Earlier this year we all went into lockdown… remember? Not like the current lockdown where most people seem to be carrying on regardless, I mean when the streets were eerily quiet, and our capital cities looked like a set from a post-apocalyptic movie.
During this time, I remember seeing news stories about the positive impact of the Covid-19 pandemic on the environment as everyone moved indoors, cars stayed off the roads and heavy industry shut down. There were striking pictures of Nitric Oxide levels over China showing a massive reduction in the production of greenhouse gases. It seemed that something good may come out of the pandemic, almost as if the Earth was pressing the reset button and taking back control.
During this time, I remember seeing news stories about the positive impact of the Covid-19 pandemic on the environment as everyone moved indoors, cars stayed off the roads and heavy industry shut down. There were striking pictures of Nitric Oxide levels over China showing a massive reduction in the production of greenhouse gases. It seemed that something good may come out of the pandemic, almost as if the Earth was pressing the reset button and taking back control.
Source: https://earthobservatory.nasa.gov/images/146362/airborne-nitrogen-dioxide-plummets-over-china
Not only did levels of greenhouse gases go down but water purity in our rivers improved due to reduced disturbance, animals started to appear where they hadn’t been seen in years and people started cycling and walking rather than driving. The skies were vibrant blue, bluer than many had ever seen before and people took time to go out into nature on their doorstep. Well those that could take 3 months working from home in the garden and were not suck in a hospital or worse an ITU!
But it isn’t all sunshine and roses. There is an elephant in the room, which nobody seems to want to talk about… so I’m going to. Waste!
More specifically the rubbish we throw away. Thanks to a request from Daniel S. for my opinion on the subject and that there has been no new “amazing game-changer press release” this week, I can return to this blog…
During lockdown our local Council have calculated that in the last 6-7 months people living in our area have produced 2,626 tonnes MORE rubbish than in the same period in 2019. Home deliveries are soaring, along with all of the packaging required to deliver all of those “essentials” from Amazon… yes ECIC I really did need the Complete Series of House… I must confess I do have an Amazon “habit”! [ECIC - It’s an addiction! Just put it into the “it’s for my Xmas stocking” box, before I find out!!!]
Looking at this made me wonder just how much waste the pandemic is creating, so I asked the hospital where I work about how much PPE we’re using. Oh my goodness, that was a mistake!
But it isn’t all sunshine and roses. There is an elephant in the room, which nobody seems to want to talk about… so I’m going to. Waste!
More specifically the rubbish we throw away. Thanks to a request from Daniel S. for my opinion on the subject and that there has been no new “amazing game-changer press release” this week, I can return to this blog…
During lockdown our local Council have calculated that in the last 6-7 months people living in our area have produced 2,626 tonnes MORE rubbish than in the same period in 2019. Home deliveries are soaring, along with all of the packaging required to deliver all of those “essentials” from Amazon… yes ECIC I really did need the Complete Series of House… I must confess I do have an Amazon “habit”! [ECIC - It’s an addiction! Just put it into the “it’s for my Xmas stocking” box, before I find out!!!]
Looking at this made me wonder just how much waste the pandemic is creating, so I asked the hospital where I work about how much PPE we’re using. Oh my goodness, that was a mistake!
Personal Protective Equipment
If I had asked you 12 months ago what PPE stood for I suspect you, and certainly the general public, may have looked at me blankly, but now PPE is an everyday term… heck, even my parents know what it is and talk to me like they’re the experts on the subject.
In the NHS we are being told to wear a surgical face mask at all times whilst on the hospital premises. When caring for a patient who has Covid-19 we need to wear a surgical face mask, visor and plastic apron. If we’re going to be doing aerosol generating procedures the mask needs to be FFP3 (air filter type) and the apron is changed to a surgical gown. It may all sound very confusing, especially for the general public, but in hospitals this is “normal scaling up of IPC” and we’re all used to it and it mostly goes smoothly.
But just how many of these items of equipment is the NHS using and how much waste is it producing as a result of the pandemic? Daniel S. asked “is it all really needed, where is the evidence it works!?!” Well how discourteous :-), “us” in the IPC world “love” our PPE and some IPC teams are ruthless in ensuring we all stick to the guidelines! Heck, I quote Ignaz Semmelweis all the time, to anyone who will listen to my historical medicine! But honestly Daniel S. is right, there is lot of it right now…isn’t there?
If I had asked you 12 months ago what PPE stood for I suspect you, and certainly the general public, may have looked at me blankly, but now PPE is an everyday term… heck, even my parents know what it is and talk to me like they’re the experts on the subject.
