Healthcare waste: from incineration to pyrolysis: a comparative life cycle assessment of two different healthcare plastic waste management processes

Abstract

Background

Plastic waste from healthcare is an increasing environmental challenge, particularly in resource-intensive clinical pathways such as dialysis. Peritoneal dialysis (PD) generates large quantities of single-use plastic materials, making its waste stream a priority for sustainable intervention. Conventional disposal through incineration contributes substantially to greenhouse gas emissions (GHG) and produces hazardous ash. Pyrolysis, a chemical recycling process that converts mixed plastic waste into usable outputs, has been proposed as a lower-carbon alternative. This study aimed to estimate the change in GHG emissions and key environmental co impacts if a hospital nephrology service were to switch its PD plastic waste treatment from incineration to pyrolysis.

Methods

A comparative life cycle assessment (LCA) was conducted for the management of 1 kg of plastic waste from PD. OpenLCA modelling with established life cycle inventory datasets was used to quantify environmental impacts across multiple categories. Two scenarios were assessed: full incineration and a combined system in which pyrolysis was used with a 10% residual fraction sent to incineration. Impact categories included climate change, freshwater ecotoxicity, marine eutrophication, human toxicity, mineral resource use and water consumption. Sensitivity Analysis were also undertaken.

Results

The combined pyrolysis system with 10% residual incineration generated a net climate change impact of −0.230 CO₂e per kg of healthcare plastic waste managed, compared with +1.996 CO₂e per kg under full incineration. Across all sixteen environmental impact categories assessed, the pyrolysis pathway demonstrated lower impacts than conventional incineration. Pyrolysis generated net environmental credits in seven categories, including climate change, non-renewable energy use, freshwater eutrophication and photochemical oxidant formation.

Conclusions

Pyrolysis shows clear potential as a lower-carbon alternative for managing plastic waste from PD and could support efforts to align clinical waste management with broader sustainability goals. Despite these environmental advantages, economic constraints and differing national regulations currently limit widespread adoption. The findings indicate that pyrolysis may play an important role in reducing the environmental burden of plastic waste in high-volume clinical services. Further work is needed to evaluate the operational feasibility of this approach and to position pyrolysis within a wider set of sustainable waste management strategies.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15024-w.

Background

The healthcare sector is a significant contributor to global greenhouse gas (GHG) emissions and overall environmental burden, largely through its reliance on disposable materials and energy-intensive processes. Waste management is a significant part of this footprint accounting for around 1.074 kg CO₂e per kg of healthcare waste [1]. Reducing the environmental burden of medical waste remains a complex challenge with important links to procurement policy, appropriate categorisation, segregation and finally the type of waste treatment. Procurement policies should favour reusable products over single-use items where feasible, due to their potential to reduce resource consumption and waste generation [2]. Among clinical specialties, those that depend on resource-intensive treatments, such as dialysis, not only generate paper waste etc but also produce disproportionately high volumes of plastic waste [3]. Peritoneal dialysis (PD), in particular, relies heavily on single-use plastic materials. The carbon footprint of plastics varies widely depending on type, production, treatment method and material. Plastic items, for instance, can have a carbon footprint of between 2.6 to 7.6 kg CO₂e per kg across the life cycle [4].

Infectious healthcare waste is usually initially pre-treated (e.g. through autoclaving or disinfection) to eliminate health risks before disposal, although legal requirements for specific treatment methods can vary considerably between regions and countries [5, 6].

As an example, the city of Modena currently sends most healthcare waste directly for incineration, bypassing intermediate treatment steps. Incineration is a high-energy process that consumes fossil fuels and generates fly ash (a by-product containing heavy metals and other toxic substances) comprising around 18.9% of total incinerated waste [7].

Mechanical recycling and pyrolysis represent two fundamentally different alternatives to incineration for managing healthcare plastic waste.

Mechanical recycling is a physical process that involves sorting, cleaning, shredding and reprocessing plastics into pellets or flakes, which are then remoulded into new plastic products [8]. However, the use of mechanical recycling is difficult in healthcare as its efficiency is constrained by the need for high-purity inputs, which is more likely with chemical recycling [9].

In contrast, pyrolysis is a chemical recycling method that thermally decomposes plastic waste in the absence of oxygen. The process breaks down mixed and contaminated plastic into simpler hydrocarbon products, including pyrolysis oil, gases, and char. These outputs can be refined into fuels or chemical feedstocks such as ethylene and propylene, potentially serving as building blocks for new plastics [10]. Among these products, the solid char can act as a substitute for lignite in solid-fuel-burning applications, offering a secondary route to emissions savings by displacing fossil-derived fuels [11]. Pyrolysis holds particular promise for healthcare waste streams that are often too heterogeneous or contaminated for mechanical recycling [12] This is particularly true for dialysis-related plastic waste, which commonly combines multiple polymer types and is frequently affected by biological contamination from body fluids and medications, making mechanical recycling impractical in most cases.

