From left: Liz Yates and Louis Nguyen

When Liz Yates, MD, MPH, began her surgical residency at the Brigham, she brought along her deep interest in climate change and desire to make a difference.

“I think climate change is going to have a big impact on resources and disparities in the future,” she said. “I wanted to help reduce our contribution to climate change as a systemic issue and a global problem.”

In 2020, Yates was paired with mentor Louis Nguyen, MD, MBA, MPH, vascular surgeon and vice chair for Digital Health Systems in the Department of Surgery, to investigate potential projects. Together, they developed and championed Watching Our Waste, an initiative to reduce the incorrect use of red medical waste bags in surgical and procedural areas.

Red bags are used in Operating Rooms (ORs) and other clinical areas of the hospital to safely dispose of materials that are saturated with blood or other biohazardous waste. However, they are often used incorrectly to dispose of lightly soiled gowns, gloves and similar items. This improper use carries a financial and environmental cost: Not only is red bag waste five times more expensive to process than regular trash, but it also releases more greenhouse gas emissions during processing. The higher costs occur because red bag waste is transported to a special facility in Rhode Island to be autoclaved — a process that uses high-pressure steam to sterilize materials — for decontamination before it can be transported to a separate waste-to-energy facility.

“The project developed as a kind of nexus of our two interests, and it’s been a really incredible collaboration,” Yates said. “We combined my background and education in climate change and climate science with Dr. Nguyen’s unique experience and expertise in behavioral economics, which is the approach we’ve leveraged to get people to change their behavior.”

Getting Buy-In

Although Nguyen understood that reducing red bag waste was a worthy goal, he knew that for the project to be successful they would need buy-in from incredibly busy staff who were focused on patient care. That’s where his background in behavioral economics came in.

“My contribution to the project was to turn Liz’s interest in the environment into something that was implementable and respectful of everyone’s primary jobs, which is taking care of patients,” he said. “We wanted to come up with a solution that made it easy for staff to make the right choice, but still preserved their autonomy. So, we came up with a set of systems that would benefit the environment and implemented them into the regular workflow.”

In designing the program, Nguyen and Yates involved all stakeholders, including clinical staff and leaders in Environmental Services and Infection Control, to incorporate their feedback and ensure any proposed changes would not compromise patient and staff safety.

Loay Kitmitto, director of Environmental Services, was an enthusiastic supporter. “Red bag waste is so much more expensive to process, and we knew that it was being used incorrectly,” said Kitmitto. “We had wanted to make these changes for a while, but it helped to have the backing of the physicians who are actually working on the floor.”

From the start, they also had the support of Gerard Doherty, MD, surgeon-in-chief. “Having senior leadership recognize that this is an important project was a great boost to our efforts, because it takes a team effort to make a difference,” said Nguyen.

Implementation Brings Positive Change

Behavioral economics is a research field that uses psychology and economics to understand why people and societies behave the way they do — particularly when it acts against their interests — and applies these insights to encourage the desired actions.

Using these concepts, the team devised a simple plan to reduce red bag waste in the ORs: Make access to red waste bins slightly less convenient than the regular trash bins.

“In most of these surgical areas, the red waste bins had been the most available and easiest to reach, making it easy to use them incorrectly,” Yates said. “Instead, we made the openings for those bins a little smaller and put them a little further away. So now, as a clinician, you have to consciously choose to use that red bin, rather than it being the default. This enables clinicians to make the ‘right’ choice more easily, without impeding their workflow.”

After its initial pilot in the ORs, the project has since been adopted in Cath Lab and other procedural areas in the hospital. Overall, red bag waste at the Brigham has dropped by 29 percent in the ORs post-implementation, with even larger reductions expected in other procedural areas.

“We’ve really reduced our red bag use in the Operating Rooms and have almost eliminated them in the Cath Lab, so that’s been really rewarding,” said Yates.

The team has also developed and implemented a tool to track how much waste each area of the hospital is producing, which had never been done before.

“Each month, I collect data from the hospital’s waste managers and vendors to track recycling, trash and compostables, and one of our team members builds it into a monthly dashboard,” Yates said. “Now we can actually see improvements, and we’re starting to break it down by each area of the hospital, so we can tell where the waste is coming from and how different areas of the hospital are changing over time.”

Expanding the Reach

The Watching Our Waste team is now rolling out other initiatives to reduce waste across the Brigham and other Mass General Brigham hospitals, such as BWFH and Salem Hospital.

When working on new projects, Yates said the team seeks to act as consultants.

“We never impose our perspectives or viewpoints on a clinical working space, but we do leverage our connections as clinicians with boots on the ground,” said Yates. “We go into a space, see the day-to-day activities and ask everyone who works there what they want improved. Then we come up with a few recommendations and get them approved by all leadership before we implement any processes. It’s really effective to get buy-in on the front end so that we don’t face much resistance with actual implementation.”

Both Yates and Nguyen said that one of the biggest wins for the project has been the positive feedback they’ve received.

“I think our greatest impact has been to help change the culture,” Nguyen said. “We let people know it’s good to think about environmental issues as a part of all the other things we do in the hospital, and we want to continue this approach of collaboration among different groups as a platform for further change.”