In the NHS we are being told to wear a surgical face mask at all times whilst on the hospital premises. When caring for a patient who has Covid-19 we need to wear a surgical face mask, visor and plastic apron. If we’re going to be doing aerosol generating procedures the mask needs to be FFP3 (air filter type) and the apron is changed to a surgical gown. It may all sound very confusing, especially for the general public, but in hospitals this is “normal scaling up of IPC” and we’re all used to it and it mostly goes smoothly.
But just how many of these items of equipment is the NHS using and how much waste is it producing as a result of the pandemic? Daniel S. asked “is it all really needed, where is the evidence it works!?!” Well how discourteous :-), “us” in the IPC world “love” our PPE and some IPC teams are ruthless in ensuring we all stick to the guidelines! Heck, I quote Ignaz Semmelweis all the time, to anyone who will listen to my historical medicine! But honestly Daniel S. is right, there is lot of it right now…isn’t there?
This is a wedding dress made out of rubber gloves! Honest...Click for larger image
PPE usage in the NHS during the pandemic
At the risk of tempting fate the Trust I’m working in is relatively quiet in terms of Covid-19 patients, but busy with normal NHS patients. Even so, our daily use of PPE is:
This is a staggering amount of PPE, and we aren’t yet bursting at the seams with “Covid” patients. We also have a superb infection control team, an excellent sustainability team and managers who care about the environmental impact we’re having. However, this in anyone’s book is a massive amount of PPE every day.
So, let’s scale this up. I do like big numbers… our Trust has about 1300 acute beds (2 pretty large District General Hospitals)… so let’s say we’re an average user of PPE, and there are approximately 1,250 hospitals in the UK. Now let’s run the numbers for daily usage of PPE across NHS hospitals:
GOSH! And that’s every day!!
As Daniel S. said “I can feel David Attenborough’s disappointment every time I tear off an apron and I die a little inside!” I feel the same way; it makes me really concerned about the environmental impact of all the waste that is being produced during the pandemic and where it is going. The BBC’s Blue Planet may have brought the plight of plastic to the masses but seemingly even Sir David Attenborough cannot get airtime to sound the alarm over PPE!
Figures from China suggest medical waste during the pandemic has increased 6 times, and in Spain by 3.5 times. There is also evidence of facemasks appearing on nature trails and washing up on beaches around the World.
Another thing Daniel S. was concerned about was the fact he’d been told that double-wrapped surgical instruments are no more sterile than single wrapped ones, so why the additional waste? One study showed that single wrapped double-ply crepe was just as good at keeping medical equipment “microbiologically clean” as double layers of muslin. However it also states that wrapping twice was better than wrapping once as when you remove the outer layer you are less likely to contaminate the inside. Keeping sterile items in a closed cupboard is also significantly better, but alarmingly for the Earth using impervious plastic wrappers maintains sterility for much longer; up to 18 months! ARGH more plastic waste!!! Also good to note: do not store sterile packages above scrub sinks or in treatment rooms where you are doing minor ops... I know this is common sense but alas common sense is not common, as outbreak data confirms!
So, what can we do?
Well ECIC did find an amazing artist making face shields out of garden waste and flowers so these would at least be compostable… These will probably be adequate for the general public’s use but sadly they are not validated for NHS use!
At the risk of tempting fate the Trust I’m working in is relatively quiet in terms of Covid-19 patients, but busy with normal NHS patients. Even so, our daily use of PPE is:
- Gloves = 90,000
- Surgical face masks = 16,400
- Plastic aprons = 11,400
- FFP3 face masks = 540
- Visors = 320 (some can be cleaned and reused)
- “Covid” gowns = 340
This is a staggering amount of PPE, and we aren’t yet bursting at the seams with “Covid” patients. We also have a superb infection control team, an excellent sustainability team and managers who care about the environmental impact we’re having. However, this in anyone’s book is a massive amount of PPE every day.
So, let’s scale this up. I do like big numbers… our Trust has about 1300 acute beds (2 pretty large District General Hospitals)… so let’s say we’re an average user of PPE, and there are approximately 1,250 hospitals in the UK. Now let’s run the numbers for daily usage of PPE across NHS hospitals:
- Gloves = 56,250,000
- Surgical face masks = 10,250,000
- Plastic aprons = 7,125,000
- FFP3 face masks = 337,500
- Visors = 200,000 (note: some PPE visors in the NHS are made from British PET using ocean waste!
