trocars used:performance ofhybrid instruments
was better evenwith low numberof reuses of
instruments,
decontamination
with separate
packagingdecontamination
using fossil-fuelrich energy
sources,changing
carbon intensityof instrumenttransportation

Work wasfunded by
SurgicalInnovations
Ltd. who
manufacture
hybridlaparoscopic
instruments

Globalwarming
SU 2559gCO2eqHybrid445gCO2eq120

Human health
SU: 6.30.e−6.
DALY
Hybrid: 1.09
e−6. DALY
Ecosystem
SU: 1.24 e−9
species.yr
Hybrid:1.96 e−8
species.yr
Resources
SU: US $0.2944Hybrid: US $0.0464
SU: single-use; RU: reusable; DALYs: disability-adjusted life years

Surgical scissors
Reference

Objective

OutcomeResults

Sensitivity
AnalysesRawmaterials

Manufacturing(Packaging)Distribution

Rizan et al.
(2022, UK)

Evaluate theenvironmenta
l impact &financial costof repairing
surgicalscissors for 3
scenarios
no repair,
onsite(hospital) andoffsiteGlobal warming
impact, with GHG
expressed ascarbon dioxide
equivalents(CO2eq) +17 midpoint
impact categories
providingendpoint
estimates fordamage onhuman health,naturalenvironment, andresource scarcity

Amounts not
specified –Figure withcarbonfootprint for
eachcategory
available

Amounts not
specified –Figure withcarbon footprint
for eachcategory
available

Amounts not
specified –Figure withcarbonfootprint for
eachcategory
available

Ibbotson etal. (2013,
Germany)

Evaluate theenvironmenta
l impact &total cost ofownership(customer

18 explicit impact
categories indifferent units,
such as kgCO2eq
and kg oileq

Graph
Presented inacontribution
percentageof the total

Graph

-

Use
phase/reuseAmounts
notspecified –Figure withcarbonfootprint for
eachcategory
available

EoL/Recycling

Total

Amounts not
specified –Figure withcarbon footprint
for each category
available

70.3 gCO2eq/use
Onsite repair:56.3 gCO2eq/use
Offsite repair:
57 g
CO2eq/scissor
use

Graph

Graph

Graph

Final report June 2023 – Study single-use materials in medicine and health care

121

Scenario analysis toevaluate the impactof assumptions in
number of uses,
reducing number of
repairs, increasing
distance to offsite
repair centre,
alternative electricity
sources, and waste
handling processes.
Whitin all scenarios,
highest carbon
footprint for nonrepaired scissors
and lowest for those
repaired onsite
LCA results arereliable throughout
all assumptions anddata uncertainties.
TCO results are
more dependent on

Remarks

perspective)
comparing
disposable
scissors of
stainlesssteel,
disposable
scissors offibrereinforced
plastic andreusablestainlesssteel
TCO: total cost of ownershipenvironment
al impact
results of thestainlesssteel
disposable
scissors

the choice of casestudy parameters,such as price andcase-specific costsof sterilization.

Medical blue wrap
Reference

Babcock etal. (2016,
US)

Friedericy etal. (2021,
The
Netherlands)

Objective

To compare SU
polypropylene
blue wraps and
RU aluminium
containers

To compare theenvironmental
impact of SU
and RUsterilisation
packaging for
surgical
instruments
To investigate
theenvironmental
break-evenpoint of usecycles ?

Outcomes

Globalwarming
potential(kgCO2eq)

ResultsRawmaterials

Sensitivity analysis
Manufacturing(packaging)
Graph:
SU: 22.2% of
total impact
RU: 1.6% of
total impact

DistributionUse
phase/reuse
Graph:
SU: 77.3% of
total impact
RU: 97.5% of
total impact

EoL/Recycling

Total

Graph:
SU: 2.5% of
total impact
RU: 0.9% of
total impact

SU: 823 000
kgCO2eq
RU: 377 000
kgCO2eq-

Carbonfootprint:SU
incineration:
1869
kgCO2eq
SU recycling:
883 kgCO2eq
RU landfill:285 kgCO2eq
RU recycling:
270 kgCO2eq

Three scenarios forelectricity compared
to EU-27 mix- 100% photovoltaic
cells EU conditions
give a potential
reduction in the ecocost of the RSC
system of 28 euro
per 5000 cycles- 100% coal-fired
power plants: large
increase in eco-cost- World average mix:
increase in eco-cost

Solid waste(kg)
Carbonfootprint(kgCO2eq)
ReCiPe(points/5000
cycles)
EcoCosts(€/5000
cycles)

ReCiPeGraph
EcoCosts
Graph
Break-evenpoint (SUincineration

Final report June 2023 – Study single-use materials in medicine and health care

122

Remarks

vs RU
landfill) :Carbonfootprint: 98
use-cycles
ReCiPe 228
use-cycles
Eco-costs 67
use-cycles.
SU: single-use; RU: reusable; EU: european

Sharp containers
ReferenceMc
Pherson etal. (2019,
US)

Grimmond
et al.
(2021, UK)

Objective

Outcome

Impact GHG
emissions
during 12
months1100-bedfacility (5hospitals) of
RU and SU
sharpscontainer.

GHG emissions(CO2, CH4, N2O)
in metric tons ofcarbon dioxideeq.(MTCO2eq)

Globalwarming
potential(GWP) ofhospitals
replacing SU
by RU sharp
containers.
12 months
hospital-wideuse in 40
trustsCarbon dioxide
equivalents(CO2eq). OtherGHGs areconverted totheir CO2eq
based on perunit radiative
forcing using
IPCC 100-year
GWP
Total annual
metric tonnes ofCO2eq of bothcontainment
systems; kg
CO2eq/1000
FLL
kg CO2eq/1000
patient activity
episodesResultsRawmaterials
SU SC: 148.6
RU SC: 3.1

SU SC: 2179.4
RU SC: 116.7

Sensitivity
analyses
Manufacturing(Packaging)Distribution
SU SC:69.8
RU SC: 77.6

SU SC:
554.2
RU
SC:422.0

Use
phase/reuse
SU SC: 0
RU SC: 4.9

SU SC: 0
RU SC:58.4

EoL/Recycling

Total

SU SC: 30.2
RU SC: 0.6

SU SC:
248.6MTCO2eq
RU SC (lifespan of
26.4 years): 86.20
MTCO2eq (162.4
MTCO2eq reduction
or 65.3%, p<0.001)+ elimination of 50.2
tonnes plastic (31.8
landfill + 18.4
incineration), 8.1
tonnes cardboard.
SU SC: 3896.4
MTCO2eq
RU SC (lifespanof 18 years): 628.9
tonnes CO2eq

SU SC: 1162.8
RU SC:31.9

Final report June 2023 – Study single-use materials in medicine and health care

reduction of 3267.4
MTCO2eq or 83.9%+ elimination of 900.8
tonnes plastic (landfill+ incineration), 132.5
tonnes cardboard.

123

Lifespan RU
SC: variationsof 41.7 years &15 years has
minimal impact(0.4 & 1.3%)
US electricity
sources alter
processing andmanufacturing
GHG by 82%
Items insensitivity
analyses had
small effects(<5%) onfinal GWP.
One exception
was theoretical
RU SC
lifespan of
1year which
achieved an
endcomparison
reduction of
57.3% (26.6%
less than thebasecomparison)

Remarks

Grimmondand Reiner(2012, US)

Globalwarming
potential(GWP) ofreplacing SU
by RU sharp
containers.
Study period
from 12months preand post
replacement

GHG emissions(CO2, CH4, N2O)
in metric tons ofcarbon dioxideeq.(MTCO2eq)

SU SC: 32.1
RU SC: 4.9

SU 1 RU SC:
Not included
only Figure

SU & RU
SC: Not
included only
FigureSU & RU SC:
Not included
only Figure

SU SC:
139.1MTCO2eq
RU SC (lifespan of
39.6 years): 25.1
MTCO2eq
Replacement by RU
SC: reduction ofannual GWP by 127
MTCO2eq (-83.5%)
and diverted 30.9
tons of plastic and
5.0 tons of cardboard
from landfill

Distance
between healthcare facility
andmanufacturer
were reversed:
GWP reduced
from 83.5 to
64.5% for RU
SC, but
manufacture
remainedlargestcontributor

SU: single-use, RU: Reusable, SC: sharp container; GHG: greenhouse gas, GWP: global warming potential; MTCO2eq metric tonnes carbon dioxide equivalent

Surgical gown / isolation gown / coverall
Reference

Bijleveld andUijttewaal(2022, The
Netherlands)

Objective

To compare
environmental
impacts of RU
and SU surgicalgowns

Outcomes

Carbonfootprint(kgCO2eq)

ResultsRawmaterials
Graph

Manufacturing(packaging)
Graph

Distribution
Graph

Use
phase/reuse
Graph

EoL/Recycling

Total

Graph

Graph

Sensitivity analysis

Remarks

Green energy:
reduction of 5-11%

No absolute
figures are
given, only
graphs.

