Disability and Rehabilitation: Assistive Technology

ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: https://www.tandfonline.com/loi/iidt20

Durable medical equipment reuse and recycling:

uncovering hidden opportunities for reducing
medical waste

Anne Ordway, Jennifer S. Pitonyak & Kurt L. Johnson

To cite this article: Anne Ordway, Jennifer S. Pitonyak & Kurt L. Johnson (2020) Durable
medical equipment reuse and recycling: uncovering hidden opportunities for reducing
medical waste, Disability and Rehabilitation: Assistive Technology, 15:1, 21-28, DOI:
10.1080/17483107.2018.1508516

To link to this article: https://doi.org/10.1080/17483107.2018.1508516

Published online: 14 Oct 2018.

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
2020, VOL. 15, NO. 1, 21–28
https://doi.org/10.1080/17483107.2018.1508516

ORIGINAL RESEARCH

Durable medical equipment reuse and recycling: uncovering hidden opportunities

for reducing medical waste
Anne Ordwaya, Jennifer S. Pitonyakb and Kurt L. Johnsona
a
Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; bSchool of Occupational Therapy, University of Puget
Sound, Tacoma, WA, USA

ABSTRACT ARTICLE HISTORY

Purpose: The purpose of this study was to investigate hospital practices for the management of Received 15 December 2017
unwanted durable medical equipment (DME) and to understand how health care providers conceived of Revised 27 July 2018
their role in preventing DME waste. In order to fully identify opportunities for DME waste prevention, we Accepted 31 July 2018
began this study at the point where health care providers prescribed patients DME.
KEYWORDS
Methods: We conducted a basic interpretive qualitative study in a large regional health care system in Disability; rehabilitation;
the United States employing semi-structured interviews and a focus group. Study informants included durable medical equipment;
clinicians, physicians and others involved in prescribing patients DME as well as those who played a role environmental sustainability;
in environmentally sustainable health care. Informants were targeted at the patient and health care sys- health care system
tems levels. Data were analysed using conventional qualitative content analysis.
Results: Analysis of data revealed some of the hospitals were implementing sustainability practices to
reduce their output of DME waste such as breaking down unwanted DME into its core components for
recycling. In addition, one hospital was operating a DME reuse programme for low-income uninsured and
underinsured patients. While a concern for the environment seems to have been embedded in the day-
to-day operations of these hospitals, we found that health care providers were not educating patients on
options for DME reuse and recycling.
Conclusion: These findings may point to a disconnect between practices to prevent DME waste at a
health care systems level and clinical decision-making for patient care and merits additional investigation.

ä IMPLICATIONS FOR REHABILITATION

 DME reuse and recycling is likely to have environmental as well as economic and social benefits.
 The management of DME waste should include rehabilitation providers.
 Rehabilitation providers should be trained in environmentally sustainable health care practices.
 Rehabilitation providers should educate patients on how to sustainably manage their unwanted DME.

Introduction medical devices [4,5] and cost savings from the reprocessing of
commonly used devices [6,7]. While more health care facilities are
The health care industry has a large and costly impact on the
implementing single use medical device reprocessing pro-
environment. The production and disposal of health care waste
grammes, the opportunity for diverting from landfill other types
result in greenhouse gas emissions and pollution, which are
thought to have a substantial impact on the environment and of procured goods, most notably durable medical equipment
public health [1]. Disposing of an estimated four billion pounds (DME), has received little attention.
of waste into commercial incinerators and landfills annually, the DME is defined as a reusable item that exists primarily to pro-
US health care industry is the second largest contributor to land- vide a therapeutic benefit for individuals diagnosed with a med-
fills after the food industry [2]. Given the increasing salience of ical condition or illness [8]. There is a wide spectrum of
environmental issues to public health, many health care facilities noncomplex and complex rehabilitation technology (CRT) that
across the United States are attempting to reduce their environ- falls under the U.S. Centers for Medicare and Medicaid definition
mental impact by minimizing the amount and toxicity of of DME including walkers, power wheelchairs, shower benches
their waste. and hospital beds. Older adults with chronic health conditions
Although many sectors in the health care industry produce and individuals with long-term disabilities are the primary users
medical waste, most of the research on medical waste manage- of DME in the United States [9,10]. Given a steady increase in the
ment has been focussed on hospitals. The hospital operating rates of individuals ageing into and with disability, there is both
room, one of the largest users of medical supplies and thereby an unmet need and growing demand for DME. While meeting
producers of health care waste, has been the target of most this need is a pressing issue in health care, the practical impacts
health care greening practices [3]. Specifically, studies have been of a surplus of used DME that will eventually be disposed of as
conducted to investigate the safety of reprocessed single use landfill waste must also be considered.

