Mapping Greener HealthcareMapping Greener Healthcare

The St Lukes dialysis unit has gone through many expansions since its opening in 1994. Following the 2007 expansion, technicians noted that although there were now four water treatment systems, only the two installed from post 2002 had a ‘water saving’ feature, while the original water plants wasted approximately 70% more reject water to drain. 

In November 2009, with support from their Green Nephrology Local Representative, Dr John Stoves, the renal technicians submitted a proposal to the Trust Board, recommending upgrade of the two older water treatment plants. For a capital outlay of £60,000, they estimated that the upgrade could deliver a yearly saving of £20,000 on water supply and sewerage.

The project brought together the renal team with the Trust Patient Service Manager, the Deputy Director and Director of Estates, the Director of Finance, and the Procurement Department. A business case was developed and a budget of £60,000 was agreed from the capital replacement fund.  Following a five-month procurement process, the new plants were installed in January/February 2011. A straight replacement with Gambro systems was chosen to maintain standardisation and simplify maintenance.

Environmental & Financial Benefits (section updated November 2012) 

The new systems are saving 8 million litres of water per year, a carbon saving of 8.42 tonnes CO2e* and cost saving £18,000 from avoided water supply and sewerage.  Under the Trust’s Cost Improvement Programme, 20% of the savings are returned to the renal department budget.

* Calculated using conversion factors for water supply and water treatment, taken from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 9, Table 9a): 344 kg CO2e / million litres (water supply) and 709 kg CO2e / million litres (water treatment)

Additional Benefits

Future proofing: The updated systems allow greater water flow to the dialysis unit, therefore allowing for future expansions of the unit, and providing further ‘redundancy’ in case of water treatment system breakdowns.

Heat disinfections: as the newer systems are able to automatically heat disinfect, it is no longer necessary for two nurses have to stay behind after everyone else has finished to switch the water system in to heat disinfection.

Maintenance: costs have been further reduced as the renal technicians can now carry out maintenance in-house.

Waste (concentrate) water from the reverse osmosis (RO) unit at the Renal department is now recycled into the main soft water storage break tanks - these are very large tanks and serve our hot water requirements for the main hospital site. The calculated water saving is 3,145 M3/Year or 3,145,000 L/Year - cash saving of £6,300 p.a. - this consumption has been closely monitored since the installation and it can be verified as achieving this reduction on the subsequent water bills.

The installation costs to recycle the RO water (break tank, pumps & pipe-work etc) was in the region of £6k so that the pay back for this scheme was less than 12 months.

Carbon calculations

3.145 million litres diverted from sewerage annually and, through re-use, avoiding the need for supply of the same volume of mains water.

3.145 x 709 kg CO2e / million litres (water treatment)* + 3.145 x 344 kg CO2e / million litres (water supply)* = 3311 kg CO2e per year

Conversion factors taken from2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 9, Table 9a)

Problem – several members of staff routinely left their PCs switched on continuously. This is clearly a waste of electricity but also prevents regular IT updates e.g. anti-viral software.

Although automatic switch off software is available e.g. “nightwatchman” this has a financial cost and as yet there are no definite plans by the Trust IM&T department to introduce these types of software solution.

We decided to get our renal unit IT administrator to write a script that would be pushed out onto all the PCs within the renal unit.  The script is only a few lines of code, which was then installed onto each PC remotely, together with a scheduled job for each PC. The whole process took under 60 minutes to set up.  In the process, two new plans were created.  The first plan was that all Renal PCs/laptops, with the exception of the nurse's station PC and Duty Room PC were shutdown at 10PM each night, if left on.

The second plan was the creation of a new power option scheme called Renal, which operates throughout the working day and affects all Renal PCs and laptops. 

This new scheme conserves power by switching off the monitor after 30 minutes of inactivity.  After an additional 15 minutes (ie 45 mins) of inactivity the disk(s) will turn off.  Finally, after a further 15 mins (ie 60 mins) of inactivity, the machine will go into standby mode.  To restore power in the first two instances, the user simply taps any key on the keyboard to restore the desktop to it previous state.  If and when the machine is in standby mode (blinking power button), the user presses the power button as if you were switching the machine on.  The desktop is then restored to its previous state.

