Expanding Waste Segregation Initiatives to Reduce Regulated Medical Waste: A Multi-Departmental Quality Improvement Project

Abstract

Background

Regulated medical waste (RMW) drives up health care costs, largely due to misclassification of general waste, especially in operating rooms (ORs), intensive care units (ICUs), and obstetrics and gynecology (OBGYN) departments. This study aimed to reduce RMW volume and costs at Akron City Hospital (ACH) through department-specific interventions aligning with Occupational Safety and Health Administration (OSHA) and Ohio Environmental Protection Agency guidelines.

Methods

Periodic analyses compared hospital-wide aggregate RMW volume, pick-up frequency, and disposal costs before and after interventions. The ORs initiated interventions in October 2022, expanding to ICUs and OBGYN by February 2024. Strategies included staff education, flyers on red bag receptacles, and adjustments to container availability and size. Monthly data (January 2022 to June 2024) were analyzed using two-tailed heteroscedastic t-tests. Subsequently, an autoregressive integrated moving average (ARIMA) model was used to forecast monthly weights from July to December 2024.

Results

Monthly total RMW weights at ACH dropped from 56 366 lbs in 2022 to 45 148 lbs in 2023 and 37 017 lbs in early 2024 (P < .001). Variability declined, with standard deviation (SD) decreasing from 6177 lbs (2022) to 4062 lbs (2023) and a small increase in variability in early 2024 (SD increased from 4062 to 4366 lbs, non-significant). Seasonal reductions were sustained across quarters. Corresponding RMW disposal costs decreased from $175 189.51 (2022) to $140 321.18 (2023) and $57 528.17 (6-month cost, 2024). Time series predictive analytics indicated stable monthly weights, and anomaly detection confirmed improved consistency post-intervention.

Conclusion

Department-specific interventions significantly reduced RMW volume and costs while enhancing sustainability. Tailored education and operational adjustments offer a scalable model for sustainable waste management in health care, addressing both financial and environmental challenges.

Introduction

Regulated medical waste (RMW), defined as waste potentially contaminated by blood, bodily fluids, or infectious materials, presents both significant financial and environmental challenges for health care institutions. Due to the need for specialized handling and disposal, RMW management incurs substantially higher costs compared to general solid waste disposal. Garcia¹ and Lee et al² noted that RMW disposal costs are 6 to 10 times higher due to stringent regulatory requirements. Despite guidelines from the Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) on waste classification, improper segregation, in which general waste is misclassified as RMW, remains prevalent and continues increasing in costs.

The financial burden is particularly high for large, multi-departmental hospitals like Akron City Hospital (ACH). Cheng et al³ identified factors such as hospital size, patient volume, and service range as key drivers of increased waste production, necessitating tailored strategies for waste reduction. Misclassification of general waste in high-risk areas like operating rooms (ORs), intensive care units (ICUs), and obstetrics and gynecology (OBGYN) departments further inflates RMW volumes. Proper segregation has been shown to reduce RMW weight by up to 30% and lower annual costs by hundreds of thousands of dollars.⁴ However, effective segregation requires comprehensive education for health care workers. Joseph et al⁵ highlighted that gaps in awareness and biomedical waste management practices among health care workers contribute to these increased costs to hospitals.

In addition to financial concerns, improper RMW management has significant environmental impacts. Approximately 15% of health care waste is hazardous, and poor disposal practices, such as incineration, produce harmful emissions contributing to environmental degradation.⁶ Sustainable waste management practices, including waste minimization and segregation, are critical to reducing health care’s ecological footprint.⁷

At ACH, a 750-bed Level I tertiary care center, we launched a multi-departmental quality improvement (QI) initiative, grounded in Plan–Do–Study–Act (PDSA) cycles and Lean Six Sigma (Define–Measure–Analyze–Improve–Control) principles, to optimize waste segregation and reduce RMW volumes and costs. We focused on staff education, iterative receptacle adjustments, and stakeholder engagement in high-waste areas (ORs, ICUs, and OBGYN). By embedding cyclical, data-driven refinements rather than a one-time intervention, we aimed to achieve sustainable reductions in total hospital RMW weight and associated expenses, with lessons scalable to similar institutions.