CONTACT Anne Ordway ordwaa@uw.edu Department of Rehabilitation Medicine, University of Washington Medical Center, Box 356490, Seattle, WA 98195-
6490, USA
ß 2018 Taylor & Francis
22 A. ORDWAY ET AL.

The three most likely pathways for DME that is no longer compliance and risk management, infection control, clinical engin-
needed include disposal by hospitals as medical waste, disposal eering and equipment surplus.
by DME users as home medical waste or diversion from these The study design incorporates a complementary mix of data
waste streams through reuse and recycling. The terms reuse and collection methods to facilitate a deeper understanding of how a
recycling are often used interchangeably in the literature. hospital system manages used DME with a focus on sustainability
However, in this study, reuse of DME refers to the practice of practices such as reuse and recycling [14]. First, individual semi-
using a device again to fulfil its original purpose, whereas recy- structured interviews were conducted with informants over a
cling of DME is the practice of breaking down a used device to four-month period in 2015. The original protocol was piloted to
make raw materials, which can be used to manufacture new prod- assess the clarity and order of the questions with a therapist who
ucts [11]. has played an extensive role in the prescription and provision of
Currently, there are no published studies on the management DME to patients in a clinical setting. The final protocol contained
of DME waste or the potential impact of DME waste on the envir- several specific questions asked to everyone (e.g., “Describe your
onment. Using an exploratory qualitative approach [12], we inves- role at the University with DME”) and open-ended questions that
tigated practices for DME reuse and recycling in the University of were followed up by probes (e.g., “How do patients get DME for
Washington (UW) Medicine regional health care system as a first use at home or in the community? Take me step-by-step through
step in understanding how hospitals manage DME waste and this process.” and “What education or information do patients
how health care providers conceive of their role in preventing receive about how to discard DME that is no longer needed?”).
DME waste. Our starting point for this inquiry was not at the Because qualitative research is often an emergent process [15],
point where unwanted DME becomes part of the waste stream. the protocol evolved as new information was collected, and ques-
Instead, we began further upstream with health care providers tions were tailored to informants. In total, 12 interviews were con-
and DME prescription and provision in order to identify opportu- ducted with informants who made decisions about DME at either
nities for DME waste prevention. In this analysis, we seek to the patient or systems level. Interviews were audiotaped and later
answer the following research questions: transcribed verbatim.
1. What are the clinical practices and health care processes for Themes that emerged from the analysis of interview data were
prescribing and providing DME to hospital patients including further refined in a focus group of seven participants (including
those to prevent DME waste? two study investigators). For the focus group, we purposefully
2. How do hospitals manage DME that is no longer needed? selected individuals with knowledge of and experience with the
3. What are the policy and procedural barriers as well as the reuse and recycling of DME in multiple contexts such as represen-
benefits and unintended consequences for a hospital-based tatives of local DME reuse organizations and DME suppliers. We