If the new power scheme activates at any time, none of the logged on user’s work is lost.

The response by our staff has been positive although many members seem to be/are unaware.

At the moment this has only been implemented within the renal unit. The Trust IM&T department are aware of our project however but at present are pursuing proprietary software solutions.

Financial Appraisal

Our hospital currently pays a favourable rate for electricity of 7.8p per KWh. For the purposes of our calculation we have assumed that ALL PCs get switched off at 10PM and get switched back on by staff at 8AM. We have also compared this to having ALL the PCs switched on constantly. The reality will be slightly different as not all PCs were being left switched on overnight. However, not all PCs are being switched back on at 8AM and in the absence of accurate usage data for each PC the calculations below should provide a reasonable estimate of savings.

Using Dell's energy savings calculator (http://www.dell.com/content/topics/topic.aspx/global/products/landing/en/client-energy-calculator?c=us&l=en&s=gen/) the energy costs are as follows:

32 desktop PCs running 24 x 7 consume 22038 KWh annually with annual costs of £1719

32 desktop PCs running 14 x 7 consume 14090 KWh annually with annual costs of £1100

Savings 7948 kWh, £619 annually

16 x laptops running 24 x 7 consume 3916 KWh annually with annual costs of £305

16 x laptops running 14 x 7 consume 2563 KWh annually with annual costs of £200

Savings 1353 kWh, £105 annually

In summary, the above small changes are saving 9301 kWh and £724 annually for no outlay.

Carbon savings

9301 kWh x  0.58982* = 5486 kg CO2e savings per year

(*conversion factor for UK Grid Electricity, taken from Table 6, 2011 Guidelines to Defra / DECC‘s GHG Conversion Factors for Company Reporting:  Methodology Paper for Emission Factors)

Over 90% of the primary care practices in the Bradford and Airedale PCT use a centralised IT system (SystmOne®), allowing detailed electronic health records to be shared by groups of healthcare professionals in various care settings.

The rising prevalence of recognised CKD prompted a multidisciplinary review of local renal service provision and a programme of work to strengthen communication at the interface between primary and secondary care.

Strategy for Change

• Development of a CKD e-consultation service in SystmOne®, allowing GPs to send electronic referrals and share patient electronic health records with a renal specialist after first obtaining verbal patient consent.
• Participating GPs attended education events and received paper and electronic guidance about the new service. It was explained that the service should be used to obtain advice for specific queries and to request virtual review of patients with an indication for hospital clinic referral that was ‘borderline’ according to local criteria.
• GPs use criteria agreed in local guidelines to ‘request advice’ or ‘question the need for hospital clinic review.
• The renal specialist is able to open the electronic health record and view important clinical details such as patient comorbidities, medication history, lifestyle factors, previous communications from other specialists, reports of previous imaging and a chronological display of selected numerical data (BP, estimated glomerular filtration rate, blood biochemistry and urinalysis).
• A decision is then made as to whether a patient should be referred to clinic, undergo tests or interventions in the primary care setting, or continue to be monitored and treated by the primary care team.
• Responses are saved in the patient’s electronic health record and also sent as tasks to alert the referring primary care team.

A single practice pilot of e-consultation indicated potential benefits, with better coordination of patient management and avoidance of clinic referrals. We therefore introduced e-consultation to 17 volunteer implementation practices in July 2007,supported by two nephrologists.

Effects of Change

• E-consultation was regarded by GPs and patients alike as a convenient service that provided timely and helpful advice and avoided unnecessary referral to the hospital clinic. GPs recognised that e-consultation presented an educational opportunity that increased their confidence in managing CKD in the community. Patients were generally willing to consent to the viewing of their electronic health record by a renal specialist.
• For the nephrologist, e-consultation permitted a detailed and efficient review of a patient’s primary care electronic health record, facilitating prompt and informed decision-making. Patients in need of renal outpatient clinic assessment were readily identified, and others benefited from the provision of timely advice. Avoidance of unnecessary hospital clinic visits was seen as an effective way of releasing resources in the specialist unit for those patients who need them most, as well as saving on transport and other environmental costs. The NHS Sustainable Development Unit estimates that an outpatient visit generates a carbon footprint of approximately 40 kgCO2e (Carbon Dioxide Equivalent).
• Between September 2007 and September 2008 11 out of 68 (16%) econsultations were finally referred to clinic, comparedto 376 out of the 398 (94%) paper referrals.