Case Presentation

Study Design and Setting

This was conducted as a QI project at ACH, a tertiary care facility registered as one of the large generators of infectious waste with the Ohio EPA. We employed PDSA cycles for each department: ORs (October 2022), ICUs (December 2023), and OBGYN (February 2024).

Identifying Institutional Barriers

Prior to each phase, stakeholder interviews and direct observations identified key institutional barriers to proper RMW segregation:

• Inconsistent receptacle placement, leading to confusion about which bins to use.

• High staff turnover in ICUs, necessitating repeated education.

• Limited feedback loops, with no clear process owner for monitoring compliance.

Intervention Components

In October 2022, the QI intervention began in ACH’s main ORs. The PDSA cycle progressed as follows:

• Plan (ORs October–November 2022): Baseline monthly total hospital RMW weight data (January–September 2022) and staff focus groups identified misclassification and receptacle issues.

• Do (ORs October–November 2022): Educational sessions were held during weekly huddles on OSHA Standard 1910.1030(b)/Ohio EPA definitions, and signage was placed on all large RMW receptacles (Figure 1).

• Study (December 2022): Data showed modest reduction in OR RMW weight, but direct observation showed persistent non-RMW disposal.

• Act (January 2023): Large red bags were removed and replaced with single kick buckets, which are small RMW receptacles repurposed to limit bag capacity, based on PDSA feedback and weight comparisons (Figure 2).

Figure 1.

Informational signage depicts which items appropriately belong in regulated medical waste receptacles to aid staff in proper waste segregation.

Figure 2.

In one of Akron City Hospital’s operating rooms, a large clear bag, regular waste receptacles, and a small kick bucket for regulated medical waste were present after the removal of the large red regulated medical waste bag and its receptacles.

In December 2023, the intervention expanded to the ICUs, encompassing the Heart and Lung Unit, Medical ICU, and Surgical ICU:

• Plan: OR cycle outcomes were reviewed; it was confirmed that high staff turnover and inconsistent receptacle placement were on-going barriers; and it was determined that replacing large red-bag receptacles would be implausible in high-volume ICU settings (smaller bins risk overflow, compromise infection control, disrupt workflows, and increase labor).

• Do: Organized roundtable educational sessions were held for both day and night shift nurses on all 3 ICU floors; clear, OSHA- and EPA-compliant signage were fixed to every red-bin receptacle in all 26 patient rooms per floor, plus bathrooms and common areas.

• Study: The total hospital RMW weight comparison between December 2023 and January 2024 demonstrated a continued decrease.

• Act: Unit-based champions were established to maintain signage and conduct brief quarterly refreshers, and RMW metrics were integrated into quarterly performance dashboards to reinforce accountability and sustain gains.

In February 2024, we introduced the initiative in OBGYN:

• Plan: The main OR and ICU results were analyzed; OBGYN stakeholder input was solicited on receptacle placement and feedback loops.

• Do: Education sessions were held for day/ night shift nurses and residents; vaginal delivery rooms reduced their usage from 2 to 1 red bag; OBGYN ORs swapped 2 large red bags for 1 kick bucket.

• Study: February 2024 versus March 2024 weight comparison showed further RMW reductions.

• Act: Monthly weight reviews were scheduled through June 2024 and a quarterly staff refresher process was formalized.

Data Collection and Analysis

Data on RMW weight (in pounds), the number of pick-ups, and disposal costs aggregated for the entire hospital were obtained from Environmental Services. Metrics were compared across 3 key time periods: pre-intervention (January–September 2022), post-intervention in the ORs only (October 2022–November 2023), and post-intervention across all departments (February 2024–June 2024). We considered creating a fourth intermediate time period to capture the short interval between ICU implementation and OBGYN rollout (ie, December 2023–January 2024). However, this period included only 2 full months of post-ICU data, which was insufficient for a robust statistical comparison. Introducing a fourth, underpowered phase would have fragmented the dataset and weakened the analysis. To preserve statistical power and interpretability, we grouped ICU and OBGYN interventions together into a single “all departments” post-intervention period.