Recycling SU gown:
reduction, but still
higher impact than
RU gowns.
Lower number ofreusing (25 times):
limited increase

Vozzola etal. (2018a,
US)

To compare theenvironmental
impact of RU
and SUcleanroom
overalls

Globalwarming
potential(kgCO2eq)
Process
energy (MJ)
Naturalresource
energy (MJ)
Water
consumption(kg)
Solid waste(kg)

Global warming potential
Manufacturing coverall +supply chain (transport)
RU:115 kgCO2eq
SU HDPE: 414 kgCO2eq
SU PP: 824 kgCO2eq
Manufacturing packaging
RU:22.8 kgCO2eq
SU HDPE: 48.4 kgCO2eq
SU PP: 48.4 kgCO2eq
Natural resource energy
Manufacturing coverall +supply chain (transport)
RU:1790 MJ
SU HDPE: 6130 MJ

Global warming
potential
Laundry
RU:336kgCO2eq
SU HDPE: 143
kgCO2eq
SU PP: 204
kgCO2eq
Sterilization
RU:1.08kgCO2eq
SU HDPE: 0.461
kgCO2eq
SU PP: 0657
kgCO2eq
Use Transport

Globalwarming
potential RU: 0
SU HDPE:
6.19
SU PP: 8.35
Naturalresource
energyRU: 0
SU HDPE:
86.1
SU PP: 123

Final report June 2023 – Study single-use materials in medicine and health care

Globalwarming
potential
RU:517SU HDPE:
712
SU PP: 1220

Input form
the American
Reusable
TextileAssociation

Process
energyRU: 4560 MJ
SU HDPE:
6930 MJSU PP:
11100 MJ

124

SU PP: 12900 MJ
Manufacturing packaging
RU:355 MJ
SU HDPE: 792 MJ
SU PP: 792 MJ

RU:42.1
kgCO2eq
SU HDPE: 99.9
kgCO2eq
SU PP: 132
kgCO2eq

Naturalresource
energyRU: 8380 MJ
SU HDPE:
10900 MJSU PP:
19200

Natural resourceenergyLaundry
RU: 5560 MJ
SU HDPE: 2370
MJ
SU PP: 3380 MJ
Use Transport
RU:661 MJ
SU HDPE: 1530
MJ
SU PP: 2030 MJ
Sterilization
RU:5560 MJ
SU HDPE: 2370
MJ
SU PP: 3380 MJ

Vozzola etal. (2018b,
US)

To compare 4
environmental
impacts of RU
and SU isolation
gowns

Globalwarming
potential(kgCO2eq)
Naturalresource
energy (MJ)
Water use(kg)
Solid waste
consumption
(kg)

GWP
SU
manufacture &delivery: 300
kgCO2eq(gown) + 6.95
kgCO2eq(packaging)
RU
manufacture &delivery: 68.6
kgCO2eq(gown) + 1.03
kgCO2eq(packaging)
NRE
SU
manufacture &delivery: 4996
(gown) + 120
MJ (packaging)
RU
manufacture &GWP
RU Laundry:
146 kgCO2eq +0.411 kgCO2eq(water) + 2.08
kgCO2eq(restore waste
water)NRE
RU Laundry:
2.538 MJ + 7.31
MJ (water) +14.4 MJ (restore
waste water)
Blue water
RU Laundry:
8.71 kgBlue water
RU: 80.7 kg
SU HDPE:
304 kgSU PP: 345
kg
Solid waste
RU: 10.2 kg
SU HDPE:
171 kgSU PP: 238
kg

GWP
SU Landfill:1.99 kgCO2eq(gowns +packaging) +0.794 kgCO2eq(biologicalwaste)RU Landfill:0.139 kgCO2eq(gowns +packaging) +0.0132
kgCO2eq(biologicalwaste)NRE
SU Landfill:
34.9 MJ(gowns +packaging) +Final report June 2023 – Study single-use materials in medicine and health care

GWP
SU: 310kgCO2eq
RU: 218
kgCO2eq

Different weight of
SU RU gowns
Laundry process

NRE
SU: 5150 MJ
RU: 3712 MJBlue water
SU: 74.6 kg
RU: 43.8 kg
Solid waste
SU: 63.4 kg
RU 0.4134.42kg(dependingon 100% or
0% recycling)125

delivery: 1133
MJ (gown) +16.7 MJ(packaging)-0.682 MJ(biologicalwaste)RU Landfill:2.538 MJ
(gowns +packaging) +-0.0114 MJ(biologicalwaste)

Blue waterSU
manufacture &delivery: 74,6
kg (gown)
RU
manufacture &delivery: 35.1
kg (gown)

Vozzola etal. (2020,
US)To evaluate
environmental
impacts ofreusable anddisposable
surgical gowns

Globalwarming
potential(GWP)(kgCO2eq)
Naturalresource
energy (MJ)
Water use(kg)
Solid waste
consumption
(kg)

GWP
SU
manufacture &supply chain:
1.495 kgCO2eq(gown) + 121
kgCO2eq(packaging) +6.26 kgCO2eq(sterilization)
RU
manufacture &delivery: 143
kgCO2eq(gown) + 76.7
kgCO2eq(packaging)
NRE
SU
manufacture &supply chain:
23.958 MJ(gown) + 2.040
MJ (packaging)

GWP
RU Laundry:
278 + 19.8
kgCO2eq(sterilisation)

Solid waste
SU Landfill:
63.2 kg (gowns+ packaging) +0.194 kg
(biologicalwaste)RU Landfill:0.413-4.41 kg(gowns +packaging) +0-0.00323 kg(biologicalwaste)GWP
SU: 10.9
kgCO2eq
RU: 1.40
kgCO2eq

GWP
SU: 1636
kgCO2eq
RU: 557kgCO2eq

Different weight of
SU RU gowns
Laundry process
Transport

NRE
RU Laundry:
4821+ 343
kgCO2eq(sterilisation) +Blue water
RU Laundry:
57 + 1.39 kg(sterilization)

NRE
SU: 149 MJ
RU: 23.9 MJ
Solid waste
SU: 0.505 kg
RU: 0-0.00842
kg

Use phasetransport
GWP
SU: 3.47
kgCO2eq
RU: 38.7
kgCO2eq

Final report June 2023 – Study single-use materials in medicine and health care

NRE
SU: 26289
MJ
RU: 9396 MJBlue water
SU: 1097 kg
RU: 185kg
Solid waste
SU: 265 kg
RU 35.5-43.4
kg(dependingon 100% or
0% recycling)

126

Study fundedby American
Reusable
TextileAssociation
Life Cycle
Assessment
Committee

+ 89 MJ
(sterilization)
RU
manufacture &delivery: 2.366
MJ (gown) +1.246 MJ
(packaging)

NRE
RU: 53.5 MJ
SU:596 MJBlue waterSU
manufacture &delivery: 1058
kg (gown) +36.6 kg(packaging) +2.38 kg(sterilization)
RU
manufacture &delivery: 69.7
kg (gown) +56.7 kg(packaging)
Solid waste
manufacture &delivery: 224 kg(gown) + 40.3
kg (packaging)
RU
manufacture &delivery: 0-7.9
kg (gown) +35.5kg(packaging)
SU: single-use; RU : reusable, GWP: global warming potential, NRE: Natural resource energy; PP: single-use polypropylene, SU HDPE: high density polyethylene;

Laryngeal mask airway
Reference

Eckelman etal. (2012,
USA)

Objective

To compare theenvironmental
impact of SU
and RU

Outcomes

Results

Globalwarming (kgCO2eq)

Raw
Manufacturing
materials (packaging)
SU production+polymerisation PVC: 23% of
the GHG emissions and
60% of human healthimpacts; polycarbonate

Distribution
SU trucktransport:
15% of theGHGemissionsUsephase/reuse
RU natural gas
production +combustion to
produce steam
for theEoL/Recycling

Total

SU waste: 11%of the GHG
emissions and
15% of humanhealth impacts

GHG
emissions
SU: 11.3
kgCO2eq

Final report June 2023 – Study single-use materials in medicine and health care

Sensitivity
analyses

Remarks

RU:-fully loaded
autoclave (10pieces): 5.6
kgCO2eq

Only global
warming
impacts arereported,other impact

127

laryngeal mask
airwayLiang (2019,
Sweden)To compare theenvironmental
impact of SU
and RUlaryngeal mask
airwaysOtherenvironmental
concerns
Human healthrelatedimpacts

Globalwarming(kgCO₂eq) +17 midpoint
categories &3 endpoint
indicators:
humanhealth,ecosystem
quality, andresources

production: 14% of the GHG
emissions; thermoforming
13% of the GHG emissions

Graph

autoclave: 77%of the GHG
emissions

Graph

Graph

RU: 7.4
kgCO2eqGraph

No figures are
given.
Comparative
analysis of thesingle-use andreusable LMA
for 3 endpoints(human health,ecosystems
and resources):
reusable LMA
has less than
40% impact
burdens
compared withthe disposable
LMA.