Nephrology uses a large number of consumables and is likely to be responsible for a significant amount of the total NHS carbon footprint. We reviewed the waste disposal in our designated nephrology procedures room, using a 4 week audit, to illustrate how improvements can be made locally and hopefully kick-start more widespread change within the department and hospital as a whole.

• For each week, the number of sharps bins, orange sacks and black sacks produced was recorded. As the amount of waste is directly proportional to the number of procedures performed, the number and type of each procedure performed per week was also documented.
• During the first two weeks we recorded the amount of waste produced using the waste disposal mechanisms which have been in place for years as a control.
• During the second two weeks, we added an extra bin into the procedures room to allow black sacks and orange sacks to be used simultaneously.

Results

• In the first two weeks, waste was only disposed of in either sharps bins or orange sacks.In weeks three and four, waste was divided separately into clinical and non-hazardous bags resulting in a much smaller number of sacks for incineration.
• During the third and fourth weeks, 66% and 59% respectively, of the waste produced during the procedures, did not require incineration. Furthermore, the majority of the waste in the black sacks wasplastic packaging and could potentially be recycled.
• The amount of incinerated waste fell dramatically to 33% and 41% (in the third and fourth weeks respectively) of the total waste produced.
• The number of sharps containers used remained constant, at a rate of one large container per week.

There is also a correlation between the type of procedure performed and the amount of waste produced. Some procedures such as PD catheter insertion produce a greater amount of waste as more disposable sterile equipment is used. In Week 1, a total of 29 procedures were performed, one of which was a PD catheter insertion but the total number of sacks used was 6.5. In Week 3, a total of 10 procedures, including 3 PD catheter insertions, were performed, and 6 sacks in total were used. Therefore, although the overall number of procedures performed in weeks 3 and 4 were fewer than in the initial two weeks, the overall number of waste sacks produced was not significantly different.

The majority of waste in the black sacks was recycleable (although not precisely measured in this study) and therefore the next step locally must be to engage with the estates department and establish recycling for paper, card and plastics. This may also require collaborative pressure from other hospital departments to create the impetus for change within the Trust. At the same time there is a need for widespread acceptance and involvement with appropriate waste disposal to effect a real change in waste collection throughout all clinical areas within the nephrology department.

This small inexpensive intervention has dramatically reduced the amount of waste sent for incineration. In financial terms this is also resulting in savings as the average cost of disposing of incinerated waste is in the region of £400 per tonne comparedwith £80 per tonne to disposal of waste to landfill sites. We are now trying to get recycling facilities within the hospital to reduce thenumber of black sacks produced.

Countess of Chester Hospital Dialysis Unit has tried to reduce the amount of paper used through a 'Reduce, Reuse and Recycle' Programme.

Results of Local Changes

• Since paper copies of blood results have been stopped from Pathology it has been calculated we will save a minimum of 3344 sheets of paper per annum (projected).
• All printers within the unit have been defaulted to print double sided by our IT team.
• Patient paper care plans have been reduced from 14 pages to 6, a reduction of 51%.
• Staff and patient education and encouragement to recycle successfully measured by the recycling pick up needing to increase from once every 2 weeks to twice per week.
• Overall paper consumption reduced from approximately 10,000 sheets to 2,500 sheets every 8 weeks, a reduction of 75%. With forecasted financial benefits of paper costs from £187.20 to £47.84 per annum giving a saving of £139.36.

Carbon savings (section updated November 2012)

£139.36 x 0.78 kg CO2e * / £ = 109 kg CO2e

* emissions factor for supply of paper products, 2012 Guidelines to DEFRA/DECC Greenhouse Gas Conversion Factors for Company Reporting, Annex 13

How To Guide:

Reduce

• Stop all paper copies of blood results as located within the IT system.
• Double side all printed documents.
• Reduce paper care plan to essential information only.

