Reducing Waste at the Bedside: A Resident-Led Project to Decrease Waste and Cost From Diagnostic Paracentesis Open Access

Health care waste is an ethical, economic, and environmental problem. Developed countries such as the United States generate, on average, over twice the amount of health care waste as resource-poor countries.¹  Single-use disposable items account for a large portion of the waste produced in resource-rich settings.²  Medical waste is managed by burning, landfill deposition, or shipping it to lower-income countries, which often have lax environmental rules.^3,4  The ensuing land, water, and air pollution disproportionately affect the health of vulnerable populations.⁵  Physicians are well positioned to decrease medical waste by examining how practices in their workplaces contribute to waste production.

In this study, we examined how internal medicine residents use prepackaged kits for diagnostic paracentesis, a commonly performed procedure at our hospital. We had seen many of the items in the kits being discarded without being used. The aims of the study were to determine (1) the amount of waste associated with using a commercial kit for diagnostic paracentesis, and (2) associated waste and estimated cost reduction with the introduction of a new resident-designed kit containing only necessary supplies for diagnostic paracentesis.

The study was conducted at a 226-bed academic medical center in central Texas in 2023. The internal medicine residents used a Safe-T Plus Thora-Para Drainage Kit for both diagnostic and therapeutic paracenteses, as our hospital has no other readily available kit for diagnostic paracenteses only.

Seven diagnostic paracenteses, performed by different residents or with instruction from different attendings, were observed, and the number of items discarded without use, defined as waste generated, was noted. Cost of the commercial kit was determined by averaging online published retail prices across multiple medical product sites as of May 2024.

The residents on the team, with the advice of internal medicine and gastroenterology attendings, then designed and assembled a new kit for diagnostic paracentesis, which included just the necessary supplies. Since the kit was intended for diagnostic paracentesis only, it included a smaller gauge needle than in the commercial kit, as well as culture bottles. Other items that were excluded from the novel kit, but present in the commercial kit, are visible in the Table. We also designed and included illustrations on how to perform the procedure and guidance on judicious lab testing (Figure). The kit was made readily available to residents, who were notified about it during morning reports, house staff meetings, and visits to workrooms. The cost of this kit was calculated by adding average online retail prices of the components, or by using the Google Price Insights tool when available, as of May 2024. The prices were rounded to the nearest dollar. The use of the kit by internal medicine residents was surveyed at 3 and 8 months after introduction. Kit use was also estimated by monitoring the number of remaining kits available in resident workrooms.

Per predetermined guidelines from the institutional review board, this project fell into exempt status as a quality improvement endeavor.

The commercial kit had 29 items, and a median of 16 (55.2%) of these were discarded without use during diagnostic paracentesis (Table). The cost of the commercial kit was $123 (including an additional $18 for the culture bottles, which are not included in the kit, but are preferable for culturing ascitic fluid).⁶  The novel customized kit had 15 items, including 2 culture bottles, with only 1 item potentially going unused (extra band-aid). The total cost for the novel kit was calculated to be $28, generating an estimated cost savings of $95 per procedure.

Sixty-four categorical residents were eligible to respond to the survey about use of the novel kit. Only 3 out of 26 (11.5%) residents had reported using the kit at the 3-month survey, though 17 respondents (65.4%) reported that they knew the kit was available. At the 8-month survey, 12 of 30 (40.0%) resident respondents had used the kit, with 7 of 12 (58.3%) using the kit more than once.

We estimate that roughly 30 paracentesis kits were used by the internal medicine residents over the course of 1 year after kit introduction, based on remaining available kits in the workrooms.

Our study shows substantial waste is generated when using a commercial kit for diagnostic paracentesis, and a custom kit can cut down waste and save on costs. Analysis of National Inpatient Sample data showed almost 3.5 million admissions for decompensated cirrhosis from 2009 to 2018.⁷  Many of these patients would need diagnostic paracentesis, so the decrease in medical waste and cost savings from using a paracentesis kit with only necessary items can be significant for a medical system.

This project also highlights the possibility of resident-led changes to improve the environmental footprint of hospitals, as residents designed and disseminated this novel kit for use by other residents. Residents have a unique vantage point of the day-to-day work of an inpatient service; they can, and should, take part in the examination and correction of wasteful practices.

Our project is important and worthwhile as it created awareness among the residents about waste in health care and provided an opportunity for residents to design a project that led to an important change. Preparing the next generation of physicians to embrace sustainability efforts is critical to reducing harms due to climate change.⁸ 

Our project was limited by the lagging adoption of the custom kit. We believe this is due to habit and deferral of many procedures to the interventional radiology department. Additionally, introduction of this kit could perversely lead to increased waste. If residents performed a therapeutic paracentesis after a diagnostic paracentesis, they would need to use one of the commercially available kits in the hospital. This would create more waste—not only would the items from the novel kit be thrown out, but so would the items from the commercial kit after use. This is an important consideration for a project with the aim of reducing waste overall.

Our future directions include working with the sterile processing department to ensure the ready availability of the kits and having these kits available at other hospitals in the same academic network.

Implementing a customized diagnostic paracentesis kit reduced both waste and cost compared to a commercial paracentesis kit, while involving residents in improving the environmental impact of their practices.

The online supplementary data contains a visual abstract.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented at the American College of Gastroenterology Conference, October 20-25, 2023, Vancouver, British Columbia, Canada.