As part of the EU Horizon-funded KitNewCare project, which aims to improve the environmental and social sustainability of kidney care in Europe, this study undertook a detailed analysis of healthcare plastic waste generated at AOU Policlinico di Modena in Italy. Although several reviews exist on healthcare waste management there is limited evidence from life cycle assessment (LCA) studies evaluating alternative treatment strategies using real-world clinical data.

There are now a growing number of LCAs in healthcare as shown in PubMed searches or by exploring the Healthcare LCA database, but most studies focus on products, devices, or individual clinical procedures rather than on existing hospital waste systems or on decisions to change waste treatment contracts and infrastructures [13–15].

This study aimed to estimate the change in GHG emissions and key environmental co-impacts if a hospital nephrology service were to switch its PD plastic waste treatment from incineration to pyrolysis. Importantly, the study was designed to inform service-level decision-making, including whether nephrology units should consider pyrolysis rather than incineration for PD plastics and what the environmental trade-offs may be when shifting hospital waste management contracts towards pyrolysis-based systems. By focusing on peritoneal dialysis, a treatment modality associated with a notable plastic waste burden, this analysis also informs broader approaches to sustainable medical waste management.

Methods

This study used a comparative process-based LCA to evaluate the environmental impacts of pyrolysis and incineration for healthcare plastic waste generated in PD care at AOU Policlinico di Modena, Italy.

LCA was employed as a standardised framework to evaluate the environmental impacts associated with all stages of plastic waste management, from production and usage in clinical care to final disposal or recycling. The analysis compared two processes: incineration, the conventional treatment in Modena, and pyrolysis, an emerging chemical recycling technique. LCA boundaries included raw material extraction, transportation, shredding/autoclaving (when applicable), incineration, pyrolysis and material outputs. The data collection and LCA presented here were carried out between April and July 2024 at the AOU Policlinico di Modena, Italy. LCA methodology followed the ISO 14040/14044 standards.

LCA methodology

The LCA was conducted using the Environmental Footprint (EF) 3.1 method as recommended by the European Commission Product Environmental Footprint (PEF) guidelines [16]. Modelling was performed in OpenLCA v2.0 using the Ecoinvent database version 3.9.1 (cut-off system model) [17]. LCIA Method- EFv3.1 with normalised values was used compatible with PEF.

A system expansion (substitution) approach was applied to account for co-products generated during waste treatment processes. For pyrolysis, outputs including ethylene, energy (electricity generated in the incineration process) and char were assumed to displace equivalent conventional products (i.e. fossil-derived ethylene, grid electricity, and lignite fuel).

Functional unit

The functional unit for this study is defined as the management of 1 kg of waste, where this waste was generated by the care of a patient undertaking dialysis. The functional unit facilitates comparison with other clinical settings (Barcelona Clinic was used here as the comparative clinical site) and allows the Modena LCA results to be extrapolated to patient-level impacts using modality-specific waste generation data.

System boundaries

The system boundaries in this study are shown in Fig. 1. System boundaries include activities such as the extraction of materials required for production, transportation, use and disposal. Disposal involved the treatment and management of medical waste generated from PD care.

Fig. 1.

Flow diagram of functional unit: waste management of healthcare waste in Modena; comparison of using pyrolysis instead of traditional incineration. Figurelabs- generated from instructions by the authors

Figure 1 illustrates the system boundaries applied in this study; these include upstream polymer production, manufacture of dialysis consumables and associated plastic waste, waste bag and bin production, transportation, pre-treatment steps (e.g. shredding and autoclaving where applicable) and final treatment via incineration or pyrolysis. Processes such as hospital infrastructure, capital equipment and staff travel were excluded based on their negligible contribution to the functional unit (1 kg of waste managed) and to maintain consistency with comparable waste focused LCAs, while consumable infrastructure elements with shorter lifespans (e.g. waste bins) were included. To ensure comparability between scenarios, equivalent assumptions for transport and handling were applied where appropriate and any differences in operational requirements (e.g. autoclaving prior to pyrolysis but not incineration in the Modena context) were explicitly modelled rather than normalised or excluded. The study reflects operational conditions in Modena, Italy, using site-specific primary data and Ecoinvent v3.9.1 background datasets, with a temporal boundary representing current practices (2024). System expansion was used to account for avoided burdens associated with recovered products from pyrolysis (e.g. ethylene and lignite substitutes), assuming displacement of conventionally produced equivalents.