- individual
autoclave: 37
kgCO2eq- autoclave
efficiency +10%: 6.8
kgCO2eq- 10 reuses: 11.4
kgCO2eqSU:- transport by air:
20.5 kgCO2eq- Source electricity- Ingredientsdetergents- Reuse cycles

categories
are reported
in acomparative
analysis

No absolute
figures aregiven

SU: single-use; RU : reusable, LMA: laryngeal mask airway; GHG: greenhouse gas

Vaginal speculum
Reference

Donahue etal. (2020,
US)

Objective

Environmental
impact of 3
vaginal specula:
one SU acrylic
and two RU
stainless steel
speculaOutcomes

Results

Globalwarmingemissions (kgCO2eq)

Raw
Manufacturing
materials (packaging)
RU stainless steel 304:
24.9%
RU stainless steel 316:
34.4%
SU acrylic: 90.6%

Sensitivity
analyses
Distribution
RU
stainlesssteel 304:
0.46%
RU
stainlesssteel 316:
0.4%

Use
phase/reuse
RU stainlesssteel 304:
74.1%
RU stainlesssteel 316:
65.2%

EoL/Recycling

Total

RU stainlesssteel 304: RU stainlesssteel 316: -RU stainlesssteel 304
(lifespan 20ex.): 5.72 kg
CO2eq
RU stainlesssteel 316
(lifespan 20ex.):6.51 kg
CO2eq
SU
acrylic:17.54
kg CO2eq

SU acrylic:
2.9%

SU acrylic: NA

SU acrylic:
6.5%

Final report June 2023 – Study single-use materials in medicine and health care

Impact changes in
autoclave loading
was significant
when shifting toindividuallysterilizing specula(not as great
between half-fulland completely
loaded autoclave)
Difference between
the most carbon
intensive grid and128

Remarks

Rodriguez
Morris andHicks (2022,
US)

Snijers et al.
(2022, The
Netherlands)

Environmental
impact of SU
acrylic and RU
stainless steel
speculaEnvironmental
impact of SU offossil plastic(ABS), SUbiobased plastic(PLA) and RU
stainless steel
speculaGlobalwarming
potential
Acidification
potential
Human health:carcinogens
Ecotoxicity
potential
Eutrophication
potential
Fossil fueldepletion
potential
Human health:noncarcinogens
Ozone
depletion
potential
Respiratory
effects
Photochemical
oxidant
creation
potential

Numbersnotreported

Globalwarmingemissions (kgCO2eq)

Numbersnotreported

Numbers notreported

Numbers
not reported

Numbers notreported

Numbers notreported

Graph

Graph

Graph

Graph

Graph

Globalwarming
potential
RU stainless
steel(lifespan 5
years): 326
kg CO2eq
SU acrylic:
2220 kg
CO2eq
Ozon
depletion
RU stainless
steel(lifespan 5
years):
0.00033kgCFC-11e
SU acrylic:
0.000042
kgCFC-11e

Numbers notreported

Numbers
not reported

Graph

Graph

RU: 99% (500uses)
SU: NA

Numbers notreported
Graph

Graph

RU: 0.13 kg
CO2eq
SU ABS:
0.30 kg
CO2eq
SU PLA:
0.14 kg
CO2eq

least carbon
intensive grid
resulted only in a
33-36% reduction in
total CO2eq
emissions
For stainless steel,the steel production
is overall the mostsensitive impact.
The use of nitril
gloves are adominant input, andmakes RU
speculums havemore total impacts
in the ozone
depletion category
when compared to
SU acrylic
speculum.
For electricity inputs
is the most sensitive
the electricity
coming from hardcoal. Also significant
as electricity fromhard coal isdominant in use
phase of RU
stainless steel
specula.
Scenario analysis
using a moresustainable
electricity mix:
reduction between
10 and 15% forreusable, but also a
reduction for singleuse (if produced in
the Netherlands)

SU: single-use; RU: reusable; NA: not applicable; ABS: Acrylonitrile butadiene styrene; PLA: single-use biobased plastic

Final report June 2023 – Study single-use materials in medicine and health care

129

Impacts fromtransportation,
cardboardpackaging,labour andoverheadwere notincluded

Scoping LCA(only including
globalwarming)

9.3

APPENDIX 3: Inviting letter in French

Final report June 2023 – Study single-use materials in medicine and health care

130

Final report June 2023 – Study single-use materials in medicine and health care131

Final report June 2023 – Study single-use materials in medicine and health care132

Final report June 2023 – Study single-use materials in medicine and health care

133

9.4

APPENDIX 4: List items excluded by FAMHP

Final report June 2023 – Study single-use materials in medicine and health care134

Final report June 2023 – Study single-use materials in medicine and health care

135

Final report June 2023 – Study single-use materials in medicine and health care

136

9.5

APPENDIX 5: List excluded items

Excluded items (non-exhaustive list)
Disinfectants and cleaning products
Toothpicks, earplugs
Toilet paper, coffee cups, paper pouches
Incontinence products for adults, monthly pads
Glucose monitoring equipment: glucose sticks, needles, plasters with needles
Blood tubes, specimen collecting jars (urine, faeces, …), wound swabs
Infusion (intravenous & enteral) therapy equipment: tubes, lines, infusion bags, syringes, taps, needle-freesystems, connectors, caps, catheters, transfers needles
Masks (surgical masks/FFP2)
Medication, pre-filled syringes, contrast agents, anaesthetics
Wound care and related items: suture, compresses, gauze, tampons, bandages (transparent/adhesive
non-transparent/postoperative)
Kits/Sets (with/without instruments)
Aspiration and ventilation equipment: aspiration pots, bags and probes, HEPA and humidity filters, oxygen
nasal tubes
Other medical materials: EKG pads (foam), condoms for probes (ultrasound/temperature)

Final report June 2023 – Study single-use materials in medicine and health care

137

9.6

APPENDIX 6: Data provided by the included hospitals and overview of
missing data
Purchase department

Pharmacy department

ID

RegionAmountCost

AmountCost

OR material(laparoscopic
devices/sets/ …)
AmountCost

1

Flanders

x

-

x

-

-

-

2

Brussels

-

-

x

-

-

-

3

Wallonia

x

x

x

x

-

-

4

Brussels

x

-

x

-

-

-

5

Flanders

x

x

x

x

x

x

6

Flanders

x

-

x

-

-

-

7

Flanders

x

x

x

x

-

-

8

Wallonia

x

x

x

x

-

-

9

Wallonia

x

-

x

-

-

-

10

Flanders

x

-

x

-

-

-

11

Wallonia

x

x

-

-

-

-

Data 2022 (10 months)

12

Flanders

x

-

x

-

x

-

Items shortlist
Data 2021

Final report June 2023 – Study single-use materials in medicine and health care

Remarks

Data 2022 (9 months)

138

9.7

APPENDIX 7: Longlist of items

ITEM

VERWERKINGGLOVES (NS)BEHAVOIURGLOVES (S)

N.A.

MEDICATION CUPS

TD/LLDSTERILISATION BAG

STERILISATION

COVERCAPS FOR TEMPERATURE
MEASUREMENTPLASTIC BAG (EXCL. TRASH CANS)CHANGE OF ITEM/DEVICE

ABSORBING SHEET/TRAYLINERLAUNDRYSURGICAL AND OTHER CAPSLAUNDRY

BASINS

LLD/HLDSTERILISATION DRAPESSTERILISATIONSHOE COVERSBEHAVOIUR/LAUNDRYMILK BOTTLESSTERILISATIONTONGUE DEPRESSOR (NS)HLDTONGUE DEPRESSOR (STERILE)

STERILISATION

BREAST(FEEDING) COMPRESSLAUNDRYSHEETS EXAMINATION TABLESLAUNDRY

ANAESTHESIA MASKSSTERILISATIONNEEDLE BINSWASTE

SPO2 SENSOR

LLD/(N/D)

BRUSH ENDOSCOPIC VALVESHLDGARROT LATEX FREE STRECH BLEU

LLD

SPECULUM

STERILISATIONGOWN (NS)LAUNDRY

GOWN (S)LAUNDRY

MOUTH RETRACTOR

HLD

DENTAL JAR

HLD

BIB

LAUNDRY

LID FOR DRINKING CUPTDPROTECTIVE COVER MATRESSLAUNDRYWASH CLOTH

LAUNDRYWASH CLOTH (IMPREGNATED)LAUNDRY

DIAPERS (BABY)LAUNDRY

LID MEDICATION CUPSLLD

PLASTIC GARGABE BAGSBEHAVOIURSCISSORS (STERILE)

STERILISATIONSHARPS CONTAINERS

WASTE

SINK

LLD

TWEEZERSSTERILISATIONKOCHER (STERILE)

STERILISATION

LITE GLOVESTERILISATIONLARYNGAL MASKSTERILISATIONOXYGEN MASKHLDINCONTINENCE PADS

LAUNDRY

SURGERY GOWNSLAUNDRY

PLATE

LLD

BEHAVOIUR

Final report June 2023 – Study single-use materials in medicine and health care

139

TROLLEY COVERSLAUNDRYSCRUB BRUSH

STERILISATIONWARM-UP JACKETLAUNDRY

WIPES

LAUNDRY

RX-COVERSLLD

SURGICAL DRAPESLAUNDRY

DRAPE

LAUNDRY

MESURING CUPHLDLARYNGOSCOOPBLADESSTERILISATION /HLD

NEEDLE HOLDERLAUNDRYBLOOD PRESSURE CUFFSLLD

TRAY 250ML AUTOCLAVSTERILISATIONVESSEL SEALING (ECHELON)STERILISATIONTABLE COVER

LAUNDRYVESSEL SEALING (ENDO GLIA)STERILISATIONTROCARSSTERILISATIONPILLOWCOVER

LAUNDRYTELEMETRIE CARRYING BAG

LAUNDRY

STERILE CUPSTERILISATIONASPIRATION JARHLDAEROSOL MASK + JAR

STERILISATION /HLD

BREASTFEEDINGPUMP KITSTERILISATION /HLDMAYO TUBE

STERILISATION /HLDVENTILATION TUBESSTERILISATIONNAPKINLAUNDRY

TRANSFER NEEDLESSTERILISATIONPAPER MEDICATION BOX

CHANGE OF ITEM/DEVICEDESINFETION WIPE (SMALL)