- “Covid” gowns = 212,500
GOSH! And that’s every day!!
As Daniel S. said “I can feel David Attenborough’s disappointment every time I tear off an apron and I die a little inside!” I feel the same way; it makes me really concerned about the environmental impact of all the waste that is being produced during the pandemic and where it is going. The BBC’s Blue Planet may have brought the plight of plastic to the masses but seemingly even Sir David Attenborough cannot get airtime to sound the alarm over PPE!
Figures from China suggest medical waste during the pandemic has increased 6 times, and in Spain by 3.5 times. There is also evidence of facemasks appearing on nature trails and washing up on beaches around the World.
Another thing Daniel S. was concerned about was the fact he’d been told that double-wrapped surgical instruments are no more sterile than single wrapped ones, so why the additional waste? One study showed that single wrapped double-ply crepe was just as good at keeping medical equipment “microbiologically clean” as double layers of muslin. However it also states that wrapping twice was better than wrapping once as when you remove the outer layer you are less likely to contaminate the inside. Keeping sterile items in a closed cupboard is also significantly better, but alarmingly for the Earth using impervious plastic wrappers maintains sterility for much longer; up to 18 months! ARGH more plastic waste!!! Also good to note: do not store sterile packages above scrub sinks or in treatment rooms where you are doing minor ops... I know this is common sense but alas common sense is not common, as outbreak data confirms!
So, what can we do?
Well ECIC did find an amazing artist making face shields out of garden waste and flowers so these would at least be compostable… These will probably be adequate for the general public’s use but sadly they are not validated for NHS use!
In reality there is little that we can do about the amount of PPE that is being used. The use of PPE is being driven by both medical need and political pressure.
HOWEVER we can start by making sure we only use PPE when it is necessary. I know there are cases where the wearing of a gown and gloves is for every patient interaction, even in order to hand patients a prescription. This is not strictly “necessary” but IT IS what we are being TOLD to do by the Department of Health; this is not coming from local IPC teams. It might be bonkers; there is “little evidence” but this isn’t just about science; it is done to ensure “standard quality” across the NHS and give the “appearance and reassurance” that everything possible is being done. I appreciate the frustration especially that “this is the way” even in non-clinical areas; I have had to stop my teaching sessions as I cannot tolerate wearing a face mask to give a 2 hour lecture.
It might surprise you to know but there are times when PPE can be a barrier to good infection control. I know this sounds a bit odd but it’s true.
In the past I have seen some very dubious practice with regards PPE. Probably my number one personal annoyance is when I see someone who has put on an apron and gloves to look after a patient with diarrhoea in a side-room, come out of the room with gloves and apron still on, and start drinking their cup of coffee or tea at the nurse’s station! I kid you not. Do they not realise that the whole point of wearing the PPE is to stop their own clothes from becoming contaminated with infectious poo?! PPE does not specifically protect the wearer against things like C. difficile, it’s to stop transmission of C. difficile to someone else… but they’ve just gone and eaten or drank something which they might have contaminated with infectious poo!! It’s no wonder the NHS gets outbreaks of Norovirus every winter.
In theory, if you “can” wash your hands effectively then you don’t need gloves. Whoa, stop! The IPC teams are having kittens!!! There is little evidence to support that gloves and washing hands is better than just washing hands. But we DO advise wearing gloves in clinical areas, why then? Well in hospitals (not the supermarket) there are increased concentrations of bacteria and infection, say Covid-19, and in hospitals it is more complex to control the spread of infection and keep the place clean or infection-free. Therefore using gloves in clinical areas may be more effective; you remove most of the contamination when you don-off the glove into the bin and then as an “extra precaution” you wash your hands – “doubling the chances” for “decreasing the risk of transmission”. Do I think we should be wearing gloves at the supermarket? No, all you are doing is moving anything infectious from one thing to another on the gloves, and then you play with your face mask, transmitting infection and adding to the waste!
But sometimes PPE becomes a problem even when it is being used correctly. An amazing infection control team from the South East (okay I’m biased, the 4th author might seem a familiar name!) realised that the use of PPE in their Critical Care Unit during the initial period of the Covid-19 pandemic was actually contributing to increased infection rates with bacteria. Oops! The basic problem was that Critical Care staff were not able to decontaminate properly between patients because of the amount and type of PPE they were wearing and how busy they were, and so they were spreading bacteria from patients into the environment and back again as well as between patients. The PPE was being USED CORRECTLY but the PPE itself was causing a problem. Our message (along with others) went back to the Department of Health and NHS England, and the PPE guidance was changed to allow the use of short sleeved gowns and aprons.