Life cycle inventory and analysis

This section outlines the process used to quantify the environmental impacts of healthcare plastic waste through LCA, comparing two alternative waste management strategies: traditional incineration and pyrolysis. The methodology includes:

Material identification and weighing

All materials involved in each stage of the waste process (e.g., bins, transportation, shredding, autoclaving, incineration, pyrolysis) were catalogued and their weights measured.

Clinical

Waste data were collected from nephrology clinics at AOU Poloclinico di Modena staff and management systems, with particular focus on PD related healthcare waste. Secondary data was sourced from Jeswari [18].

Incineration plant

From an incineration perspective, transportation, waste bin processing, electricity generation, fuel consumption and the amount of waste residue were modelled on data from Modena waste plant [19].

Plastic contribution

Characterise plastic use in haemodialysis (HD) and PD, we drew on data from a parallel observational study using a material flow analysis in a renal clinic in Barcelona. Plastic and other material use for 42 home dialysis patients was prospectively recorded during training and follow-up episodes, and each item was classified by material type (polyvinyl chloride (PVC), PET, polypropylene (PP), low-density polyethylene, cardboard, steel, glass and dialysate) and weight. Plastic and other material use for 42 home dialysis patients was prospectively recorded during training and follow-up episodes and each item was classified by material type (polyvinyl chloride (PVC), PET, polypropylene (PP), low-density polyethylene, cardboard, steel, glass and dialysate) and weight. For the present analysis, we used the plastic fractions from this material flow inventory to estimate the relative contribution of dialysis-related plastics to overall healthcare waste and to inform the categorisation of plastic waste streams by polymer type.

Descriptions and assumptions of data collected are in Table S1 in appendices 2.

Inputting data into OpenLCA

The material weights and types, along with the flow diagrams, were entered into OpenLCA [20]. Processes for each stage in the waste management process were developed and connected to the flow diagram.

This data was utilised to simulate the life cycle of the devices and materials used in PD treatments.

An environmental impact assessment was performed using the chosen methods in OpenLCA in combination with the Eco Invent database [17]. This process involved evaluating environmental impacts across various categories, including global warming potential, ecotoxicity and acidification. The LCA results were examined to determine the components and processes with the greatest environmental impact.

Life Cycle Impact Assessment (LCIA)

The LCA analysis used OpenLCA v2.0 software and the Ecoinvent v3.91 reference database. The LCA methodology followed the recommendations outlined by the International Standard Office and the European Commission’s Product Environmental Footprint guidelines [16, 21].

Sensitivity analysis

A sensitivity analysis is used to determine how changes in input parameters, data assumptions or methodological choices affect the final environmental footprint. This methodology is highlighted in Table 1.

Table 1.

Sensitivity analysis summary

Label (see Fig. 1)	Factor changed	Reason for this change
Transport
SA1	Changing from Diesel Train to Electric Train	An electric train route is available from Modena to Modena, removing diesel combustion emissions from the rail leg.
SA2	Adding a separate shredding and autoclaving plant	Shredding and autoclaving can be performed at a different location
Pre-treatment of waste
SA3	Shredding	Legislation differs across Europe as to its need
SA4	Autoclave
Energy
SA5	Use wind energy to process bins instead of usual energy mix	Author assumption: Usually easy to swap
SA6	Shred using wind energy
SA7	Autoclave using wind energy
SA8	Undertake pyrolysis using wind energy	It is possible to undertake Pyrolysis with wind energy [22]
SA9	Double electrical efficiency	Differences amongst waste plants in terms of electricity generation [23].
SA10	Change energy demand for process (20%)	Several factors influence pyrolysis processes [24, 25]
SA11	Change energy demand for process (40%)
Product yield
SA12	Char has no noticeable credit/yield	Author assumption
SA13	Char has 50% ability to sequester carbon	Nan has shown the ability of Char to sequestrate Carbon to these level [26].
SA14	Change in ethylene yield (x%)	Genuino showed pyrolysis of HDPE, LDPE, PP, and PS produced high product yields, generating between 94 and 96 wt% oil or oil/wax fractions, whereas PET lower yields (54 wt%) [27]
SA15	Change in ethylene yield (x%)
SA16	Change in ethylene yield (x%)
Incineration
SA17	Doubled incineration i.e. only 80% suitable for pyrolysis

Uncertainty analysis

A Monte Carlo simulation was conducted in OpenLCA to assess uncertainty in the LCA results for the “Realistic Modena Pyrolysis with 10% Incineration” system. A total of 10,000 iterations were performed using a functional unit of 1 tonne of healthcare plastic waste. Uncertainty distributions from model parameters and Ecoinvent background data were propagated through the system. Mean, median, standard deviation and 5^th-95th percentile ranges were calculated to evaluate result variability and robustness.