LAUNDRYWOODEN SPATULACHANGE OF ITEM/DEVICECARE KIT WITH INSTRUMENTSTERILISATION

BED PANHLDTOWELETTESLAUNDRY

IDENTIFICATION BRACELETCHANGE OF ITEM/DEVICE

S: Sterile; NS: Not Sterile, HLD: High Level Disinfection; LLD: Low Level
Disinfection; T.D: Thermal disinfection, N.A.: Not Applicable

Final report June 2023 – Study single-use materials in medicine and health care

140

9.8

APPENDIX 8: Example amount/cost ratio for one hospital
Cost/Amount-ratio 2019

Cost (euro/bed/year)

Vessel sealing (type 2)

Vessel sealing (type 1)
Surgical gown
Trocars
Blood pressure gaugemanchettes

Sheets examinaton
tables

Bed sheet
Sterilisaton cloths

Autoclavable scale

Surgical scissors

050
Scissors
Tweasers
Pillows
Tongue depressors

100

Needle holders
Dressing change kitSterilisation bags(with tweasers)
Kidney tray
Trayliners
cups
150
200
250 Medication 300

Amount (#/bed/year)

Final report June 2023 – Study single-use materials in medicine and health care

141

350

9.9

APPENDIX 9: Consumption of medical single-use items per bed per year for
all participating hospitals

Figure 9: Overview of consumption of medical single-use items per bed per year

Final report June 2023 – Study single-use materials in medicine and health care

142

9.10

APPENDIX 10: Amount/Cost (catalogue prices) - rate
Amount / Cost (catalogue prices)

Cost - based on catatlogue prices (€/bed/year)

4000
MILK BOTTLES;
3505,0855
3500

3000

2500
NEEDLE BINS;
2037,305828

SURGERY GOWNS;
2221,927553

2000

GOWN (S);MILK BOTTLES;
1307,589935
NEEDLE BINS;
1500
1204,756
1149,664667
NEEDLE
BINS;
945,0107715
1000
MILK BOTTLES;BOTTLES;MILKSHARPS
BREAST(FEEDING)
586,3737991
COVERCAPS FOR
572,509
COVERCAPS
GOWN
562,8714BIB;
BIB;509,95
547,1655 FOR
CONTAINERS;BREAST(FEEDING)
COVERCAPS
COVERCAPS
FOR (S);FORCOMPRESS;TEMPERATURE
MILK
BOTTLES;
BIB;
449,8079466
TEMPERATURE
BRUSH
345,623MILK
BOTTLES;SCISSORSSURGICALAND
TEMPERATURESURGICALAND
BRUSHSCISSORSSURGICALAND
BREAST(FEEDING)
BIB;
381,0737
COMPRESS;TEMPERATURE
PROTECTIVE
COVER
SURGICALAND
SURGICALANDPROTECTIVE
COVER
SURGICALANDPROTECTIVE
COVER
GOWN
(NS);
SCISSORSPROTECTIVE
COVER
PROTECTIVECOVER
SCISSORS
278,7098519
MEASUREMENT;
GOWN
(S);
317,9904
288,575500
MEASUREMENT;ENDOSCOPIC
SPECULUM;SCISSORS
GOWN(NS);
226,8735
LID
FOR
DRINKING(STERILE);LARYNGOSCOOPBLA
189,5096296
OTHER
CAPS;
MEASUREMENT;FORDRINKING
OTHER
CAPS;
ENDOSCOPIC(STERILE);
OTHER
CAPS;
180,8060553
COMPRESS;
GOWN
(NS);
MEASUREMENT;MATRESS;CAPS;
KIDNEY
TRAY;
GOWN
(S);
SPECULUM;LIDKIDNEY
OTHER
CAPS;
MATRESS;KIDNEY
TRAY;
OTHER
CAPS;
MATRESS;
182,0515632
DIAPERS(BABY);MEDICATION(STERILE);
MATRESS;MATRESS;MEDICATION
CUPS;CUPS;(STERILE);(BABY);TRAY;
DIAPERS(BABY);MEDICATIONCUPS;KIDNEYTRAY;
KIDNEY
TRAY;
SPECULUM; OTHER
98,19030833
LARYNGOSCOOPBLA
DENTALJAR;
KIDNEYTRAY;
NEEDLEBINS;
MEDICATIONGARROT; DIAPERS
CUPS;
GOWN
(NS);
DENTALJAR;
KIDNEY
TRAY;
53,03773013
VALVES;
72,82
98,10466667(STERILE);
91,4936
84,12970101
CUP;
83,54706667
52,67813333
DES;
77,92848
46,44738344
15,08924333
43,04988417
VALVES;
42,59097525
41,74406978
CUP;
71,99421422
41,82047336
38,49005926
66,68590417
0,005905
24,37190667
23,72084644
51,35631111
50,92139738
49,32166667
19,37590178
18,76983333
43,9589616
12,52267083
11,94772083
39,18485577
8,497814667
8,486106511
37,34487961
7,177914286
3,146825333
32,54686411
30,81742296
28,36163571
25,52613462
25,1205
22,68823333
19,85484233
GOWN
(S);
47,65817,12736536
DES;
7,4733
4,352674667
4,046947667
2,847466667
2,398649666
2,316668333
1,978128167
0,954798641
0,160048778
GARROT
11,6330131
GARROT
1,649606
GARROT;;;0,87091
0,911894

COVERCAPS FORTEMPERATURE
MEASUREMENT;
218,1786703

COVERCAPS FORTEMPERATURE
MEASUREMENT;MEDICATIONMEDICATION
CUPS;165,9305
MEDICATION
CUPS;CUPS;
67,57304803
67,73231111
63,35762256

0
0

200

400

600

800

1000

Amount (#/bed/year)
Figure 10: Amount/Cost – rate procurement data based on catalogue prices

Final report June 2023 – Study single-use materials in medicine and health care

143

1200

9.11

APPENDIX 11: Considerations on sustainability of raw materials

Paper pulp
Paper(board) is made from different forms of pulp, which in turn is obtained mainly from wood, recycled paperor other cellulose-bearing material such as straw, grass, cotton or other (e.g. bamboo, reeds, jute, etc.). Pulp
can be also produced by repulping of the recycled paper (Moya and Pavel 2018).
Pulp preparation and product production (moulding process) account for the highest environmental impact in
the life cycle of manufacturing moulded pulp products (Didone et al. 2017 in Zhang et al. 2022) As the paperindustry is an energy and carbon intensive industrial sector, some points of consideration need to be made(Federaal Instituut voor Duurzame Ontwikkeling 2016).
Deforestation
Numerous organisations promote sustainable forest management through establishing independentcertification schemes, the two largest and most well-known certification programs are PEFC (Programme for
the Endorsement of Forest Certification) and FSC (Forest Steward Council). Choosing for paper made fromfibers derived from sustainably managed forests contributes to the preservation of forests, the protection of
biodiversity and respect the rights of indigenous peoples (Federaal Instituut voor Duurzame Ontwikkeling2016).
Energy and water consumption during production
There is a huge difference in energy consumption depending on the type of paper. Three times more energy
is required to produce white paper (with fresh fibres) than recycled paper (Federaal Instituut voor Duurzame
Ontwikkeling 2016). Consequently, an important focus is the percentage of recycled paper used in the kidney
tray.
Besides energy, water is also an essential ingredient for making paper pulp and removing impure ingredients.
The toxic constituents added to water for the production of pulp (especially in recycling) is one of the mostsignificant impacts of the paper industry.
Emissions toxic substances during production
Chemical additives (bleaching products, dyes, glues, etc.) are needed to produce new paper and for removing
the dyes and inks from the used paper. As a result, the paper industry is one of the most water-polluting
industries (Federaal Instituut voor Duurzame Ontwikkeling 2016). Certain labels focus on the use ofchemicals and production process-related aspects such as emissions to air and water. The most commonlyused production labels are EU Ecolabel, Nordic Swan Ecolabel and Der Blaue Engel (Milieu Platform
Zorgsector).
Bleaching of paper is still done mainly by using chlorine gas. However, chlorine gas is a dangerous and toxic
product, both for human health and the environment. Paper can be certified as TCF or ECF. The
abbreviations ECF (Elemental chlorine free) indicates that the paper concerned is bleached by using chlorine
dioxide instead of using the environmentally less acceptable chlorine gas method of bleaching. TCF (Totally
Chlorine Free) indicates that the bleaching of the paper has been done by using hydrogen peroxide, thus nochlorine or chlorine derivates. This is the most environmentally acceptable method of bleaching (Federaal
Instituut voor Duurzame Ontwikkeling 2016).
Circular economy
Paper products can be reused via reprocessing into pulp by adding water and chemical ingredients to removeof inks and impurities. Usually, this recycled pulp is added to new pulp with a view to ensuring product quality.
With each recycling cycle, the fibre gets smaller. On average, paper can be recycled up to 7 times. Recent
research in Germany showed that paper can be recycled 25 times (Federaal Instituut voor Duurzame
Ontwikkeling 2016)
Besides reducing waste, recycling paper ensures that CO2 stays in the fibres longer. Europe is forerunner inpaper recycling. The Confederation of European Paper Industries (CEPI) calculated the European paper andpaperboard recycling rate for 2022 at 71.4% (Confederation of European Paper Industries 2022).
Plastics
Plastics are synthetic organic polymers formed by many small molecules (monomers). Different polymers are
created through different production methods; they have different chemical structures and varying properties.