Reuse

• Implement a scrap paper A5 file to be used , for example telephone call messages, to do lists food orders.
• Any non confidential paper waste to be used for scrap paper.

Recycle

• Ensure recycling bins are located within the renal unit.
• Patient education to encourage recycling of newspapers read on the unit.
• Ensure all paper waste is deposited in the recycle bins provided within the unit.

Using a classic resource efficiency method the team at the Renal Unit during three two hour workshops quickly identified carbon reduction opportunities, prioritised them, and moved into action. Led by Renal Unit Manager Simeon Edwards the team took the action plan developed in these sessions and integrated it into the normal management of their unit for continues improvement. The carbon reduction actions are now regularly reviewed and updated as part of normal unit management.  Resource efficiency tools are used as needed to get to the root of issues, identify possible actions, and to manage change positively.

Actions

Simple actions were attempted first: 

• Waste sandwiches were reduced from 35% to <5% by involving patients in establishing a new sandwich menu, improving choice and avoiding costs of £4,000.
• After full consultation with patients, linen use was reduced by 70%.  Some patients preferred to bring their own blankets, and the unit stopped using white sheets for patient’s chairs.  Avoided costs £4,800 and quite a good carbon saving too.
• Encouraged by this success the unit team decided to tackle aborted ambulance bookings, aiming for zero %.  The team worked with the ambulance service to synchronise treatment times.  Within a few months the cost of aborted journeys reduced from £1,500 a month to £400, giving annual savings running at £13,200. After two years it is ‘zero’.
• To reduce stress in the workplace the team undertook an analysis of the balance between staff availability and the peaks and troughs of patient activity. This led to some rescheduling which released more time to care, leading on to best practice in infection control, and improved staff attendance.
• A renal unit uses a considerable amount of disposable kit and pharmaceuticals.  Bicarbonate cartridges were changed leading to a reduction in both packaging and chemical.  Cost avoidance now running at £11,000 p.a.  Work is ongoing with manufacturers to reduce wastage of haemodialysis fluids. Dressing packs have been slimmed by a ‘lean’ analysis saving £800 p.a.  Renal disposables wastage of 5 dialysis sets per week has been reduced to zero by not setting up machines in advance.  This amounts to a saving of £13,000 p.a.  By changing direct delivery of renal lines to ‘Blue Diamond’ supplies, topped up from NHS stores Bridgewater, costs of £5,900 are being avoided.
• Cardboard for recycling was reduced by 65% when Fresenius 5L containers were switched to pallet delivery, instead of 4 to a box – avoiding the waste in the first place.

Carbon Savings (section updated November 2012)

Cost avoidances have been used in conjunction with the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting, Annex 13. This enables a CO₂ equivalent figure to be readily derived from cost figures to give staff an approximate idea of what they are achieving in carbon terms.

Haemodialysis consumes vast quantities of water. Producing the 120 litres of dialysate required for a typical four hour session requires approximately 400 litres of mains water. Reverse osmosis is an important step in the purification process that this water undergoes. Reverse osmosis systems vary in efficiency, but commonly reject up to two thirds of the water presented to them. Termed ‘reject water’, this high grade grey water does not come into contact with the patient at any stage and poses no infection risk, yet it is needlessly ‘lost to drain’ in almost all dialysis facilities.

The satellite dialysis unit in Ashford incorporated a simple water recycling system into its new design. The salvaged reject water is directed to a recovery tank.. From there it is pumped to a grey water tank. which feeds the laundry room. Float switches divert reject water to the drain if the grey water tank becomes full, and diverter valves direct the reject water directly to the drain from the reverse osmosis system during monthly chemical disinfections.

The installation of the water recycling system was only £2,500, £1,300 for tank and control panel and £1,200 for piping. The piping was laid alongside other services required by the new build, so no cost was incurred for the groundwork.

Investment Appraisal

The return on investment will depend upon:

1.    The investment: the cost of installation & maintenance.

2.    The return: the savings on mains water and waste water.  This can be calculated by multiplying the regional mains water and waste water rates by the volume of reject water which the system is able to provide in place of mains water for an alternative use (e.g. laundry). It is useful to factor in projected price rises and changes in demand to gain a view of future potential savings.