Results

The modelling has assumed 90% of the plastic waste undergoes pyrolysis, while the remaining 10% is sent to municipal solid waste incineration. Incineration generates energy, but it also produces refuse-derived ash as a byproduct, which may require further disposal. For process visualisation, Figure 2 displays the two pathways: the red pathway illustrates waste shredding, autoclaving and pyrolysis (with a component of incineration) resulting in ethylene and lignite; the green pathway represents traditional Modena processing via incineration, yielding energy and ash. Process steps and model inputs (including shredding, autoclaving, and energy balances) were described separately in the Methods section and are presented here for reference in interpreting the comparative environmental results.

Fig. 2.

Waste management: Modena incineration versus Modena pyrolysis

Carbon footprint assessment (Table 2, Fig. 2) showed that processing 1 tonne of healthcare plastic waste through pyrolysis with 10% incineration led to a net emissions output of −230 kg CO₂e compared with +1996 kg CO₂e for full incineration. This difference is largely driven by the substitution (−854 kg CO₂e) and lignite substitute (−3 kg CO₂e), which displaced conventional fossil derived products and energy sources.

Table 2.

Carbon dioxide equivalent of pyrolysis compared with incineration

Pyrolysis with 10% incineration		Incineration 100%
Pyrolysis process (90% plastics)	Contribution (kg CO₂-eq)
Market for ethylene (credit)	−853.556	NA
Modena energy used at waste plant	214.75	NA
Shredding 1 kg waste	60.867	NA
Natural gas burned in gas turbine	41.403	NA
Autoclave waste using wind energy	38.943	NA
Transport, freight, lorry, diesel EURO 5	35.105	NA
Remaking Plastic_Healthcare_Bins_Modena	32.482	NA
Market for natural gas liquids	5.457	NA
Industrial gases production, nitrogen liquid	5.089	NA
Market for neutralising agent, sodium hydroxide-equivalent	0.651	NA
Electricity, medium voltage residual mix	0.014	NA
Market for lignite (credit)	−2.682	NA
Heavy fuel oil production (credit)	−8.497	NA
Net pyrolysis footprint	−429.973	NA
Incineration Process (10% of plastics)		NA
Other processes including direct carbon emissions	142.84	1428.4
Market for sodium hydroxide, without water, in 50% solution state	20.093	200.93
Modena energy used at waste plant	18.027	180.27
Shredding 1 kg waste	6.763	67.63
Autoclave waste using wind energy	4.327	43.27
Transport, freight, lorry, diesel EURO 5	3.901	39.01
Remaking Plastic_Healthcare_Bins_Modena	3.609	36.09
Total incineration footprint	199.559	1995.59
Final footprint	−230.414	1995.59

Across all sixteen impact categories assessed, the pyrolysis pathway with 10% residual incineration demonstrated lower environmental impacts than conventional incineration alone. Pyrolysis generated net environmental credits (negative normalised values) in seven categories, most notably non-renewable energy resources (−0.468 vs +0.088), climate change (−0.031 vs +0.264), freshwater eutrophication (−0.040 vs +0.442), and photochemical oxidant formation affecting human health (−0.013 vs +0.111).

The largest relative improvements associated with pyrolysis were observed for particulate matter formation (48-fold lower than incineration), material resource use for metals and minerals (14-fold lower), freshwater ecotoxicity (13-fold lower), carcinogenic human toxicity (12-fold lower), ionising radiation impacts on human health (8-fold lower), and land use (7-fold lower). More moderate reductions were observed for acidification and marine eutrophication (approximately two-fold lower), while terrestrial eutrophication showed only marginal differences between the two pathways.

Although pyrolysis generally performed better across all categories, some impacts remained positive, particularly eutrophication, acidification, and ecotoxicity categories, reflecting the residual environmental burdens associated with energy use, transport, and pre-treatment requirements within the pyrolysis system.

The results presented in Table S2 in appendices 2 and Figure 3 are expressed as normalised values, which represent the relative magnitude of each impact category after scaling against a reference value (typically the total annual environmental load per capita in each region, as defined in the impact assessment method). Normalisation enables comparison across different impact categories (e.g. climate change, toxicity, resource use) by placing them on a common scale, rather than interpreting them in their original units. As such, the values should be interpreted as relative contributions rather than absolute impacts. The ratios reported reflect the comparative performance of incineration versus pyrolysis within each category, where values greater than 1 indicate higher impacts for incineration and values less than 1 indicate higher impacts for pyrolysis. This approach facilitates identification of trade-offs across impact categories but should not be interpreted as a direct measure of real-world magnitude without considering the underlying normalisation references and assumptions.

Fig. 3.