DME reuse programme? also included experts in environmental sustainability practices at
In this study, we describe the process for patients to acquire the UW. The focus group protocol followed a semi-structured for-
both new and used DME and environmental sustainability practi- mat and examined in further detail the processes and policies for
ces for reducing DME waste generated by hospitals. We also iden- DME reuse and recycling within UW Medicine and at local com-
tify the potential barriers and facilitators to a hospital-based DME munity organizations with DME reuse programmes. The focus
reuse programme and discuss the professional and organizational group was useful for exploring big picture questions (e.g., “How
behaviours to support DME reuse and recycling initiatives. could the current systems for DME reuse and recycling be
Findings from this study would be of interest to hospital adminis- improved?” and “What are the opportunities for collaboration
trators, hospital sustainability and environmental health commit- between UW Medicine and community reuse and recycling pro-
tees, and health care providers to inform solutions for reducing grams?”). The focus group discussion was captured in real time by
the amount of nonrecoverable waste from DME that goes into a CART provider, and an uncorrected transcript was provided to
the landfill. the research team for analysis. In Table 1, informants are listed by
data collection approach and by patient or system level. Two
Methods informants were asked to participate in individual interviews and
the focus group because of their unique knowledge of DME reuse
Participants and procedure
and recycling at both the patient and systems levels.
The setting for this study was the UW Medicine regional health
care system, which includes UW Medical Center (UWMC),
Ethical considerations
Harborview Medical Center (HMC), Valley Medical Center (Valley)
as well as other affiliated health care facilities in Washington In most cases, quality improvement activities do not require
State. UWMC and HMC have demonstrated a commitment to Institutional Review Board (IRB) approval for these activities to be
environmental sustainability that spans several decades. conducted with participant consent. However, an application was
Consequently, UW Medicine seemed an optimal setting for col- submitted to the UW IRB prior to the start of the original study.
lecting information on hospital environmental sustainability practi- Although the study was determined to be nonhuman subjects
ces including DME reuse and recycling. research, informed consent was obtained from the study partici-
Most research on hospital sustainability has not included par- pants for both the interviews and the focus group.
ticipation by clinicians [13]. In this study, however, clinical thera-
pists and physicians in the rehabilitation and acute care units
Data analysis
were purposefully selected as informants due to their expertise in
prescribing and providing DME. Other informants who, because of We applied conventional qualitative content analysis [16] to the
their positions at UW Medicine, could provide a deeper insight interview and focus group data and followed the procedure for
into the payer process for DME included clinical service managers inductive category formation [17]. The process began with a line-
and social workers. For descriptions of hospital process and pro- by-line open coding of the data. Initial codes were derived from
cedure related to DME, we solicited the participation of experts in the research questions for the original study. The principal
 DURABLE MEDICAL EQUIPMENT REUSE AND RECYCLING 23