In addition to making sure we use PPE correctly we must also make sure we dispose of it in an appropriate way. In hospital this means discarding used items into medical waste bins or reprocessing/recycling reusable items like visors and some FFP3 face masks. Outside of healthcare we need to question whether we really do need to use PPE in some environments such as our own cars or walking in the woods. When we do have to dispose of facemasks let’s put them in bins rather than dropping them by the side of the road; it won’t stop PPE going into landfill but at least there will be some measure of control in the environment.
I guess my main concern is that we need to continue to be aware of the impact of the pandemic beyond the immediate effects on ourselves and our patients, and make sure we use PPE at the right time, in the right place and in the right circumstances.
Now where did I leave my pretty pink vegetable face covering…
HOWEVER we can start by making sure we only use PPE when it is necessary. I know there are cases where the wearing of a gown and gloves is for every patient interaction, even in order to hand patients a prescription. This is not strictly “necessary” but IT IS what we are being TOLD to do by the Department of Health; this is not coming from local IPC teams. It might be bonkers; there is “little evidence” but this isn’t just about science; it is done to ensure “standard quality” across the NHS and give the “appearance and reassurance” that everything possible is being done. I appreciate the frustration especially that “this is the way” even in non-clinical areas; I have had to stop my teaching sessions as I cannot tolerate wearing a face mask to give a 2 hour lecture.
It might surprise you to know but there are times when PPE can be a barrier to good infection control. I know this sounds a bit odd but it’s true.
In the past I have seen some very dubious practice with regards PPE. Probably my number one personal annoyance is when I see someone who has put on an apron and gloves to look after a patient with diarrhoea in a side-room, come out of the room with gloves and apron still on, and start drinking their cup of coffee or tea at the nurse’s station! I kid you not. Do they not realise that the whole point of wearing the PPE is to stop their own clothes from becoming contaminated with infectious poo?! PPE does not specifically protect the wearer against things like C. difficile, it’s to stop transmission of C. difficile to someone else… but they’ve just gone and eaten or drank something which they might have contaminated with infectious poo!! It’s no wonder the NHS gets outbreaks of Norovirus every winter.
In theory, if you “can” wash your hands effectively then you don’t need gloves. Whoa, stop! The IPC teams are having kittens!!! There is little evidence to support that gloves and washing hands is better than just washing hands. But we DO advise wearing gloves in clinical areas, why then? Well in hospitals (not the supermarket) there are increased concentrations of bacteria and infection, say Covid-19, and in hospitals it is more complex to control the spread of infection and keep the place clean or infection-free. Therefore using gloves in clinical areas may be more effective; you remove most of the contamination when you don-off the glove into the bin and then as an “extra precaution” you wash your hands – “doubling the chances” for “decreasing the risk of transmission”. Do I think we should be wearing gloves at the supermarket? No, all you are doing is moving anything infectious from one thing to another on the gloves, and then you play with your face mask, transmitting infection and adding to the waste!
But sometimes PPE becomes a problem even when it is being used correctly. An amazing infection control team from the South East (okay I’m biased, the 4th author might seem a familiar name!) realised that the use of PPE in their Critical Care Unit during the initial period of the Covid-19 pandemic was actually contributing to increased infection rates with bacteria. Oops! The basic problem was that Critical Care staff were not able to decontaminate properly between patients because of the amount and type of PPE they were wearing and how busy they were, and so they were spreading bacteria from patients into the environment and back again as well as between patients. The PPE was being USED CORRECTLY but the PPE itself was causing a problem. Our message (along with others) went back to the Department of Health and NHS England, and the PPE guidance was changed to allow the use of short sleeved gowns and aprons.
In addition to making sure we use PPE correctly we must also make sure we dispose of it in an appropriate way. In hospital this means discarding used items into medical waste bins or reprocessing/recycling reusable items like visors and some FFP3 face masks. Outside of healthcare we need to question whether we really do need to use PPE in some environments such as our own cars or walking in the woods. When we do have to dispose of facemasks let’s put them in bins rather than dropping them by the side of the road; it won’t stop PPE going into landfill but at least there will be some measure of control in the environment.
I guess my main concern is that we need to continue to be aware of the impact of the pandemic beyond the immediate effects on ourselves and our patients, and make sure we use PPE at the right time, in the right place and in the right circumstances.
Now where did I leave my pretty pink vegetable face covering…
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