Normalised environmental impacts for pyrolysis and incineration

Across all sixteen impact categories assessed, the pyrolysis pathway outperformed traditional incineration. Pyrolysis returned a net environmental credit (negative score) in seven categories specifically non-renewable energy use (−0.470 vs +0.088), climate change (−0.031 vs +0.264), freshwater eutrophication (−0.040 vs +0.442) and photochemical oxidant formation (−0.013 vs +0.111) The largest comparative gains were particulate matter formation (61-fold lower than incineration), freshwater ecotoxicity (13-fold) carcinogenic human toxicity (12-fold) and land use (6 times). Margins were narrower for acidification, marine and terrestrial eutrophication (ratios between 1 and 2).

Uncertainty analysis

Monte Carlo uncertainty analysis was conducted for the realistic pyrolysis with 10% incineration scenario using 10,000 iterations and uncertainty distributions embedded within the EcoInvent 3.10 background database. The simulation produced a mean result of 415.1 kg with a median of −145.1 kg, a 5th to 95th percentile range of −9324 to 8565 and a standard deviation of 20,440, as shown in Figure S1 in Appendices 2.

Sensitivity analysis results

The sensitivity analysis results are highlighted in Table 3.

Table 3.

Sensitivity analysis results

Label	Sensitivity analysis	Baseline Pyrolysis 90%	Baseline Incineration 10%	Total baseline	SA result	Total (baseline −230.58)	Percentage change
Baseline						−230.58
Transport
SA1	Changing from diesel train to electric train	35.11	3.90	39.01	6.37	−263.22	1.14
SA2	Adding a separate shredding and autoclaving plant	0.00	0.00	0.00	28.67	−201.91	0.88
Pre-treatment of waste
SA3	Shredding removed	60.86	6.76	67.63	0.00	−298.21	1.29
SA4	Autoclave removed	38.94	4.33	43.27	0.00	−273.85	1.19
Energy
SA5	Use wind energy to process bins instead of usual energy	26.85	2.98	29.83	2.96	−257.45	1.12
SA6	Shred using wind energy	60.86	6.76	67.63	6.71	−291.50	1.26
SA7	Autoclave using wind energy	38.94	4.33	43.27	4.29	−269.56	1.17
SA8	Undertake pyrolysis using wind energy	214.75	0.00	214.75	21.30	−424.03	1.84
SA9	Double electrical output of incineration plant	−21.33		−21.33	−42.66	−251.91	1.09
SA10	Change energy demand (+20%) for pyrolysis pathway	214.75		214.75	257.70	−187.63	0.81
SA11	Change energy demand (+40%) for pyrolysis pathway	214.75		214.75	300.65	−144.68	0.63
Product yield
SA12	Char has no noticeable credit/yield	−2.98		−2.98	0.00	−227.60	0.99
SA13	Char yield equivalent to 50% carbon per mass	−2.98		−2.98	33.615	−193.99	0.84
SA14	Pyrolysis-oil ethylene yield −60%	−853.33		−853.33	−512.00	110.75	−0.48
SA15	Pyrolysis-oil ethylene yield −40%	−853.33		−853.33	−341.33	281.42	−1.22
SA16	Pyrolysis-oil ethylene yield −20%	−853.33	0.00	−853.33	−170.67	452.08	−1.96
Purity / incineration
SA17	Doubled incineration only 80% suitable for pyrolysis				0	16.97595397	−0.07

Discussion and recommendations

Principal findings and overall interpretation

This study provides the first comparative LCA of pyrolysis and incineration for healthcare plastic waste, providing important new evidence on the environmental benefits and trade-offs of these processes. Our findings demonstrate that pyrolysis significantly reduces the carbon footprint and several other environmental impacts associated with plastic waste treatment by producing outputs such as ethylene and lignite substitutes that offset fossil energy use.

Given the substantial waste and resource demands of dialysis, nephrology represents a specialty with a disproportionately high environmental footprint, an issue projected to worsen as global rates of chronic kidney disease (CKD) continue to rise [28, 29]. Using these data as displayed in Table S3 in appendicies 2, annual plastic waste per dialysis modality is approximately 670 kg for home HD, 248 kg for automated peritoneal dialysis (APD) and 76 kg for continuous ambulatory peritoneal dialysis (CAPD).

Comparison with existing literature

Pyrolisis produced sustainability lower net GHG emissions that incineration, consistent with recent LCAs of plastic waste pyrolisis. Our emission factor for high-temperature incineration of hospital plastic waste is higher than the value of 1,074 kg CO₂e per tonne reported by Rizan et al., who assessed mixed hospital waste streams rather than plastic only fractions, which likely explains part of this difference. For example, Xayachak et al. reported net GHG reductions of approximately 1.3 kg CO₂e per kilogram of plastic for monomer-recovery/fuel-production pyrolysis pathways, which is comparable in magnitude to the savings attributed in our Modena study to ethylene and lignite production [30].