Table 1. Study informants by patient or systems level.

Informant ID Approach Patient Level Systems Level
01 Interview Inpatient occupational therapist
02 Interview and focus group DME vendor DME vendor
03 Interview Inpatient rehabilitation manager
04 Interview Outpatient occupational therapy manager
05 Interview UW Medicine Compliance
06 Interview Social worker
07 Interview and focus group Hospital sustainability and waste management Hospital sustainability and waste management
08 Interview Hospital infection control
09 Interview Physiatrist
10 Interview UW Surplus Store
11 Interview Hospital clinical engineering
12 Interview Community-based DME reuse programme, general
13 Focus group Assistive technology programme
14 Focus group UW Environmental Services
15 Focus group Community-based DME reuse programme, multiple sclerosis

investigator and co-investigator independently reviewed a subset Not all patients met the eligibility criteria for charity care, how-
of the transcripts, and the results were compared for inter-coder ever, and many still needed assistance in covering the out-of-
agreement. Operational definitions were assigned to each code, pocket costs for equipment. Informants were asked what, if any,
and codes were subsequently classified into categories [18]. Once information on purchasing affordable DME, new or used, was pro-
a provisional coding scheme was developed, the investigators vided to patients. We found that some of the acute care and
commenced an iterative process of coding, checking in, modifying inpatient rehabilitation units maintained equipment resource lists
the coding scheme and final coding of the interview and focus that included suppliers of both new and used equipment.
group data. The analysis of the data was validated by the research Informants involved in patient care said they provided their
study advisory committee, which was comprised of three experts patients with this information either verbally or in writing and, in
in the areas of DME prescription and provision, payer policy for singular instances, located the equipment themselves. Others said
Medicare and Medicaid, and assistive technology (AT) reuse. referring patients to alternate sources of DME was the role of the
equipment specialist, the care coordinators or the nurse care
managers. Additionally, several informants made the point that
Results not all DME was appropriate for reuse. They said CRT such as
The purpose of this study was to investigate DME reuse and recy- power wheelchairs is typically patient specific and, if reused, could
cling within the UW Medicine health care system. We focussed pose health and safety risks to other patients, whereas a pair of
our inquiry on the clinical practices and health care processes for crutches in good condition could be reused safely. We inferred
both the prescription and provision of DME and the reuse and from the data, therefore, that prescribing clinicians seldom pre-
recycling of unwanted DME. The analysis of the interview and sented used DME as a viable option for patients discharging from
focus group transcripts resulted in 19 categories, which have the hospital.
Eventually, some patients will dispose of their used equipment.
been organized under four themes that communicate our inter-
We asked the informants to describe what, if any, information
pretation of the main points for this analysis. Table 2 lists and
they provided patients about managing DME they may no longer
provides a brief description of the 19 categories.
need, including options for reuse and recycling. Informants stated
they did not instruct patients on how to sustainably dispose of
Theme 1: Patients received little or no information on DME their equipment and were relatively unaware how patients man-
reuse and recycling aged their used equipment. One therapist explained her immedi-
ate concern was securing equipment for patients before they left
From the perspective of study informants, good discharge plan-
the hospital:
ning for patients included arranging for necessary equipment,
and a challenge of obtaining DME for most patients was cover- I would have to say that’s an area that I don’t talk about very often. It’s
age. Coverage for a patient’s DME was dependent on the source because the whole idea is I want them to have it for whatever reason I
want them to have it. I’m thinking about the here and now … .I do get
of health insurance (e.g., a private plan or government plan) and people on occasion that will ask me, what do I do with it? I always
the type of health insurance plan (e.g., PPO or HMO), although encourage them to find a senior center or a church they can donate it
having a health plan was no guarantee of coverage. Low-income to, but it’s not something in my spiel that I customarily tell people.
uninsured and underinsured patients in the UW Medicine system The general sentiment was since the process for patients to
who required DME typically received some form of assistance by obtain their equipment was so involved, disposing of used equip-
the hospital. Some patients were referred to medical social work- ment was simply not a point of discussion. Other informants
ers, who could purchase DME in situations where lack of equip- questioned whether discussing DME disposal, especially at point
ment was holding up discharge. In the case of HMC, Washington of discharge, may send a mixed message to patients about the
State’s largest safety net hospital, much of the patient population importance of the prescribed device to their health. A physiatrist
qualified for charity care. Washington State’s Health Data and added he would be more inclined to discuss the disposal of DME
Charity Care policy requires all hospitals to cover medically neces- with patients who had temporary disabilities and could turnover
sary hospital services for patients with incomes less than or equal an assistive mobility device in a matter of months than with
to 100% of the Federal Poverty Level [19]. According to study patients who had chronic health conditions and life-long needs
informants, the equipment for many patients was covered under for their devices. We concluded there was not a systematic pro-
this policy. cess at UW Medicine for educating patients or health care
24 A. ORDWAY ET AL.

Table 2. Coding categories and descriptions of their contents.