In general, the return on investment is likely to be greater for a new-build unit, where the installation costs may be lower, and there is greater flexibility in arranging an appropriate alternative use for the salvaged water.

Environmental savings

The finite volume of water on the earth is constantly being recycled and purified. So we must use water wisely. A ‘carbon footprint’ does not therefore do full justice to the environmental benefits of water conservation. However, energy is also required to treat and move the water that we use, and conserving water therefore also saves energy and reduces the carbon footprint of the renal unit.

Accounting for the energy used to power the pump, the carbon savings at the Ashford unit are approximately 750 kg CO2 equivalents per year. This figure is reached by a two step calculation. Firstly, calculate the carbon savings made by recycling the reject water in place of mains water. To do this, apply a mains water life-cycle conversion factor (available from, for example, the DEFRA website) to the volume of water saved per year. Secondly, subtract from this the carbon cost of any electricity required to pump the water to its place of use over the course of a year (this second step requires you to know the power of the pump, the duration of its use during the year, and a conversion factor for electricity to carbon consumption).

Carbon savings (kg CO2e/year)

=

[Volume water saved in one year (L)  x  mains water carbon conversion factor (kgCO2e/L)], e.g. DEFRA

-

[electricity used for pumping per year (kWh)  x carbon conversion factor (kgCO2e/KWh)]

How to Guide - Getting Started

1. Discuss the idea with your Renal Technician. They will play a vital role in any water conservation project, understanding the local set-up better than anyone else.

2. Involve your local Estates department.  The support and advice of the hospital Estates department is also vital. Their engagement may require the presentation of a sound business case. In most cases, it will be the Estates department that benefit financially from the methodology.

3. Clarify the scenario.  Will the methodology be implemented into the design of a ‘new build’ dialysis unit, at the time of replacing the RO system in an existing dialysis unit, or perhaps alongside an existing and satisfactory RO system already in place in a dialysis unit? These different scenarios will influence the total costs involved, but the return on investment may still make the project worthwhile.

4. Clarify the potential volume of reject water that will be salvaged each year.

In order to maximise the financial and environmental benefits of the project, it is important to match the volume of reject water available to an alternative use that requires a similar volume. Many reverse osmosis systems record the volume of reject water produced, but this can be ascertained with a simple flow meter if necessary. It should be remembered that, where reverse osmosis systems are being replaced, the newer system is likely to be more efficient and produce less reject water.

5. Assess the quality of the reject water to be salvaged.  The precise quality of the reject water produced will vary from region to region. Whilst it will almost always meet the requirements for its intended use, it is vital that this is assured prior to proceeding further. Your renal technician will be well versed in checking the water quality.

6. Given the volume and quality of the reject water available, now identify the intended use for this water.  Possibilities include: sanitation, laundry, boiler feed, sterilisation units and irrigation – on site or supplied to a neighbouring facility. Practical considerations are important. For example, salvaged reject water can only be used in laundry services if the plumbing required is feasible and affordable.

7. Calculate the financial cost per year of the current practice of supplying mains water for this intended use.  This will require knowledge of the mains water rates for your hospital, information which the Estates department can provide.

8. Calculate the financial savings resulting from the reduction in waste water from the haemodialysis unit. This will require knowledge of the waste-water rates for your hospital. Remember that some reject water may still be lost to drain if it exceeds the demand/capacity of the salvage system, and during disinfection cycles.

9. Calculate the initial total financial expenditure incurred in implementing the methodology (including the infrastructure required to transport the reject water to the place of use). Costs may include: storage tanks, pipework, pumps and installation costs.  Maintenance costs are likely to be small.

10. From these figures, develop a repayment projection and calculate the breakeven point (the point in time by which the savings - due to reduced mains water and reduced losses-to-drain - might be anticipated to have recouped the investment costs of the methodology, and from whence the use of reject water for the new purpose realises potential savings).