Final report June 2023 – Study single-use materials in medicine and health care144

Different types of plastic are used for medical devices such as polyethylene (PE) divided into high-density
polyethylene (HDPE) or low-density polyethylene (LDPE), polyvinyl chloride (PVC), polypropylene (PP) andpolyethylene terephthalate (PET) . Figure 11 gives an overview the greenhouse gas emissions along the life
cycle of the different forms of plastics (ETC/WMGE 2021).

Figure 11: Greenhouse gas emissions intensity factors and material flows in (ETC/WMGE 2021)

Both PE and PP are standard medical grade plastics (Ashter 2022)- PE is a versatile and durable thermoplastic. Properties such as excellent impact resistance andresistance to chemicals, along with zero moisture absorption making it a preferred material for
medical applications.
- PP: certain medical grades of polypropylenes are stable at high temperatures. As PP has an excellent
chemical resistance, is dimensionally stability, and compatibility towards different sterilization
methods, they are chosen for applications that requires steam sterilization.
The rapidly increasing production of (disposable) plastics, most of these fossil-derived plastics are nonbiodegradable, will lead to more waste and to more negative impacts on both human health and environment.
(Health Care Without Harm Europe 2021a) Among all of the globally produced plastics, one third is nonrecyclable and half is used for single-use purposes (Zhang et al. 2022).
Environmental impacts
Plastics can have negative impacts in each stage of its life cycle (Health Care Without Harm Europe
2021a):- Emissions and toxic chemicals from both oil and gas extractions and manufacturing.
- Microplastics, microfibers and additives can be released in the environment during the use phase.
- Plastics used in health care are not commonly recycled, most plastic waste is disposed. In Belgium
medical waste is incinerated. This is a harmful process which generates carbon emissions and toxic
gases. When plastics are landfilled they can persist for years and leaching toxic chemicals andmicroplastics to soil and water.
Recent years, biobased plastics are emerging as alternatives to the currently dominant fossil-based plastics.
However, the share of biobased polymers is very small compared to the fossil-based plastics (ETC/WMGE
2021). Biobased, biodegradable and compostable plastics have the potential to reduce the greenhouse gas
emissions, but also present other challenges as sustainable land use and competition with food to protect
and maintain natural capital. The overall impacts of biopolymers need to be thoroughly evaluated case bycase (ETC/WMGE 2021; European Commission 2022a).
Health impacts
Similar to the environmental impact, each stage of the plastics life cycle poses threat to human health.
(Health Care Without Harm Europe 2021a)
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-

Toxic chemicals are used and released from both raw resource extraction and manufacturing.
Harmful chemicals that are used as plastic additives.
Toxic substances are released into air, water and soil if plastic is incinerated. If plastics arelandfilled, it breaks down in microplastic and nanoplastic. These small particles can be inhaled oringested with water or food.

Stainless steel / inox
Stainless steel is a steel alloy that contains high percentages of iron and chromium, making it resistant tocorrosion and wear. These alloys are further classified into families and grades that are defined by theirunique characteristics and chemical compositions.
Medical grade stainless steels are part of the austenitic stainless steel family, a category known for its highformability and exceptional corrosion resistance. Grades 304 and 316 stainless steels contain high levels ofnickel which provide additional chemical properties, making them suitable for use within the extreme demandsof the medical industry.
Most steel production in Europe and globally is primary production, converting iron ore to steel through thebasic oxygen furnace (BOF) route. This emits, on average, just over 2 tonnes of CO 2 per tonne of steel
produced. Secondary steel is made in electric arc furnaces (EAF), with one-fifth the CO2 emissions of primary
steelmaking even when much of the electricity comes from fossil fuels. (Material Economics Sverige AB 2018)
Gas emissions and energy consumption are the major environmental concerns with steel production(Nidheesh and Kumar 2019). Furthermore, ecotoxicity impacts are among the most crucial consequencesof iron and steel production (Liu et al. 2020).
Medical textiles
The different life cycle stages of medical textiles can cause significant negative environmental impacts.
Greenhouse gases and other pollutants as well as the use of water, land, chemicals are harmful for theenvironment (Health Care Without Harm Europe 2021b).
Type of fibre
To produce fibres and fabrics, the textiles industry mainly relies on non-renewable resources (oil, fertilizers,
chemicals) (ETC/WMGE 2019; Health Care Without Harm Europe 2021b). Different fibres have different
environmental impacts during production. Cotton and polyester tend to have greater production impacts thansome emerging fibres. Synthetic fibres can lead to marine microplastic pollution. Some fibres are more
durable than others, for instance polyester or a polyester/cotton mix can survive more laundry cycles than
100% cotton. Synthetic fibres are easier to launder since they absorb less water and use less energy duringdrying. (Watson and Fisher-Bogason 2017).
Effect of chemicals
Numerous substances have been identified in textile production, of which some have been classified ashazardous for human health (carcinogenic, mutagenic, allergic or toxic to reproduction) and others as
hazardous for the environment (f.i. for global water pollution) (Health Care Without Harm Europe 2021b)(REACH for chemicals). Per production stage there are problematic chemicals/chemical-related issues andalso in textile finishes there are chemicals found. The legal limit for the use of chemicals may differ between
countries, and product manufacturers can obtain textiles form anywhere in the world. The market for medical
textiles is currently dominated by Europe, followed by North America and Asia-Pacific. Compliance ofimported products is often a concern (Health Care Without Harm Europe 2021b).
Health Care Without Harm (2021b) focuses on reducing entire classes of problematic chemicals. Theirchemicals of emerging concern are:- Per-and polyfluordoalkyl substances (PFAS)• Primary function of PFAS: water, oil and dirt repellence.
• PFAS are extremely persistent, often referred to as ‘forever chemicals’.
• Leaching of PFAS out of textiles might not only have an environmental impact; PFAS inclothing may also form a direct exposure route to humans, since there is dermal contact withthe textiles. It has been shown for example that PFOA can penetrate human skin.
- Flame-retardants• Harmful to human health and toxic to wildlife.

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•

-

Leaking from products into dust and air where they may persist in the atmosphere andaccumulate in living organisms.
Antimicrobials• Risk from antimicrobial textiles are evaluated via acute and chronic toxicity, skin sensitizationand irritation, and the disturbance of skin ecology.
• Potential unintended consequences of biocidal substances/antimicrobial-impregnated textiles
have not been explored fully, they must be critically reassessed for both safety and necessity.

Also for textiles, there are eco-labels which contain criteria such as natural fibres, water use, energy use,chemicals/detergents… , f.i. Nordic Swan and EU Ecolabel. (Watson and Fisher-Bogason 2017).
Recyling
Generally, approximately 20% of reusable textiles is recycled (downcycled), only 1% is used in new textile.
Fibers are often blended with others, which makes recycling more difficult.

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9.12

APPENDIX 12: Steps in reuse phase of reusable speculum in Ghent University Hospital

Final report June 2023 – Study single-use materials in medicine and health care

148

9.13
Process

APPENDIX 13: Inventory analysis for LCA
Inputs

OutUnit
Providerputs
Reusable speculum – Manufacturing and packaging
Stainless179
g/speculum
steelElectricity formoulding
packaging 4
g/package ofplastic LDPE
8-10, dubble& LLDPE
packaged
packaging 200
g/package of
cardboard
8-10
Reusable speculum – Distribution

Steel, chromium steel 18/8 {GLO}| market for | Cut-off, U
Metal working, average for chromium steel product manufacturing {RER}| processing| Cut-off, U_elec DE
Packaging film, low density polyethylene {GLO}| market for | Cut-off, U

Corrugated board box {RER}| market for corrugated board box | Cut-off, U

Land
602
km
Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6transport fromto generic market for | Cut-off, U
Germany –Aspen to The
Netherlands –Noord
Holland
Reusable speculum –Treatment phase (Pre use phase)
Cart wash
Electricity

1,00

Detergent

0,09

kWh/1
proces
L/1 proces

Softend water

150,0

L/1 proces

Rinsing agent

0,06

L/1 proces

Steam

28.00

kg/proces

Electricity, medium voltage {BE}| market for | Alloc Rec, U_Belgian energy supplier
Green BE 2022
0,4 Alkylbenzene sulfonate, linear, petrochemical {GLO}| market
for | Cut-off, U
0,1 Sodium tripolyphosphate {GLO}| market for | Cut-off, U
0,5 Tap water {RER}| market group for | Cut-off, U
Water, completely softened {RER}| market for water, completely softened | Cut-off, U
0,2 Chemical, organic {GLO}| market for | Cut-off, U
5
0,2 Chemical, inorganic {GLO}| market for chemical,
5 inorganic | Cut-off, U
0,5 Tap water {RER}| market group for | Cut-off, U
Heat, from steam, in chemical industry {RER}| steam production, as energy carrier, inchemical industry | Cut-off, U_elec and heat from municipal waste
incineration_BE_no recirculation tap water 2.75