Two-tailed heteroscedastic t-tests were conducted to compare mean values between periods, with significance set at P less than .05. The autoregressive integrated moving average (ARIMA) model was fitted to the monthly weight series to forecast July–December 2024. The model’s autoregressive component uses lagged observations as predictors, the Integrated component enforces stationarity via differencing, and the moving average component incorporates lagged forecast errors. All statistical analyses were performed in Minitab and Python.

Results

This study analyzed monthly total hospital RMW weights, aggregated for all departments, from January 2022 to June 2024, highlighting significant reductions in waste volumes, associated costs, and variability. Descriptive statistics revealed a progressive decline in mean monthly weights over the years. Comparisons of mean monthly weights showed a reduction from 56 366 lbs in 2022 (SD 6177 lbs) to 45 148 lbs in 2023 (SD 4062 lbs) and further to 37 017 lbs from February–June 2024 (SD 4366 lbs), representing 20% and 35% decreases, respectively.

Statistical analysis using t-tests confirmed that the year-over-year reductions in hospital-wide RMW weights were statistically significant (P < .001). The greatest reduction in weights occurred between 2022 and 2024 (19 349 lbs, P < .001), and the significant, continued weight reduction from 2023 to 2024 (8131 lbs, P < .001) suggested a consistent downward trajectory in RMW generation.

An analysis of quarterly trends illustrated seasonal patterns and reductions in total hospital waste weights over time (Figure 3). In 2022, weights were consistently high across all quarters. In 2023, total weights were reduced uniformly across quarters, and this downward trend persisted in the first 2 quarters of 2024, with significantly lower weights than in corresponding quarters of previous years.

Figure 3.

Total regulated medical waste weights are grouped by quarter for 2022, 2023, and the first half of 2024 shows a continuous downward trend.

The financial implications of these reductions were equally substantial (Figure 4). With a processing cost of RMW of $0.26/lb, the total cost in 2022 was $175 189.51 for 676 390 lbs of waste. By 2023, the cost had dropped to $140 321.18 for 541 776 lbs, and in the first half of 2024, it further declined to $57 528.17 for 222 103 lbs. These cost savings directly corresponded to the decline in hospital RMW volumes.

Figure 4.

Annual processing costs of regulated medical waste in 2022, 2023, and the first half of 2024 highlight cost savings from reduced volumes.

Predictive analytics using the ARIMA model forecast stabilization in monthly total weights for the second half of 2024, predicting values between 32 763 lbs and 33 223 lbs (Figure 5).

Figure 5.

An autoregressive integrated moving average model can be used to forecast monthly total weights from July to December 2024, which shows stabilization and sustainability of observed weight reductions.

This forecast suggests sustainability of the observed total hospital RMW weight and cost reductions and supports strategic planning from recent interventions by identifying probable trends in upcoming months. An anomaly detection analysis identified January 2022 as a significant outlier, with an unusually high weight of 65 447 lbs, likely reflecting pre-intervention inefficiencies. Importantly, no significant anomalies were detected post-intervention, indicating the consistency and reliability of waste management improvements.

Discussion

The findings of this study emphasize the significant impact of department-specific interventions on reducing RMW volumes and disposal costs. By focusing on high-waste departments such as the ORs, ICUs, and OBGYN, the interventions effectively addressed the specific waste streams and practices contributing to improper segregation and inflated disposal volumes. This targeted approach not only achieved significant reductions in waste but also demonstrated the importance of department-level tailoring in waste management strategies.⁸

Financially, the initiative resulted in a 24.8% decrease in processing costs from 2022 to the first half of 2024, consistent with the findings of Plezia et al,⁹ who reported similar cost-saving effects from improved waste segregation in high-waste departments. These reductions underscore the broader financial benefits of prioritizing waste management, including operational efficiency and reduced resource use.