11. Convince your Trust to fund the work. Whilst this will certainly require the support of your Estates department, it may also require the approval of the Director of Finance. It is also worth applying for funding from Salix Finance, an organisation set up by the Carbon Trust to deliver interest free funding to accelerate investment in energy efficiency technologies within the UK public sector. Their website is http://www.salixfinance.co.uk/home.html

12. System maintenance should become part of routine estates plant room inspections - a simple check function tick list is sufficient. Water storage tanks will require cleaning in line with Trust protocols for other tanks in the hospital.

During haemodialysis, blood is removed from the patient and pumped through a dialyser, before being returned to the patient. Inside the dialyser, waste products in the blood diffuse across a membrane into the ‘dialysate’ fluid, a blend of treated water and chemicals. However, if the dialysate is too cool, the patient may become uncomfortably cold. Cool dialysate also reduces the rate of diffusion, making the treatment less efficient. For these reasons, the dialysate is usually warmed to just below body temperature. The way this warming is done varies. Most machines use a heater controlled by a thermostat to warm the dialysate. However, some machines will also have a heat exchanger incorporated into the system before this heater. In these machines, heat is recaptured from the dialysis effluent (‘used’ dialysate) and transferred to the incoming dialysate, warming it up before it enters the heater and thereby saving energy and reducing the environmental impact of a haemodialysis treatment.

The Kent and Canterbury renal service has predominantly purchased Braun Dialog+ haemodialysis machines, and these have been supplied without heat exchangers. However, the purchase of newer haemodiafiltration machines with built-in heat exchangers highlighted the potential financial and environmental savings that heat exchangers can offer. The renal technicians at the Maidstone dialysis unit decided to investigate the possibility of retro-fitting heat exchangers to their existing machines.

Retro-fit heat exchanger kits for Braun Dialog+ machines can be fitted by most renal technicians in less than half an hour. The technical team selected five machines at random and ran simulated dialysis treatments before and after fitting the machines with heat-exchangers. When they measured the electrical energy used by the machines on each run using a power monitor fitted between the wall socket and the machine plug, they found that the average reduction in power required for each treatment session was 0.86kWh, representing an 18% increase in efficiency (the full results are listed at the end of this case study).

In 2011, funding was obtained for retrofit of 52 machines across the East Kent renal service.  The retrofits have now taken place, and energy and cost savings are being monitored.

Environmental Savings (calculations updated October 2012)

Assuming each machine is used twice daily, six days a week for 52 weeks of the year, an annual power saving of 536.64 kWh per machine (2 * 6 * 52 * 0.86) is predicted. Applying a conversion factor of 0.58982 kg CO2 equivalents per kWh*, this in turn equates to an annual saving of 316.5 kg (0.3165 Tonnes) of CO2 equivalents per machine per year. For the 52 machines retrofitted across the Kent and Canterbury renal service, this equates to an annual power saving of 27,905 kWh and an annual carbon saving of 16.46 tonnes of CO2 equivalents.

* GHG emission factor for electricity consumed (2010 grid rolling average) taken from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 3c)

Environmental Saving                  Total                             Number                     Conversion

[in tonnes of CO2            =      power saving            *           of                *              Factor

equivalents] per yr                  per treatment                   treatments                   (0.58982)  

                                                   (0.86 kWh for                    run per yr

                                                  BBraun Dialog+)

Although the manufacture of heat exchangers incurs a carbon cost in itself, this is estimated to amount to less than one percent of the carbon savings derived from the improved energy efficiency in the first year of use alone.

Investment Appraisal

Given the local electricity rate of £0.089 per kWh, the lower energy usage translates to financial savings of £0.077 per treatment (0.089 * 0.86), and an annual financial saving of £48.05 per machine (if used twice daily, six days a week, for 52 weeks of the year).

Financial saving per treatment  =  local electricity rate  *  energy saving per treatment

                                                                (£/kWh)               (0.86 kWh for Braun Dialog+)

The unit cost of the device (£189) could be recouped within four years (£189/£48.05) and a profit made thereafter. In the case of Kent and Canterbury, following the retrofit of 52 machines with heat exchangers, an annual saving of £2498.60 (£48.05 * 52) is anticipated. 