Ultrasone cleaning
Electricity

0,50
17,50

kWh/1
procesL/proces

Electricity, medium voltage {BE}| market for | Alloc Rec, U_Belgian energy supplier
Green BE 2022
Water, completely softened {RER}| market for water, completely softened | Cut-off, U

Softend water
Detergent

0,044

L/proces

0,4 Alkylbenzene sulfonate, linear, petrochemical {GLO}| market for | Cut-off, U
0,1 Sodium tripolyphosphate {GLO}| market for | Cut-off, U
0,5 Tap water {RER}| market group for | Cut-off, U

kWh/1
proces
L/1 proces

Electricity, medium voltage {BE}| market for | Alloc Rec, U_Belgian energy supplier
Green BE 2022
0,4 Alkylbenzene sulfonate, linear, petrochemical {GLO}| market
for | Cut-off, U
0,1 Sodium tripolyphosphate {GLO}| market for | Cut-off, UWashing machineElectricity

12,00

Detergent

0,22

0,5 Tap water {RER}| market group for | Cut-off, U
Softend water

35,00

L/1 proces

Water, completely softened {RER}| market for water, completely softened | Cut-off, UWashingmashine osmose water
Sterilisation

85,00

L/1 proces

RO water_elec Belgian energy supplier Green BE 2022

Compressed
airFresh water(softend)
Electricity

0,20

Nm³/h

0,037

m³/h

Compressed air, 700 kPa gauge {RER}| market for compressed air, 700 kPa gauge |Cut-off, U_elec Belgian energy supplier Green BE 2022
Water, completely softened {RER}| market for water, completely softened | Cut-off, U

1,40

kWh

Electricity, medium voltage {BE}| market for | Alloc Rec, U_Belgian energy supplier
Green BE 2022

Final report June 2023 – Study single-use materials in medicine and health care149

Steam(Osmosewater)

23,4kg/h

Heat, from steam, in chemical industry {RER}| steam production, as energy
carrier, in chemical industry | Cut-off, U_elec and heat from municipal waste
incineration_BE_without waterRO water_elec Belgian energy supplier Green BE 2022

Electricity

0,004

Packaging1&
2 - PP
Packaging1&
2 - PET
Packaging1&
2 - Paper
Waste water(cartwash,
cleaning,
sterilisation)
Waste water(condensate
steam)
Waste
packagingcollection
plastic
Waste
packagingcollection
cardboard
Packagingplastic LDPE
& LLDPE

8

kWh/speculumgElectricity, medium voltage {BE}| market for | Alloc Rec, U_Belgian energy supplier
Green BE 2022
Packaging film, low density polyethylene {GLO}| market for | Cut-off, U_PP

0,0025kg/speculum

Packaging film, low density polyethylene {GLO}| market for | Cut-off, U_PET

10g

Paper, woodfree, uncoated {RER}| market for | Cut-off, U

5,26

L

Wastewater, average {Europe without Switzerland}| treatment of wastewater,
average, capacity 1E9l/year | Cut-off, U

3,52

kg/h

Wastewater, unpolluted {CH}| treatment of, capacity 5E9l/year | Cut-off, U

65km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

65km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

4g/package of
8-10

MATTER model recyclingg/package of
8-10

Waste paperboard, sorted {Europe without Switzerland}| treatment of waste
paperboard, unsorted, sorting | Cut-off, U
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, recycled | Cut-off, U_without waste sorting
Containerboard, linerboard {RER}| containerboard production, linerboard, testliner| Cut-off, U_without waste sorting
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, semichemical | Cut-off, U
Containerboard, linerboard {RER}| containerboard production, linerboard,kraftliner | Cut-off, U

SealerPackagingcardboard

200

MATTER model recovered PE TS=0.98

Reusable speculum – Use phase
Waste
packagingcollection
paper
Waste
packagingcollection
plastic
Waste
management
Paper

65

km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

65km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

10

g

Waste
management
packaging
Plastic PP

8g

Waste paper, sorted {Europe without Switzerland}| treatment of waste paper,
unsorted, sorting | Cut-off, U
Paper, woodfree, uncoated {RER}| paper production, woodfree, uncoated, at
integrated mill | Cut-off, U_no virgin input
Paper, woodfree, uncoated {RER}| paper production, woodfree, uncoated, at
integrated mill | Cut-off, U
Waste polypropylene {RoW}| treatment of waste polypropylene, municipal
incineration | Cut-off, U
Electricity, medium voltage {BE}| market for | Cut-off, U
Heat, district or industrial, natural gas {BE}| heat and power co-generation, naturalgas, combined cycle power plant, 400MW electrical | Cut-off, U
Waste polyethylene terephthalate {RoW}| treatment of waste polyethylene
terephthalate, municipal incineration | Cut-off, U
Electricity, medium voltage {BE}| market for | Cut-off, U

Waste
management
packaging
Plastic PE

Heat, district or industrial, natural gas {BE}| heat and power co-generation, naturalgas, combined cycle power plant, 400MW electrical | Cut-off, U

Reusable speculum – End of Life phase
Waste
management
speculum

179

Scrap steel {Europe without Switzerland}| treatment of scrap steel, municipal
incineration | Cut-off, U

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150

Landtransport 76(truck) to
AntwerpBottom ashes
179
g
from
speculum
Single-use fossil plastic based (ABS) speculum
Fossil plastic(ABS:
Acrylonitrile
butadiene
styrene) +Electricity for
injection
molding
Packaging plastic 1
LDPE &
LLDPE
Packaging plastic 2
LDPE &
LLDPE
Packaging cardboard
Landtransport
from The
Netherlands
Waste
packagingcollection
cardboardWaste
packagingcollection
plastic
Waste
management-Cardboard

Waste
management
plastic 1
LDPE &LLDPE
Waste
management
plastic 2
LDPE &LLDPE
Waste
management
speculum Fossil plastic(ABS:
Acrylonitrile
butadiene
styrene)Waste
management
Landtransport(truck) to
Antwerp
Energyrecoveredfrom
speculum

34,40

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U
Pig iron {RER}| pig iron production | Cut-off, U

Acrylonitrile-butadiene-styrene copolymer {GLO}| market for | Cut-off, UgInjection moulding {RER}| processing | Cut-off, U_elec NL

10

g

45

g/package of
200

1215

g/package of
200km

Packaging film, low density polyethylene {GLO}| market for | Cut-off, U

Packaging film, low density polyethylene {GLO}| market for | Cut-off, U

236

65

Corrugated board box {RER}| market for corrugated board box | Cut-off, U
Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

kmTransport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

65

km

1215

g/package of
200

10

g

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U
Waste paperboard, sorted {Europe without Switzerland}| treatment of waste
paperboard, unsorted, sorting | Cut-off, U
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, recycled | Cut-off, U_without waste sorting
Containerboard, linerboard {RER}| containerboard production, linerboard,
testliner | Cut-off, U_without waste sorting
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, semichemical | Cut-off, U
Containerboard, linerboard {RER}| containerboard production, linerboard,kraftliner | Cut-off, U
MATTER model recycling
MATTER model recovered PE TS=0.98

45g/package of
200

MATTER model recycling
MATTER model recovered PE TS=0.98

34,4

kg

Waste polystyrene {RoW}| treatment of waste polystyrene, municipal incineration |Cut-off, U

76km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

34,4

g

Electricity, medium voltage {BE}| market for | Cut-off, U
Heat, district or industrial, natural gas {BE}| heat and power co-generation,
natural gas, combined cycle power plant, 400MW electrical | Cut-off, U

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151

Single-use biobased plastic (PLA) speculum
Bioplastic
PLA
Transport
from Thailand- freight ship
Bangkok to
Rotterdam
Transport
from Thailand- truck
Rotterdam to
NoordHolland
Electricity for
injection
molding
Packaging plastic 1
LDPE &
LLDPE
Packaging plastic 2
LDPE &
LLDPE
Packaging cardboard
Landtransport
from The
Netherlands
Waste
packagingcollection
cardboardWaste
packagingcollection
plastic
Waste
management-Cardboard

39,9

g

Polylactide, granulate {GLO}| market for | Cut-off, U

16888

km

Transport, freight, sea, container ship {GLO}| transport, freight, sea, container ship |Cut-off, U

100

km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, UInjection moulding {RER}| processing | Cut-off, U_elec NL

10gPackaging film, low density polyethylene {GLO}| market for | Cut-off, U

45

g/package of
200

Packaging film, low density polyethylene {GLO}| market for | Cut-off, U

1215

g/package of
200
km

Corrugated board box {RER}| market for corrugated board box | Cut-off, U

236

65

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

kmTransport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

65

1215

km

g/package of200

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U
Waste paperboard, sorted {Europe without Switzerland}| treatment of waste
paperboard, unsorted, sorting | Cut-off, U
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, recycled | Cut-off, U_without waste sorting
Containerboard, linerboard {RER}| containerboard production, linerboard,
testliner | Cut-off, U_without waste sorting
Containerboard, fluting medium {RER}| containerboard production, fluting
medium, semichemical | Cut-off, U
Containerboard, linerboard {RER}| containerboard production, linerboard,kraftliner | Cut-off, U