Environmental Benefits/Human health of pyrolysis

The reduction in climate change impacts suggests that pyrolysis may offer important environmental benefits over incineration, particularly in relation to climate change mitigation [31].

Pyrolysis carries a substantially lower human-toxicity burden than incineration with carcinogenic toxicity scores of 0.014 vs 0.160 (≈12-fold lower) and non-carcinogenic of −0.002 vs 0.044.

The residual carcinogenic and non-carcinogenic toxicity within the pyrolysis system is dominated by background electricity requirements with Italian hard-coal mixes and German hard-coal imports together contributing approximately 1.65 × 10⁻⁷ CTUh in the underlying inventory. Secondary contributions arise from diesel use at the Modena plant, refinery diesel and EURO-5 lorry transport; chlor-alkali NaOH and ethylene-chain inputs add small carcinogenic-organic loads. Toxicity outcomes are partly driven by background electricity sufficient that switching the pyrolysis energy supply to wind (SA8), or shredding/autoclaving on wind power (SA6, SA7), would reduce the residual carcinogenic and non-carcinogenic loads further. This is all displayed in Fig. 1.

When the Modena impact estimates per kg of plastic waste are combined with modality-specific waste flows, the clinical relevance of the functional unit becomes more tangible. Assuming a difference of about 2.23 kg CO₂e avoided per kilogram of plastic when pyrolysis replaces incineration, this corresponds to an illustrative saving of around 1.49 tonnes CO₂e per home HD patient per year, 0.55 tonnes for an APD patient and 0.17 tonnes for a CAPD patient.

Regulatory and legal challenges

In Italy, pyrolysis plants are not regulated under a single dedicated framework distinct from waste incineration. Instead, they fall under the general waste management provisions of Legislative Decree 152/2006, which requires case-by-case authorization (Art. 208) [32] and, where applicable, an Integrated Environmental Authorization (AIA) [6]. Furthermore, under current EU interpretation, thermal processes such as pyrolysis are subject to waste-incineration emission standards only when their outputs are combusted (2010/75/UE) [33]; consequently, regulatory classification and associated emission controls depend on specific plant configuration and operation (2019/2010/UE) [34]. As a result, emission limits and monitoring requirements for pyrolysis installations may vary between facilities (SNPA, 2023) [35]. Regarding hazardous healthcare waste, the regulatory framework in Italy is particularly stringent and governed by D.P.R. 254/2003 [36] in line with a general ‘maximum precaution principle’. Although pyrolysis offers a technologically advanced alternative to traditional incineration, achieving complete sterilization and substantial volume reduction it is legally classified as a thermal treatment process. Unless the resulting syngas or oils undergo extensive purification to meet commercial fuel standards, these installations must comply with the rigorous emission limits and technical requirements set for waste incineration, including mandatory post-combustion at 1100 °C for chlorinated compounds (Italian Legislative Decree 46/2014) [37]. Moreover, despite the high-temperature thermal breakdown of pathogens, the residual solid char typically retains its hazardous classification and must follow specific characterization and disposal protocols (ISPRA, 2025) [38].

Secondly there is limited regulatory coverage of pyrolysis, across EU member states. The implementation of pyrolysis as a healthcare waste treatment solution is affected by diverse, fragmented EU regulatory frameworks. Unlike mechanical and certain chemical recycling technologies, pyrolysis is not uniformly covered under Regulation (EU) 2022/1616, which governs recycled plastic materials intended for food contact, nor under consistent end-of-waste criteria across member states [39]. This legislative gap limits clarity on the acceptance and use of pyrolysis outputs, particularly pyrolysis oil, raising concerns about safety and quality assurance. Furthermore, without harmonized regulations, pyrolysis risks competing with mechanical recycling for the same feedstocks, potentially undermining more established circular approaches. Differences in national legislation, varying recognition of pyrolysis as a recycling versus recovery process, and the high cost of infrastructure and monitoring further compound implementation challenges across the EU [40].

An additional consideration is that future waste-to-energy facilities may integrate carbon capture and utilisation/storage technologies, which could improve the climate performance of incineration-based waste treatment. However, such systems were not modelled here because the analysis reflects current operational conditions rather than hypothetical retrofit scenarios.

While this study is based on LCA its findings have direct implications for health service decision-making. Healthcare providers should consider waste not only as an operational issue, but also to a strategic consideration within both procurement and waste contracting.

Hospitals typically rely on default incineration-based waste contracts; however, these results suggest that alternative pathways, such as pyrolysis may offer different environmental trade-offs. Contracts should at least contain incentives for minimising environmental impacts (lowering carbon, particulate matter, human toxicity etc) as well as for regulatory compliance, infection control and cost.