HOW-TO GUIDE: GETTING STARTED

The case study and discussion outlined above includes most of the information required to develop a sound business case for a programme to retro-fit heat exchangers to existing dialysis machines. The following guidance will help you explore the practicalities and assess the financial benefits further.

1. Firstly identify whether the machines in your unit are fitted with heat exchangers.
2. If not, identify the make of the machine, whether a retro-fit kit exists and what it costs.
3. Also, clarify any plans to replace or update the machines.
4. Remember that the figure quoted here for the energy saving per treatment (of 0.86 kWh) has been derived from tests using Braun Dialog+ machines. If your unit uses different machines, for which retro-fit heat exchangers are available, you will need to clarify the potential energy saving per treatment (either using the method outlined in this case study, or through correspondence with the manufacturer).
5. Ascertain the number of machines to which you plan to fit heat exchangers, and how frequently they are used.  
6. Find out the local rate for electricity.
7. You should now be in a position to follow through the calculations outlined above. This will enable you to determine the potential financial and environmental savings for your unit.
8. Funding for projects of this nature is most commonly sought through the budget of the renal service. However, interest free loans for energy efficiency measures may also be available from Salix Finance - http://www.salixfinance.co.uk/home.html

In 2005, an assessment by the waste management team responsible for the Birmingham Heartlands Hospital satellite dialysis unit at Runcorn Road identified two separate, but not uncommon, issues. The first issue was the disposal of the plastic acid and bicarbonate cartridges which were needlessly entering the clinical waste stream and therefore being incinerated, an expensive and environmentally damaging route of disposal.  The second issue was the disposal of the very large amounts of cardboard packaging associated with the clinical supplies purchased by the unit. Despite its recyclable nature, this was entering the domestic waste stream. Moreover, collections were infrequent and the cardboard was frequently accumulating in piles. As well as taking up valuable space within the unit, the identification of the fire risk that this posed had prompted the facility’s leaseholder to cover the resulting increases in insurance costs by requesting a higher rental fee. The solution to all of these problems was the purchase of a baling machine to compact the waste.

The machine is housed in the storage room adjacent to the main dialysis unit and measures approximately 6ft by 3ft by 3ft. An electronic machine was chosen ahead of piston-driven alternatives as it makes very little noise, an important consideration given the close proximity to a clinical area.

At the end of a patient’s dialysis session the acid cartridge is emptied and rinsed with tap water by the nurse. The cartridges are collected in plastic bags holding eight cartridges each . These bags are then baled together, along with bags containing other plastic waste collected within the unit . Ten bags are baled at a time, with cardboard layers at the top and bottom, to produce packages that weigh approximately 19 kg and are held together with binding tape. Packages of this size can be easily moved with the aid of a roller fork. Excess cardboard is baled together in separate packages weighing around 10kg. These plastic and cardboard packages are collected from the unit on a weekly basis, free of charge, by a local company which recycles them.  A similar set up is also in place at a second satellite dialysis unit in Castle Vale. 

Other plastic items that are collected and baled include shrink wrap, containers for alcohol-based hand gels, bicarbonate cartridges (although this is increasingly sourced in bags), and the containers for bleach and Citrosteril. Particular care must be taken with the containers of substances subject to COSHH regulations (the control of substances that are hazardous to health, such as disinfectants like bleach and Citrosteril), and dialysis units should ensure that they have the necessary sewer discharge consent if these substances are to enter the water course undiluted.

Investment Appraisal

The return on investment will depend on the investment and running costs (resulting from the purchase, installation and maintenance) and the savings resulting from the diversion of waste into cheaper disposal pathways.

A typical dialysis unit will use one acid cartridge per patient. Although the Runcorn Road Satellite Dialysis Unit is a 26 station unit, it is currently run at such a capacity that it generates 270 empty acid cartridges per week, each weighing 300 grams. This equates to 14040 cartridges per year, or 4.2 tonnes of plastic. The cost of disposing of clinical waste is determined by an economy of scale; larger units will produce greater amounts of clinical waste, and will be in a position to negotiate lower disposal costs per tonne. For the purposes of this case study, we have used a cost of £750 per tonne, which is considered representative of the current cost for most satellite units. The cost of sending 4.2 tonnes of plastic to clinical waste is therefore around £3150 per year.