Waste
10
g
MATTER model recycling
management
plastic 1
MATTER model recovered PE TS=0.98
LDPE &
LLDPE
Waste
45
g/package of
MATTER model recycling
management200
plastic 2
MATTER model recovered PE TS=0.98
LDPE &
LLDPE
Biobased
39,90
Waste plastic, mixture {RoW}| treatment of waste plastic, mixture, municipal
plastic (PLA)
incineration | Cut-off, U
Landtransport 76
Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6(truck) toto generic market for | Cut-off, U
Antwerp
Energy39,90gElectricity, medium voltage {BE}| market for | Cut-off, U
recoveredHeat, district or industrial, natural gas {BE}| heat and power co-generation,fromnatural gas, combined cycle power plant, 400MW electrical | Cut-off, U
speculum
Ethylene oxide sterilised single-use speculum consisting of polystyrene blades and polyethylene bolt
Blades: Fossil
plastic(polystyrene)g
29

Polystyrene, general purpose {GLO}| market for | Cut-off, U

Final report June 2023 – Study single-use materials in medicine and health care152

Bolt: Fossil
plastic (polyethylene)
Electricity for
injection
molding
Ethylene
oxide (EO)
sterilization
Electicity forEOsterilisation
Packaging plastic 1
LDPE &
LLDPE
Packaging plastic 2
LDPE &
LLDPE
Packaging cardboard
Landtransport
from Poland
to Antwerp
Landtransport
from Antwerp
to UZ Ghent
Waste
packagingcollection
cardboardWaste
packagingcollection
plastic
Cardboard

Packaging 1plastic plastic
LDPE &
LLDPE
Packaging 2plastic plastic
LDPE &LLDPE
Waste
management
blades:(polyst
yrene)
Waste
management
bolt:
polyethylene
Landtransport(truck) to
Antwerp
Energyrecoveredincineration
bladesEnergyrecoveredincineration
bolt

g
2

Polyethylene, high density, granulate {GLO}| market for | Cut-off, UInjection moulding {RER}| processing | Cut-off, U_elec PL

276

g/cyclus

Ethylene oxide {RER}| market for ethylene oxide | Cut-off, U

4,504

kW/cyclus
g/speculum

Electricity, medium voltage {PL}| market for | Cut-off, U
Packaging film, low density polyethylene {GLO}| market for | Cut-off, U

45

g/package of
200

1215

g/package of200
Km

Packaging film, low density polyethylene {GLO}| market for | Cut-off, U
Corrugated board box {RER}| market for corrugated board box | Cut-off, U
Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

1165
Km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

57
Km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

65
Km

65
1215

4

45

g/package of200

g/package of1

g/package of200

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U
Waste paperboard, sorted {Europe without Switzerland}| treatment of waste
paperboard, unsorted, sorting | Cut-off, U
Containerboard, fluting medium {RER}| containerboard production, fluting medium,recycled | Cut-off, U_without waste sorting
Containerboard, linerboard {RER}| containerboard production, linerboard, testliner |Cut-off, U_without waste sorting
Containerboard, fluting medium {RER}| containerboard production, fluting medium,semichemical | Cut-off, U
Containerboard, linerboard {RER}| containerboard production, linerboard, kraftliner| Cut-off, U
MATTER model recycling
MATTER model recovered PE TS=0.98
MATTER model recycling
MATTER model recovered PE TS=0.98

29g

Waste polystyrene {RoW}| treatment of waste polystyrene, municipal incineration |Cut-off, U

2

g

Waste polyethylene {RoW}| treatment of waste polyethylene, municipal incineration |Cut-off, U

76km

Transport, freight, lorry, unspecified {RER}| transport, freight, lorry, all sizes, EURO6
to generic market for | Cut-off, U

29

2

g

g

Electricity, medium voltage {BE}| market for | Cut-off, U
Heat, district or industrial, natural gas {BE}| heat and power co-generation, naturalgas, combined cycle power plant, 400MW electrical | Cut-off, U
Electricity, medium voltage {BE}| market for | Cut-off, U
Heat, district or industrial, natural gas {BE}| heat and power co-generation,
natural gas, combined cycle power plant, 400MW electrical | Cut-off, U

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153

9.14

APPENDIX 14: Assumptions for inventory analysis of LCA

Reusable stainless steel speculum

Data source

Number of uses of one speculum

500 (baseline)

Assumption (See (Snijder and Broeren 2022))

Substitutability recovered steel scrap for pig iron

1

Rigamonti et al. 2010 (Rigamonti et al. 2010)

Steel sorting efficiency

0,92

Rigamonti et al. 2010

Substitutability recovered paper

0,90Merrild et al. 2008 (Merrild et al. 2008)

Paper recycling efficiency

0,83

Merrild et al. 2008

Substitutability recovered paperboard

0,90

Merrild et al. 2008

Paperboard recycling efficiency

0,91

Merrild et al. 2008

Energy content steam from waste incineration (MJ/kg)

2,75

steam table 5 bar en 159°C

Energy content cleansteam (MJ/kg)

2,73

steam table 3.3 bar en 145°C

Electricity recovered from PP incineration (kWh/kg dry)

1,39

ecoinvent dataset

Heat recovered from PP incineration (MJ/kg dry)

9,69

ecoinvent dataset

Electricity recovered from PET incineration (kWh/kg dry)

0,83

ecoinvent dataset

Heat recovered from PET incineration (MJ/kg dry)

5,82

ecoinvent dataset

Loading cartwash

100 pc = 1 processexpert opinion- staff CSA

Loading ultrasone

10,00 pc = 1 processexpert opinion- staff CSA

Loading washingmachine

60,00 pc = 1 processexpert opinion- staff CSA

Loading sterilisation

60,00 pc = 1 processexpert opinion- staff CSA

Single-use fossil based plastic speculum (ABS)substitutability recovered paperboard
paperboard recycling efficiency
electricity recovered from PS incineration (kWh/kg dry)heat recovered from PS incineration (MJ/kg dry)electricity recovered from ABS incineration (kWh/kg dry)heat recovered from ABS incineration (MJ/kg dry)gross electricial efficiency (%)
gross thermal efficiency (%)
internal electricity consumption (kWh/kg)
internal heat consumption (MJ/kg)
combustion value ABS (MJ/kg)

0,90
0,91
1,40
9,73
1,44
9,66
15,84
28,51
0,13
0,49
35,6

carbon content ABS worst case (%)
content styrene worst case (%)
content butadiene worst case (%)
content acrylonitrile worst case (%)
dry mass content waste PS (kg/kg)
injection moulding yield (kg/kg)

88
60
25
15
0,998
0,994

Single-use biobased plastic speculum (PLA)
substitutability recovered paperboard
paperboard recycling efficiency
electricity recovered from PLA incineration (kWh/kg dry)heat recovered from PLA incineration (MJ/kg dry)gross electrical efficiency (%)
gross thermal efficiency (%)
internal electricity consumption (kWh/kg)
internal heat consumption (MJ/kg)
combustion value PLA (MJ/kg)
carbon content PLA (%)
dry mass content waste plastic mixture (kg/kg)
carbon content (dry mass) waste plastic mixture (kg/kg)
injection moulding yield (kg/kg)

0,90
0,91
0,66
4,62
15,84
28,51
0,13
0,49
17,9
50
0,847
0,634
0,994

Merrild et al. 2008
Merrild et al. 2008
ecoinvent dataset
ecoinvent dataset

Doka, et al., 2013 (Doka 2013)
Doka, et al., 2013
Doka, et al., 2013
Doka, et al., 2013
CE Delft report
CE Delft report; own calculation confirms
based on Wikipedia ABS
Wikipedia ABS
Wikipedia ABS
Wikipedia ABS
ecoinvent dataset
ecoinvent dataset

Merrild et al. 2008
Merrild et al. 2008

Doka, et al., 2013
Doka, et al., 2013
Doka, et al., 2013
Doka, et al., 2013
CE Delft report
CE Delft report; own calculation confirms
ecoinvent dataset
ecoinvent dataset
ecoinvent dataset

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Ethylene oxide (EO) sterilised single-use speculum consisting of polystyrene blades and polyethylene bolt
Loading sterilisator type Labtron LEOS A14
1200
Injection moulding yield (kg/kg)
0,994
ecoinvent dataset
Substitutability recovered paperboard
0,90
Merrild et al. 2008
Paperboard recycling efficiency
0,91
Merrild et al. 2008
electricity recovered from PE incineration (kWh/kg dry)
1,55
ecoinvent dataset
heat recovered from PE incineration (MJ/kg dry)
10,73
ecoinvent dataset
electricity recovered from paperboard incineration (kWh/kg
dry)
0,62
ecoinvent dataset
heat recovered from paperboard incineration (MJ/kg dry)
4,44
ecoinvent dataset
electricity recovered from PS incineration (kWh/kg dry)
1,40
ecoinvent dataset
heat recovered from PS incineration (MJ/kg dry)
9,73
ecoinvent dataset
dry mass content PE (kg/kg)
0,996
ecoinvent dataset
dry mass content paperboard (kg/kg)
0,896
ecoinvent dataset
dry mass content waste PS (kg/kg)
0,998
ecoinvent dataset

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9.15

APPENDIX 15: Distribution details for reusable and single-use specula
Reusable speculum