Education and stakeholder engagement played a pivotal role in achieving these results. Tailored educational sessions for staff in the ORs, ICUs, and OBGYN departments improved compliance with waste segregation protocols, as evidenced by the statistically significant reductions in RMW weights. Visual reminders, such as laminated flyers or reinforced proper practices, aligned with findings by Bdour et al,¹⁰ Hossain et al,⁶ and Pillay et al,¹¹ who highlighted the importance of continuous training and communication in fostering compliance.

Operational adjustments also contributed significantly to waste reduction. By optimizing the number and placement of red bag receptacles, particularly in the ORs and ICUs, the initiative minimized the misclassification of general waste as RMW, a recurring issue in health care settings.² These changes reflect Lean Six Sigma principles described by Wohlford et al,¹² which improve workflow efficiency and reduce unnecessary material use.

From an environmental perspective, the initiative aligns with broader sustainability goals. The study by Sijm-Eeken et al¹³ emphasized the integration of waste management strategies with environmental initiatives, such as energy efficiency and carbon reduction. By reducing RMW volumes and reliance on incineration, ACH contributed to minimizing its ecological footprint.⁶ Predictive analytics indicating stabilization in waste volumes further support the long-term sustainability of these measures.

Drawing on insights from Vu et al,¹⁴ Pillay et al,¹¹ Azouz et al,⁸ and Sijm-Eeken et al,¹³ the project aimed to address institutional barriers, improve operational sustainability, and integrate waste reduction with broader environmental initiatives. This study highlights the effectiveness of department-specific interventions as a scalable model for reducing RMW volumes and its associated costs in health care. The success of the ACH initiative demonstrates that similar targeted strategies can be implemented in other high-waste areas, such as emergency departments and outpatient clinics, yielding substantial financial and environmental benefits. Research by Vu et al¹⁴ and Shinn et al¹⁵ further supports the value of tailored waste management approaches, particularly when paired with education and operational adjustments. To sustain these improvements, future efforts should prioritize ongoing education, periodic audits, and expansion to additional departments.

Limitations

Despite the success of the multi-component QI intervention delivered through sequential PDSA cycles, several limitations warrant consideration. First, because waste data were reported only in aggregate, we could not stratify outcomes by individual departments and thus could not isolate the specific impact of each PDSA cycle in the ORs, ICUs, or OBGYN. Second, hospital activity levels, such as fluctuations in patient census, surgical case volume, and seasonal staffing, may have influenced RMW generation independently of our interventions, and we were unable to adjust for these factors. Third, although our iterative “Study” and “Act” steps incorporated staff feedback and monthly weight monitoring, we could not quantify the relative contribution of each educational or receptacle adjustment component. Future work should include department specific data collection, formal adjustment for activity level covariates, and longer post intervention follow up to evaluate the durability of each PDSA cycle’s effect.

Future Directions

To sustain these improvements, ongoing education and monitoring are essential. Periodic audits, feedback sessions, and continuous stakeholder engagement can help maintain high levels of compliance. Expanding the initiative to other departments, such as the emergency department or outpatient clinics, could further enhance cost savings and environmental benefits.

Conclusion

This QI initiative at ACH demonstrates a scalable and sustainable model for addressing the financial and environmental challenges associated with RMW in health care. Through department-specific interventions, targeted staff education, stakeholder engagement, and operational reform, the initiative achieved significant reductions in RMW volumes and disposal costs, with sustained improvements supported by predictive analytics. These results highlight the potential for broader implementation of similar strategies across health care settings, offering lasting financial and environmental benefits while ensuring alignment with regulatory guidelines. This study underscores the importance of a comprehensive, multi-faceted approach to waste management, providing a framework for health care organizations to reduce operational costs and advance environmental sustainability.