The Runcorn Road unit also produces approximately 1 tonne of cardboard per year. These cardboard boxes were previously being put into domestic waste bins, usually uncrushed, along with other waste. The cost to the unit of their disposal was determined by the number of bins collected per year, which in turn would be influenced by how well crushed the boxes were. It is therefore difficult to provide a method to calculate the savings made, but the waste management team at the Runcorn Road Unit estimate that the introduction of the baler, which removed the cardboard from this waste stream, has reduced the number of bin collections by 50% and has saved the unit approximately £1000 per year.

Using these figures, the annual saving (equivalent to the overall cost of the original waste disposal methods) is approximately £4000 at the Runcorn Road Satellite Dialysis Unit.

The purchase of a baler requires an initial one-off investment. This is likely to be in the region of £3500 and will include installation. The ongoing costs might be anticipated to include an annual service (for which the Runcorn Road Satellite Dialysis Unit pays £195), the cost of the binding tape (£342 for the 12 reels required by the Runcorn Road Satellite Unit per year), and the cost of the plastic bags (which is likely to be very small and has been assigned a nominal figure of £50 for this case study). Therefore the total cost incurred during the year of implementation is £4087, with an annual cost of £587 thereafter.

The Runcorn Road unit therefore recouped the outlay cost at one year, and has been saving around £4000 thereafter. A comparable saving is also being made at the Castle Vale satellite unit. The savings might be even greater in units using plastic bicarbonate containers.

Carbon Savings (section added October 2012)

Greenhouse gas (GHG) conversion factors for waste disposal were obtained from the 2011 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 9d).

The GHG for incineration of clinical waste was taken as 1,833 kg CO2e emitted per tonne of waste (DEFRA emissions factors for incineration do not specifically account for clinical waste, which is commonly undertaken at higher temperatures. To reflect the increased emissions that are likely to result from the incineration of clinical waste, the highest available emissions factor for incineration was applied).

The GHG for recycling of waste was taken as -230 kg CO2e per tonne.

Using these factors we estimated the GHG savings per year:

• Previous GHG emissions from disposing as clinical waste, per year = 4.2 tonnes x 1833 kg CO2e per tonne = 7699 kg CO2e
• Current GHG (as recycled waste), per year = 4.2 x -230 kg CO2e per tonne = -966 kg CO2e

Saving = 8,665 kg CO2e per year

Risk Management

There are no major risks associated with the implementation of a baler to compact dialysis waste. Minor risks can be minimised through appropriate staff education, and clear Health & Safety, Infection Control and Manual Handling guidance. Financial risks can be minimised through the careful development of a business case.

How-to Guide: Introducing a baling machine to compact waste from your dialysis unit

1. Clarify current practice regarding the disposal of cardboard and plastic waste within your unit. Consider how the use of a baler might improve it.

2. Identify the person(s) in charge of the waste budget for the renal unit. This is most commonly a member of the Renal Directorate or the Estates (or Hotel Management) Departments. They will be able to provide accurate information regarding the local disposal costs for the relevant waste streams.

3. Determine the cost of the baler. The person in charge of the waste budget may be able to help you identify suitable vendors. Explore maintenance contracts.

4. Liaise with the current waste contractor (almost all Trusts employ the services of private firms to remove and dispose of waste) at an early stage. Identify whether they could process the waste in the form you plan to provide it, and determine any cost that it might entail. Also, explore the possibility of alternative contractors who may remove the waste at a lower cost. In particular, the Environmental Department in your Local Council may know of companies willing to take recyclable material away at no cost.

5. Consider the future. In particular, is a move to central acid delivery planned (thereby dramatically reducing the number of cartridges produced)? Or is expansion of the unit planned, in which case the number of cartridges might be expected to increase?

6. Using the methodology outlined in the case study, calculate the potential savings for your unit.

7. Identify a suitable location for the baling machine and any alterations that might be required to house it.

8. Explore the idea with the dialysis staff to ensure that there is sufficient enthusiasm.

9. Use this document to develop and submit a Business Case.