Single-use speculumfrom fossil plastic

Single-use speculumfrom biobased plastic

Speculum: raw materials to
manufacturer

Ecoinvent database

Ecoinvent database

Transport by boat
Thailand (Bangkok) to
The Netherlands(Rotterdam)
16888 km+Land transport by truck
average size vehicle
Rotterdam to NoordHolland
100 kmPackaging materials (rawmaterials to manufacturer)

Ecoinvent database

Ecoinvent database

Ecoinvent database

Ecoinvent database

Chemicals/electricity/water
input

Ecoinvent database

Ecoinvent database

Ecoinvent database

Ecoinvent database

Wrapped speculum frommanufacturer to Ghent
University HospitalLand transport bytruck average size
vehicleLand transport by truck
average size truck

Land transport by truck
average size truck

Land transport bytruck average size
truck

From The Netherlands(Noord-Holland) to
Belgium Ghent

From The Netherlands(Noord-Holland) to
Belgium (Ghent)

Form Germany(Tuttlingen, Aspen) to
Belgium (Ghent)

602 kmWaste from Ghent University
Hospital to Antwerp
Incinerator (speculum)
Recycling (packaging
materials)

236 km236 kmLand transport by truck
average size vehicle
76 km

Ethylene oxide
sterilised singleuse speculum
Ecoinvent database

From Poland to
Antwerp (Belgium)and from Antwerp to
Ghent (Belgium)
1165 km

65 km

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9.16

APPENDIX 16: Overview of all mid- and endpoint estimates for reusable andsingle-use specula

Impact category

Reusable specula

SU ABS specula

SU PLA specula

EO SU specula

Global warming (kgCO2eq)

7.13-02

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

2.16E-02

8.99E-02

5.57E-02

7.70E-02

Mineral resource scarcity (kgCu eq)

3.05E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

2.14E-03

2.69E-03

6.04E-03

3.37E-03

Stratospheric ozone depletion (kg CFC11 eq)

1.12E-07

4.09E-08

5.16E-07

2.82E-08

Ionizing radiation (kBq Co-60 eq)

1.21E-03-1.06E-02

4.07E-03-1.41E-02

Ozone formation, Human health (kg NOx eq)

1.38E-04

3.57E-04

5.36E-04

3.95E-04

Fine particulate matter formation (kg PM2.5 eq)

8.81E-05

1.75E-04

2.83E-04

2.02E-04

Ozone formation, Terrestrial ecosystems (kg NOx eq)

1.42E-04

3.82E-04

5.56E-04

3.53E-04

Terrestrial acidification (kg SO2 eq)

2.19E-04

4.88E-04

7.53E-04

5.97E-04

Freshwater eutrophication (kg P eq)

3.57E-05

6.07E-05

9.34E-05

8.79E-05

Marine eutrophication (kg N eq)

2.78E-05

9.93E-06

6.02E-05

9.05E-06

Terrestrial ecotoxicity (kg 1,4-DCB)

3.61E+04

1.37E+04

1.37E+04

1.37E+04

Freshwater ecotoxicity (kg 1,4-DCB)

3.72E-03

5.39E-03

7.53E-03

5.96E-03

Marine ecotoxicity (kg 1,4-DCB)

5.08E-03

7.48E-03

9.80E-03

8.32E-03

Human carcinogenic toxicity (kg 1,4-DCB)

6.64E-03

8.07E-03

5.62E-03

6.75E-03

Human non-carcinogenic toxicity (kg 1,4-DCB)

1.41E+04

1.41E-01

1.72E-01

1.72E-01

Land use (m2a crop eq)

1.47E+03-6.46E-04

2.14E-02-3.67E-04

Impact category

Reusable specula

SU ABS specula

SU PLA specula

EO SU specula

Human Health (DALY’s)

1.65E-07

4.76E-07

5.16E6-07

4.53E-07

Ecosystem Quality (species.yr)

4.09E-10

1.14E-09

1.351E-09

1.05E-09

Resource Scarcity (USD2013)

7.90E-03

3.37E-02

1.65E-02

2.71E-02

Midpoints

Endpoints

SU ABS: single-use fossil based plastic; SU PLA: Single-use biobased plastic; EO SU specula: ethylene oxide sterilised single-use
specula consisting of polystyrene blades and polyethylene bolt
Figures are expressed according to LCA-standards; E-01= x 0.1;E-02= x 0.01; E-03= x 0.001; E-04= x 0.0001; …; E+01= x10;
E+02= x 100; E+03= x 1000; E+04= x 10 000; ….

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9.17

APPENDIX 17: Graphs midpoint and endpoint estimates

Midpoint estimates

Endpoint estimates

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Figures are expressed according to LCA-standards; E-01= x 0.1;E-02= x 0.01; E-03= x 0.001; E-04= x 0.0001; …; E+01= x10; E+02= x 100; E+03= x 1000; E+04= x 10 000; ….

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9.18
Scenario

APPENDIX 18: Scenario analyses
Graph

Impact category

Reusable
speculaSU ABS
speculaSU PLA
speculaEO SU
specula

Average steam production

Average Belgian Energy mix

Midpoints
Global warming (kgCO2eq)

1.28E-01

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

3.78E-02

8.99E-02

5.57E-02

7.07E-02

Mineral resource scarcity (kgCu eq)

3.75E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

2.75E-03

2.69E-03

6.04E-03

3.37E-03

Human Health (DALY’s)

2.33E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

5.76E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarity (USD2013)

1.30E-02

3.37E-02

1.65E-02

2.71E-02

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

2.28E-01

3.25E-01

2.05E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

7.63E-02

8.99E-02

5.57E-02

7.70E-02

Mineral resource scarcity (kgCu eq)

3.11E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

2.27E-03

2.69E-03

6.04E-03

3.37E-03

Human Health (DALY’s)

3.93E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

9.27E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarity (USD2013)

2.72E-02

3.37E-02

1.65E-02

2.71E-02

Endpoints*

Endpoints*

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1000 Reuses
50 Reuses

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

7.03E-02

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

2.13E-02

8.99E-02

5.57E-02

7.07E-02

Mineral resource scarcity (kgCu eq)

2.15E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

2.13E-03

2.69E-03

6.04E-03

3.37E-03

Human Health (DALY’s)

1.55E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

4.03E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarcity (USD2013)

7.82E-03

3.37E-02

1.65E-02

2.71E-02

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

9.06E-02

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

2.62E-02

8.99E-02

5.57E-02

7.07E-02

Mineral resource scarcity (kgCu eq)

1.92E-03

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

2.36E-03

2.69E-03

6.04E-03

3.37E-03

Human Health (DALY’s)

3.44E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

5.11E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarcity (USD2013)

9.42E-03

3.37E-02

1.65E-02

2.71E-02

Endpoints*

Endpoints*

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One sterilisation bag
Best Case Scenario

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

4.53E-02

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

1.37E-02

8.99E-02

5.57E-02

7.07E-02

Mineral resource scarcity (kgCu eq)

2.91E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

1.71E-03

2.69E-03

6.04E-03

3.37E-03

SU ABS

Endpoints*
Human Health (DALY’s)

1.20E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

2.89E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarcity (USD2013)

4.96E-03

3.37E-02

1.65E-02

2.71E-02

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

4.42E-02

3.25E-01

2.03E-01

2.80E-01

Fossil resource scarcity (kg oil eq)

1.34E-02

8.99E-02

5.57E-02

7.70E-02

Mineral resource scarcity (kgCu eq)

2.01E-04

1.22E-04

1.83E-04

8.26E-05

Water consumption (m³)

1.70E-03

2.69E-03

6.04E-03

3.37E-03

Human Health (DALY’s)

1.10E-07

4.76E-07

5.16E-07

4.53E-07

Ecosystem Quality (species.yr)

2.83E-10

1.14E-09

1.35E-09

1.05E-09

Resource Scarcity (USD2013)

4.87E-03

3.37E-02

1.65E-02

2.71E-02

Endpoints*

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Incineration of all packaging materials

Midpoints

RU

SU ABSSU PLAEO SU

Global warming (kgCO2eq)

6.86E-02

3.60E-01

2.38E-01

2.93E-01

Fossil resource scarcity (kg oil eq)

2.08E-02

9.95E-02

6.53E-02

8.04E-02

Mineral resource scarcity (kgCu eq)

3.03E-04

1.18E-04

1.80E-04

8.06E-05

Water consumption (m³)

2.10E-03

2.89E-03

6.24E-03

3.45E-03

Human Health (DALY’s)

1.63E-07

5.22E-07

5.62E-07

4.72E-07

Ecosystem Quality (species.yr)

5.00E-10

1.29E-09

1.50E-09

1.13E-09

Resource Scarcity (USD2013)

7.65E-03

3.77E-02

2.05E-02

2.86E-02

Endpoints*

RU: reusable stainless steel speculum; SU ABS: single-use fossil based plastic; SU PLA: Single-use biobased plastic; EO SU specula: ethylene oxide sterilised single-use specula consisting ofpolystyrene blades and polyethylene bolt; DALY’s: disability adjusted life years
Figures are expressed according to LCA-standards; E-01= x 0.1;E-02= x 0.01; E-03= x 0.001; E-04= x 0.0001; …; E+01= x10; E+02= x 100; E+03= x 1000; E+04= x 10 000; ….

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