Trade-offs, toxicity and sensitivity analysis

Despite these advantages, several environmental trade-offs were identified. Human toxicity, resource use for metals and minerals, and some water-related impacts remained positive within the pyrolysis system. However, after correction of the toxicity analysis, pyrolysis demonstrated substantially lower toxicity burdens than incineration overall, with carcinogenic toxicity approximately twelve-fold lower and non-carcinogenic toxicity also markedly reduced.

The residual toxicity burden associated with pyrolysis was driven primarily by background electricity production, particularly fossil-derived electricity within the Italian and imported European electricity mix. Secondary contributors included diesel-electric generation at the Modena facility, refinery-related diesel production and transport emissions from EURO-5 lorries. Sodium hydroxide production and ethylene-chain inputs contributed smaller residual toxicity impacts.

Toxicity outcomes were therefore strongly dependent on background electricity assumptions, suggesting that further reductions could be achieved through renewable electricity substitution.

The sensitivity analysis demonstrates that the environmental performance of pyrolysis is highly dependent on local operational and infrastructural conditions. Switching pyrolysis to wind-generated electricity (SA8) improved the overall footprint from −230.58 to −424.03 kg CO₂e, whereas increasing pyrolysis energy demand by 40% (SA11) reduced the environmental benefit to −144.68 kg CO₂e. Assumptions regarding ethylene recovery dramatically altered results, with lower recovery yields shifting the system from strongly carbon-negative to net positive emissions (SA14–SA16). Transport and infrastructure assumptions also influenced outcomes; the addition of a separate shredding and autoclaving facility reduced overall performance, while electrified rail transport improved it modestly.

Transferability can be improved by reproducing the LCA, adapting key parameters to local conditions, particularly electricity carbon intensity, transport assumptions, and waste composition. Future work could strengthen generalisability through scenario and sensitivity analyses that explicitly test these variables across a wider range of plausible healthcare system contexts.

Transferability and contextual considerations

This study reflects a specific operational context in Modena, including assumptions regarding co-located treatment infrastructure, Italian electricity generation and local healthcare waste composition. Interpretation beyond this setting therefore requires careful consideration of contextual variables such as electricity carbon intensity, transport distances, regulatory frameworks and waste segregation quality.

Transferability could be strengthened through replication of the LCA framework in other healthcare systems using locally adapted assumptions and through broader scenario analyses testing electricity systems, transport logistics, and waste composition.

Health service, procurement, and implementation implications

The findings of this study have direct implications for healthcare management and procurement policy. Waste management should not be viewed solely as an operational necessity but increasingly as a strategic component of healthcare sustainability and decarbonisation planning. Hospitals typically rely on established incineration-based waste contracts; however, the results presented here suggest that alternative treatment pathways may provide substantial environmental advantages.

Adoption of pyrolysis would likely require changes to procurement and contracting models, potentially shifting towards performance-based approaches incorporating environmental indicators such as carbon emissions, particulate matter, resource recovery, and toxicity impacts alongside traditional cost and infection-control metrics.

Implementation will also require coordination between multiple stakeholders, including healthcare providers, waste contractors, regulators, and policymakers. Each group operates under distinct incentives and constraints, including cost control, regulatory compliance, environmental protection and market viability. Robust monitoring, reporting, and verification systems would therefore be required to ensure accountability and comparability between treatment pathways.

Capital investment remains another major barrier. Pyrolysis facilities typically require investments estimated between €2–10 million, and there are currently limited financial incentives for hospitals or waste contractors to adopt such systems [41]. However, if recovered pyrolysis products generate economic value, healthcare plastic waste may increasingly be viewed as a resource stream rather than purely a disposal burden.

Future research and conclusions

To fully realise the environmental advantages of pyrolysis in healthcare, further optimisation of process design, energy systems, emissions control and circular-economy integration will be necessary. Future research should compare pyrolysis with other emerging healthcare waste strategies, including mechanical recycling and chemical depolymerisation, using harmonised LCA methodologies.

Additional work is also needed to evaluate economic feasibility, operational implementation, toxicity outcomes under different electricity systems, and the policy implications of integrating pyrolysis into healthcare procurement and waste management frameworks. Such evidence will be essential to support evidence-based decision-making and determine the role of pyrolysis within sustainable healthcare systems.

