Healthcare systems are plagued by wasteful practices by misconceiving that there is an abundance of easily accessible supplies [1]. However, the coronavirus disease 2019 (COVID-19) pandemic brought an abrupt realization of the fragility of the supply chain when healthcare product shortages highlighted the limits of resources. The healthcare industry significantly contributes to environmental degradation due to millions of tons of waste produced annually, for landfill, thermal, chemical, or irradiation processes [2], and intensive care units (ICUs) are a major generator of waste [3]. Climate change is the biggest threat to global health in the twenty-first century, and the current healthcare system’s unsustainable practices are actually undermining health itself [4]. Therefore, minimizing the environmental impact of intensive care waste is not only desirable but ethically necessary to ensure planetary health is not compromised as a consequence of intensive care provision.

Recycling for a circular economy within intensive care

One environmental sustainability strategy for intensive care units is recycling for circular economy while managing waste [5] (see Fig. 1). This approach seeks to maintain resources within the system for environmental improvements, and can also result in cost savings [6]. Smarter product use and manufacture (refuse, rethink, reduce, redesign and research) and extending the life span of products and their parts (reuse, repair, refurbish, remanufacture and repurpose) are higher priorities in the circular economy [7]. However, recycling can contribute significantly: it should not be downplayed in importance and should be included as a key part of a comprehensive circular economy strategy [8]. An Australian intensive care unit produced 540 kg total waste/week in 2008, showing that almost 60% of the general non-infectious waste could be recycled [3]. After introducing a recycling program in 2013, the same intensive care unit produced 505 kg of waste over 7 non-consecutive days, and 14% of the total waste was recycled, representing nearly half of potential recyclables [9]. The introduction of a recycling program considerably increased the percentage of recycled materials. Registered medical waste (RMW) requires specialized processing before landfill disposal or incineration, significantly increasing its cost compared to general waste, which can be 5–10 times more expensive [10]. Appropriate disposal of non-RMW waste is therefore essential for both financial and environmental sustainability.

Fig. 1
figure 1

Circular economy of healthcare resources

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Recycling within intensive care quality improvement

Enhancing recycling in an intensive care unit can be a form of quality improvement by the SusQI methodology, which emphasizes maintaining safety and clinical effectiveness while maximizing the sustainable value of healthcare resource use [11]. The SusQI framework involves four steps: set goals, study the system, design improvement and measure impact [11]. The goal can focus purely on recycling or have a clinical emphasis with incorporation of improved recycling as one of the actions, while using a sustainability lens on any intensive care quality improvement project. SMART goals (specific, measurable, attainable, realistic and timely) should be set. For example, reduce RMW to less than 20% of total waste and achieve > 10% of recycling.

Studying the system involves exploring local regulations and whether there are programs for separate waste disposal or recycling already in place in the institution. To effectively implement a plan, it is important to work closely with the ICU management, hospital administration, infection prevention and control team, and waste management companies. This is to be aware of all the relevant policies and necessary permissions. Connect with other hospitals and intensive care units to learn from others’ recycling successes.

To ensure success, it is important for the planning to be specific and clearly define the scope, goals, and actions to be taken. Additionally, it is important to consider any potential consequences such as costs or increased workload, and to establish specific measures for determining success, such as the volume of waste saved. A few resources are available to practically address an action plan in more detail (see Supplementary material).

Possible interventions to consider while designing the improvement actions include:

  • Create a “green team” to find allies, share responsibilities and take a collective approach.

  • Facilitate waste segregation with colour-coded and consistently labelled containers (e.g., plastic, paper, glass) (see Supplementary Materials). RMW receptacles should display the biohazard label and be as small as possible to reduce casually tossing in other items. Larger, open-topped solid waste receptacles incentivize their use and place a non-regulated waste container beside a smaller regulated one. Timely collection prevents overfilling bins causing inappropriate segregation.

  • Use reusable containers to prevent sending these bins to landfills, incinerators and systems that manage liquid canister contents into the sanitary sewer.

  • Conduct a pilot of locally recyclable items and evaluate the process.

  • Educate staff to ensure all members of the multi-disciplinary intensive care team are aware of the program goals and understand waste segregation. Eliminating inappropriate disposal habits among clinicians can be a challenge, and repeated reinforcement of the facility’s definition of RMW may be necessary.

A baseline assessment and re-evaluation after implementing actions help to measure the impact of the improvement interventions. Upon completion, publicize and celebrate the successes to build momentum and boost staff morale by highlighting that this is an intensive care unit they can be proud of. Also, share with community media to inform the public about successes and positive improvements for the environment [12].

Recycling as behaviour change

The COM-B model outlines factors influencing behavior change (Capability, Opportunity, and Motivation work together to influence Behavior), and can be useful for designing interventions to promote healthcare staff behaviour changes [13]. Logistical issues need to be overcome to address the ‘Capability’ and ‘Opportunity’ components of the model such as inadequate space for multiple bins, infrequent collection, perceived infectious risks and a lack of data. It is not possible to completely prevent infectious cross-contamination in receptacles, but staff education helps to minimize the contamination of general waste with infectious items [3]. Although some resistance may occur, most staff are highly ‘Motivated’ to recycle and have a willingness to ‘Behaviour’ change for sustainability and environmental protection in intensive care [14]. An intensive care unit going green can additionally help the rest of the hospital to follow suit [15]. Enacting responsible environmental stewardship in everyday intensive care work, including recycling, will help move toward a more ethical and sustainable future for hospitals.