Category Description
C1: DME Used for a medical purpose, can stand repeated use and must be medically necessary;
does not include medical supplies.
C2: Process for DME prescription and provision Hospital process for prescribing and providing a patient DME from initial assessment
to discharge.
C3: Role in DME prescription and provision Health care professional by type (e.g., occupational therapist, social worker) and their
role(s) in prescribing and providing a patient with DME.
C4: Process for DME maintenance and monitoring Hospital process for maintaining internal DME including repairs and sanitization as well
as for monitoring a patient’s own DME.
C5: Way to obtain DME Paying for DME including whether a patient is insured and if so the type of coverage
and/or other government programmes and third-party payers; includes other ways
patients and providers source new and used DME (e.g., retail, rent, consumer-to-con-
sumer services).
C6: Barrier to DME access A procedural, programmatic or financial barrier to patient access of DME products.
C7: Health care setting Site where health care is delivered from the perspective of services provided (e.g.,
inpatient rehabilitation, acute care, outpatient rehabilitation); includes geographic
characteristics of the setting (e.g., rural vs. urban).
C8: Process for DME reuse All phases of a DME reuse programme from the development to implementation;
includes hospital- and community-based programmes.
C9: Process for DME recycling Includes all phases of a DME recycling programme from the development to implemen-
tation; includes hospital- and community-based programmes.
C10: DME reuse/recycling programme Hospital- or community-based programme for the purpose of DME reuse/recycling or
include DME as a component of the overall reuse/recycling programme.
C11: Policy/procedural barrier to DME reuse/recycling Policy and/or procedure at the local, state, or federal level identified as a barrier to a
hospital- or community-based DME reuse/recycling programme.
C12: Policy/procedural facilitator to DME reuse/recycling Policy and/or procedure at the local, state, or federal level identified as a facilitator to a
hospital- or community-based DME reuse/recycling programme.
C13: Other policy/procedure Policies or procedures that may relate to but not act as barriers or facilitators to DME
reuse/recycling.
C14: Concern for instituting DME reuse/recycling programme Perceived risk to patient and/or hospital employee health and safety; perceived risk
and/or liability to organization.
C15: Value/attitude of environmental sustainability Individual and/or organizational value/attitude of environmental sustainability and/or
environmentally sustainable health care.
C16: Benefit of DME reuse/recycling Benefit to stakeholders and/or environment of a hospital- or community-based DME
reuse/recycling programme.
C17: Unintended consequence of DME reuse/recycling Unplanned impact of a hospital-based DME reuse/recycling programme.
C18: Waste hierarchy A set of priorities for the efficient use of resources from most to least preferred (i.e.,
reduce, reuse, recycle).
C19: Product stewardship A sense of responsibility on the producers of DME for end-of-life product management.

providers,on DME reuse and recycling, which is not to say that An additional option for the reuse of hospital DME was
some patients did not choose to acquire or dispose of used identified by some informants as sending equipment to the
equipment through reuse or recycling. UW Surplus Store. According to a manager at the Surplus
Store, one of the aims of the programme was to divert
University waste from the landfill, first, by selling what could
Theme 2: Hospitals implemented sustainability practices to
be reused or repurposed and, second, by recycling what
reduce their DME waste
remained. While the Surplus Store seemed like a viable local
Not all DME waste is home medical waste. All hospitals own DME solution for managing some of UW Medicine’s unwanted DME,
such as beds, mobility equipment and bathroom equipment the Surplus Store manager stated used DME made up a very
which is used by patients during hospital stays and maintained small portion of their overall inventory. When probed, a few
by hospitals until it expires. Informants in this study were asked informants confirmed that used hospital DME was routed to
to describe how their hospital managed DME waste. We found the Surplus Store but only under limited circumstances. For
there were formal and informal policies in place for the reuse and example, the technician from clinical engineering explained that
recycling of hospital-owned DME. most hospital DME was used until the end of its intended
The concept of DME triage emerged from this study. In DME life cycle:
triage, the condition of the used equipment is evaluated and the If a bed is surplused because we got a bunch of new ones, and we just
priority for either reuse or recycling is determined. Informants have extras, fine. That makes perfect sense. If it’s surplused because it’s
were asked to elaborate on the triage process for hospital beds one we cannot fix or we have put an unbelievable amount of time into,
and wheelchairs. We found that beds, for example, were costly for the idea of reselling it to somebody else to use as a bed sounds like
unethical behavior.
hospitals to replace. According to informants, a bed would be
maintained providing it did not compromise the health or safety An infection control specialist expressed concern for reselling
of patients and staff. Trained technicians in the clinical engineer- used hospital DME and said he would be, “floored if anything
ing department were responsible for repairing all hospital beds. that’s used for patient care, specifically beds and wheelchairs,
According to one technician at HMC, when a hospital bed was would ever be surplused for sale to the public.” While not mini-
truly at the end of its life cycle, it was stripped of major hardware mizing concerns for public health and safety, the Surplus Store
(some of which was reused) and the plastic and metal compo- manager expressed a different perspective and said the hazards
nents became part of the hospital’s recycling stream. of used hospital DME to an individual’s health and safety were
 DURABLE MEDICAL EQUIPMENT REUSE AND RECYCLING 25