Conclusion

This study presents the first comparative LCA of pyrolysis versus conventional incineration for the treatment of healthcare plastic waste, using data from peritoneal dialysis waste streams at AOU Policlinico di Modena. The findings demonstrate that pyrolysis can substantially reduce the carbon footprint of healthcare plastic waste management achieving a four-fold reduction in CO₂e emissions while also lowering carbon emissions, freshwater ecotoxicity, and marine eutrophication impacts. These benefits are driven largely by the recovery of high-value outputs such as ethylene and lignite substitute, which displace fossil-based materials and contribute significant avoided burdens. Pyrolysis do however show higher impacts in human toxicity (non-cancer), water use, resource use of minerals and metals, and ionising radiation, reflecting the complexity and resource intensity of the technology.

Healthcare systems urgently require more sustainable waste management solutions. Pyrolysis offers a promising pathway particularly for contaminated, mixed, or multi-polymer waste streams that are unsuitable for mechanical recycling, but its deployment will depend on regulatory clarity, financial incentives, and alignment with broader EU circular economy goals.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, the analysis is based on a single clinical and geographical context, using data from AOU Policlinico di Modena in Italy, so transferability to other hospitals, countries, or waste systems may be limited. The results are therefore most applicable to settings with similar waste composition, transport logistics, energy mixes and regulatory conditions.

Second, the LCA relies on a combination of primary site-specific data and secondary background datasets from Ecoinvent, meaning the results inherit the assumptions and uncertainties of those inventories. Several model inputs also depend on literature-based assumptions, including pyrolysis yields, product substitution credits and the treatment of char, all of which can materially influence the final impact estimates. Sensitivity analysis showed that changing these assumptions, especially around energy source and ethylene recovery, can substantially alter the magnitude of the environmental benefits.

Third, the study focuses on environmental performance rather than full implementation feasibility. It does not include a detailed economic evaluation, operational feasibility assessment, or infrastructure analysis, all of which are important because capital costs, regulatory approval, monitoring requirements and contract changes may affect real-world adoption. In addition, while the modelling captures the waste treatment pathway, it excludes broader organisational factors such as hospital infrastructure and staff travel, which were considered negligible for the functional unit but could matter at a larger system level.

Finally, the findings should not be interpreted as universally valid for all pyrolysis systems. Pyrolysis performance is highly dependent on local electricity carbon intensity, transport distances, feedstock purity and process configuration and the uncertainty analysis showed wide variability around the baseline estimate. Future studies should replicate the model in other settings and combine LCA with economic and operational analyses to improve generalisability and decision-making relevance.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

CKD

Chronic Kidney Disease

CO₂e

Carbon Dioxide Equivalent

Ecoinvent

International LCA Inventory Database

EU

European Union

GHG

Greenhouse Gas

HCWH

Health Care Without Harm

HDPE

High-Density Polyethylene

ISO

International Organization for Standardization

kWh

Kilowatt-Hour

LCA

Life Cycle Assessment

LCIA

Life Cycle Impact Assessment

MJ

Megajoule

MSWI

Municipal Solid Waste Incineration

NHS

National Health Service

OpenLCA

Open Life Cycle Assessment (software)

PD

Peritoneal Dialysis

PEF

Product Environmental Footprint

PET

Polyethylene Terephthalate

PP

Polypropylene

PVC

Polyvinyl Chloride

RRT

Renal Replacement Therapy

UK

United Kingdom

Author contributions

BD (Brett Duane) — conceptualised the study, led data collection at Modena, designed the LCA model, supervised analysis, and drafted the manuscript. JL (James Larkin) — contributed to model development, data interpretation, and manuscript revision. MA (Marta Arias) — contributed Modena clinical context, supported data collection, and reviewed the manuscript. SO (Siri Olsen) — provided technical input on pyrolysis, contributed to methods, and reviewed the manuscript. GL (Giulia Ligabue) — coordinated Modena site access, supported waste pathway mapping, and reviewed the manuscript. GD (Gabriele Donati) — contributed Modena nephrology operational data and manuscript revisions. GA (Gaetano Alfano) — supported clinical data interpretation and reviewed Modena workflow descriptions. DE (Daniel Eriksson) — contributed sustainability and waste management expertise and manuscript revision. DA (Diego Angelino) — contributed to environmental impact interpretation and edited the manuscript. EF (Evelien Fiselier) — supported LCA methodological alignment and reviewed environmental modelling. SD (Stephanie, Diaverum) — contributed nephrology and waste operations insights and manuscript revision. CC (Ciaran Clissmann) — provided technical support for data workflow management and manuscript editing. All authors reviewed and approved the final manuscript.

Funding

This research was conducted as part of the EU Horizon-funded KitNewCare project 2025.

Data availability

The datasets, life cycle inventory tables, and modelling assumptions supporting the findings of this study are provided in the Appendix of this manuscript.

Declarations

Ethics approval and consent to participate

Ethical approval was not required for this project as no patient data was collected, nor any other personal identifiable data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.