overestimated since the regulations on laboratory equipment shed new light on the feasibility of a large-scale, hospital-based
decontamination were also applied to the used hospital DME. DME reuse programme.
A few informants said an option sometimes considered for the
used hospital DME was donating it to charitable organizations
Theme 4: Provider values were oriented toward a concern for
with medical missions. One of the retail and service suppliers of
the environment
mobility equipment to UW Medicine described how they had
implemented a system for reusing and recycling their wheelchairs While saving money has been an incentive for most hospitals to
that included triage of equipment outside the United States. He engage in environmentally sustainable health care practices,
said they routinely donated reusable wheelchairs to organizations informants in this study also expressed a sense of professional
that ran used medical equipment centres such as Bridge Disability and/or personal obligation towards waste reduction. A mobility
Ministries (Bridge), a Seattle-based organization and Wheelchairs device vendor described his company’s motivation to reuse and
for the World, an international organization serving South recycle wheelchairs:
America. A physiatrist familiar with these types of charitable Can you just imagine if all this stuff just ended up in a landfill? There’s
organizations shared his opinion of sending second-hand equip- wiring in there. There’s batteries. I mean, all that stuff would just be
ment from a resource-rich country to a low-resource country: horrific environmentally. It’d be horrible. It’s not a super egregious
activity to participate in, so it’s just the right thing to do.
Sometimes you see these sorts of programs where they’re recycling
things to low resource settings, which is debatable, I guess. Why should This sentiment that reusing and recycling used DME was the
someone who’s poor get recycled equipment instead of new “right thing to do” resonated with many in this study. A director
equipment? … .I think the idea is good. You’re trying to benefit people, of campus-wide sustainability initiatives at UW described it as,
but are you doing that for your [emphasis in original] family?
“our individual and collective responsibility to use things for the
We assumed that almost none of UW Medicine’s used beds or duration of the lifespan for which they were built.” Informants
wheelchairs were routed to organizations such as Wheelchairs for from the focus group framed the discussion in terms of product
the World for the same reasons their used DME typically did not stewardship and implicated not only the user and the health care
end up at the Surplus Store. In this hospital system, most equip- system but also the manufacturers of DME. These informants
ment was described by informants as being used until product expressed professional and/or personal values of environmental
end-of-life and then recycled when possible. sustainability, which seemed to be in support of initiatives by UW
Medicine to reduce the impact of DME waste on the
environment.
Theme 3: A hospital-based DME reuse programme developed in
response to local needs
Discussion
In the course of our investigation, we discovered a hospital-based
DME reuse programme in UW Medicine. Since December 2014, In this study, we investigated practices for DME reuse and recy-
the acute care unit at Valley has partnered with Bridge to provide cling in the UW Medicine regional health care system as a first
low-income uninsured and underinsured patients with the neces- step in understanding how hospitals manage DME waste and
sary equipment to discharge safely from the hospital. The partner- how health care providers conceive of their role in preventing
ship between Valley and Bridge began, according to a study DME waste. We found that some of the UW Medicine hospitals
informant involved in the startup effort, through a serendipit- have included processes for reducing DME waste in their plans
ous encounter: for environmentally sustainable health care. These processes
included repairing equipment until product’s end-of-life, donating
How we got started was we had a staff engagement survey, and one of viable used equipment, salvaging parts from expired equipment
the big issues with our inpatient [acute care] team was these crazy,
immediate ASAP discharges. Nobody has any equipment. There’s no
and recycling core materials from equipment that had no reuse
money. There’s no family to help them get to the next place. We’re potential. While there may be opportunities to enhance these
giving away our brand new equipment, so we don’t have it the next processes, nontraditional medical–community partnerships in DME
day for our inpatients for training and trials. Bridge Ministries actually reuse such as the partnership between Valley and Bridge warrant
called me because we have a very large children’s therapy program— more research. We also found that although health care providers
outpatient center down the hill. [Bridge has] a lot of pediatric
expressed professional and/or personal values of environmental
equipment, so that’s how they contacted me. I said, well, what do you
think about the adult piece, because the staff are really frustrated. sustainability and supported DME reuse and recycling initiatives
at UW Medicine, they were not educating patients on ways to
The rationale for the programme was having (used) DME on hand sustainably obtain or dispose of the equipment. This finding may
would expedite the discharge process, reduce a patient’s length point to a disconnect between practices to prevent DME waste
of stay and, thereby, save the hospital money. She stated that the and clinical decision-making for patient care and also merits add-
acute care staff also thought there was potential for the pro- itional investigation. The education of health care providers in
gramme to address post-discharge concerns such as patient environmentally sustainable health care and the development of
readmission. Patients who have the necessary DME are typically at nontraditional medical–community partnerships in DME reuse and
a reduced risk for falls and secondary infections. From these recycling are discussed in more detail as meaningful and poten-
therapists’ perspectives, issuing used instead of new equipment tially high-impact hospital-based interventions to reduce
was a tenable solution because the equipment in question was DME waste.
noncomplex equipment (e.g., front-wheeled walkers and tub
transfer benches). Valley’s DME reuse programme was described
Educating providers in environmentally sustainable health care
as a means-tested benefit congruent with Washington State’s
charity care policy; therefore, only patients with incomes at or Health care providers have an opportunity to manage the envir-
below 100% of the Federal Poverty Level were eligible. The dis- onmental impact of their practices [20]. Given the point of origin
covery of the DME reuse partnership between Valley and Bridge for most DME is health care facilities, it follows that the
26 A. ORDWAY ET AL.

management of DME waste should include health care providers. hospital-based DME reuse programmes. The Pass It On Center, a
According to our findings, health care providers may benefit from national collaborative for the reutilization and coordination of AT,
education and training in three cores areas: (1) the impact of has issued quality indicators for AT reuse programmes. These indi-
health care delivery on the environment, (2) organizational proc- cators could be instructive for hospitals interested in developing a
esses for reducing hospital waste including DME reuse and recy- new reuse programme or in evaluating an existing programme.
cling and (3) community-based DME reuse organizations and the Some of the main concerns from the perspectives of health
processes for patients to obtain and dispose of the used equip- care providers and administrators for implementing a hospital-
ment. The education of health care providers in these core areas based DME reuse programme that emerged from our study
could lead to professional behaviours of DME reuse and recycling included patient health and safety, employee safety, hospital
with the goal of preventing unwanted DME from entering the liability and general liability for the community-based reuse
hospital waste stream. Since health care providers frequently are organization. Some study informants also discussed characteristics
the primary source of information for patients about assistive of the organization that could either promote or hinder new sus-
devices [21], health care providers could play a role in educating tainability initiatives such as organizational structure, resources,
patients on how to sustainably manage DME to prevent culture and change. Given these differences in organizational
unwanted equipment from also entering the home medical characteristics, a one-size-fits-all programme on DME reuse and
waste stream. recycling is unlikely to work for all heath care organizations, and
We found that in the routine delivery of care, a health care new initiatives may need to vary by hospital, unit or
provider’s clinical decision-making was not driven by knowledge patient population.
of the impact of health care delivery on the environment or exist- Informants in this study also identified potential regulatory
ing processes for reducing hospital waste including DME reuse barriers and facilitators at the state and federal levels to a hos-
and recycling. Findings from previous studies on environmentally pital-based DME reuse programme. We found that Washington
sustainable health care indicate that employees may not know State’s charity care policy has facilitated access to DME for low-
which medical items are reusable or recyclable or may not be income patients. There are hundreds of 501(c)(3) hospitals across
aware of institutional policies and practices for reuse and recy- the country who may be providing similar benefits to eligible
cling [22–25]. In a study on single-stream recycling, health care patients. A potential policy barrier at the federal level, however, is
employees benefitted from explicit education on what items the Anti-Kickback Statute [30]. This statute prohibits the exchange
should be recycled to reduce the hospital’s medical waste [26]. In of anything of value that could influence a federal beneficiary’s
contrast to a previous finding that greening processes need to (i.e., Medicare or Medicaid patient’s) choice of business. Receiving
occur in gradual increments [27], Conrardy and colleagues free equipment through a reuse programme might be construed
observed that health care providers in a hospital operating room as patient inducement under this statute. However, the Charitable
were quick to accept environmentally sustainable work practices and Other Innocuous Programs provision of the Affordable Care
[4]. Nonetheless, knowledge of sustainability may not translate to Act created new anti-inducement exemptions that may favour a
routine behaviours if the organizational culture lacks a sense of programme of this nature [31]. Given the array of laws and regu-
collective responsibility or community [22]. Instead, changes in lations that govern health care, an in-depth policy analysis may
practice require health care organizations to develop a culture of be warranted as part of a comprehensive feasibility study for
interprofessional responsibility for issues such as sustainability implementing a hospital-based DME reuse programme.
[28]. Given these considerations, hospital collaboration with exist- Presumably, the practice of DME reuse has environmental as
ing community-based DME reuse organizations appears to be an well as economic and social benefits. In addition to the obvious
important first step in assuring sustainable use of DME. benefit of reducing UW Medicine’s environmental footprint,
Furthermore, while individual health care providers may value informants identified cost savings through the reduced purchas-
sustainability, evidence from previous studies suggests employees ing of new equipment as a potential benefit of a hospital-based
may not transfer personal behaviours of reuse and recycling to DME reuse programme. Potential benefits to patients included
the workplace. These values instead are diffused due to the lowering their out-of-pocket costs, expediency and equity. These
assumption that individual behaviour will not make a difference benefits have been addressed in the literature on AT reuse pro-
[24,25]. Rambur and colleagues found that the implementation of grammes [32–35]. Additionally, hospital-based DME reuse pro-
institutional processes, which allow employees to engage in grammes may benefit community-based DME reuse organizations.
behaviours that align with their personal values, helped to sup- Informants in this study questioned whether the moral, economic
port ethical behaviour in the workplace [23]. Similarly, Dunphy and legal burdens of DME reuse and recycling have been shifted
concluded that economic rationalism and other situational con- from patients, health care facilities and the medical device indus-
straints in the workplace contributed to a disconnect between try to the community-based reuse DME organizations. More hos-
personal and professional behaviours related to sustainability [22]. pital-based DME reuse programmes could balance the scales
Therefore, the explicit education and training of health care pro- regarding the responsibility and accountability for sustainably
viders in environmentally sustainable health care practices may managing DME waste.
help to align their personal and professional values.
Limitations and future directions
Medical-community partnerships in DME reuse
This was an exploratory study using qualitative methods con-
Prior to initiating this study, we knew of only two hospital-based ducted as a first step in developing local solutions for reducing
DME reuse programmes in the United States: the trauma pro- the amount of nonrecoverable waste from DME that goes into
gramme at University of California Davis Medical Center [29] and the landfill. These findings based on the experiences of some
the Medical Equipment Recycling Program at the University of health care providers may inform thinking for other academic
Pittsburgh Medical Center. No data on programme outcomes medical centres that are considering hospital-based initiatives for
have been reported. As such, there is still little information on sustainable DME waste management; however, readers must
 DURABLE MEDICAL EQUIPMENT REUSE AND RECYCLING 27

consider their local conditions when interpreting these results. [8] Centers for Medicare and Medicaid Services: Medicare
For this study, we purposefully sampled health care providers in claims processing manual [Internet]. [cited 2015
rehabilitation and acute care in-patient hospital units; yet, December 10]. Available from: https://www.cms.gov/
patients’ needs for DME span the health care continuum. Regulations-and-Guidance/Guidance/Manuals/downloads/
Investigations of this phenomenon with health care providers in clm104c20.pdf
primary care or palliative care, for example, may reveal the differ- [9] Centers for Disease Control and Prevention: National
ent processes for the management of unwanted DME and the Center for Health Statistics Health Indicators Warehouse
conceptualizations of health care provider roles in preventing [Internet]. [cited 2015 December 10]. Available from: www.
DME waste. healthindicators.gov
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No potential conflict of interest was reported by the authors. 70.170 RCW § 60. 1998.
[20] McVeigh P. OR nursing and environmental ethics: medical
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