Reducing Red Bag Waste: One OR at a Time

General Information

Institution Name: Mayo Clinic Jacksonville

Author Name and Title: Emmanuel Gabriel, MD, PhD, FACS, FSSO

Name of Case Study: Reducing Red Bag Waste: One OR at a Time

Identification of Local Problem

In his operating room (OR), Dr. Emmanuel Gabriel and his team had been tracking, over a six-month time frame, how often surgical waste (drapes and gowns) were placed into red biohazard bags when they could have been placed into regular clear (non-biohazard) waste bags. Red bags were used more than 95% of the time, even for minimal cases—for example, breast lumpectomies—where there was essentially no soilage or contamination of the drapes or gowns with bodily fluids such as blood. The gap that he aimed to address in this QI project was the inappropriate use of red bags for disposal of non-biohazard waste: red bags that were used for the disposal of non-biohazard materials such as clean, unsoiled surgical drapes and towels that should have been disposed of in normal waste containers.

Context of the QI Activity

Generating waste in the OR was an unavoidable effect of performing surgery. Two types of solid waste could be generated: biohazard waste and non-biohazard waste. Biohazard waste is defined as any waste material that is contaminated with potentially infectious agents and poses a threat to public health or the environment. In the OR, the main sources of biohazard waste included drapes, towels, and disposable instruments that were grossly contaminated with human blood or other body fluids, and these were placed into red biohazard bags for disposal. Non-biohazard waste included the same items when they were not contaminated with human contents. Compared with non-biohazard waste, red bag waste requires up to an estimated ten times cost and resources to process and dispose of properly. It was therefore important to sort waste appropriately into biohazard and non-biohazard waste bags, which did not always occur properly in the OR. The rationale for this QI project was that reducing red bag waste could decrease the costs of waste disposal and help the environment by conserving resources used to dispose of biohazard waste.

During a six-month period (June 1, 2025–November 30, 2025) in Dr. Gabriel’s OR, red biohazard bags were inappropriately used in 96.5% of cases (N = 146) in which no biohazardous waste was generated – that is, the waste from these cases could have been placed in regular non-biohazard waste bags. This led to unnecessary increased costs to dispose of non-biohazardous waste, which in turn also minimized surgical sustainability and increased the carbon footprint for waste disposal.

Interventions

Dr. Gabriel and his team aimed to decrease the percentge ofn innapropriately use red bags by 50%, from 96.5% to 46.5% by June 20, 2026, without adversely impacting or increasing the amount of soiled surgical waste (which was appropriate for red bag disposal) that was placed into clear non-biohazard in his OR.

The interventions drew on a broad group of stakeholders who each touched a different part of the waste stream — surgeons, OR nurses, scrub technicians, environmental workers and custodians, and OR administrators — so that the change would hold across every role involved in waste handling rather than resting on any single team.

Dr. Gabriel and his team used the 5 Whys technique during multiple rounds of brainstorming, as shown in Figure 1 below. Potential causes of the inappropriate use of red bags included:

1. Red bags were already opened at the start of each case.
2. OR staff used red bags because they were easier to get to.
3. Changing teams during an operative day with new members who did not have the new education provided.

Overall, a key cause of inappropriate red bag use was perceived to be a lack of education and training.

A list of interventions was selected and tested to remove the causes of the gap in quality:

1. Morning huddle with all stakeholders to not open red bags automatically.
2. Red bags included in the surgical time-out for each case to re-examine whether a red bag would be needed.
3. Posting of the Society of Surgical Oncology (SSO) nugget to spread awareness about proper red bag use (Figure 2, below).
4. Holding the team accountable, including Dr. Gabriel himself, for any lapses in daily red bag misuse.
5. Reminding team members and new members routinely, especially at the start of the case.
6. Daily re-education as needed to prevent the balancing measure.
7. Daily efforts to energize and congratulate the team and all stakeholders.

These interventions engaged, educated, and empowered the surgeons, OR nurses, scrub technicians, environmental workers and custodians, and OR administrators involved, reducing red bag waste and maximizing proper use of both biohazard and non-biohazard waste. The interventions brought increased awareness and importance to sustainable surgery practices and highlighted effective and frequent communication, which promoted psychological safety and encouraged interest and inquiry among our stakeholders. Because each role was engaged, the practice was reinforced at every point in the waste pathway instead of relying on a single group.

Implementation Strategy

Prior to each case, Dr. Gabriel and the initial OR team communicated to custodial services not to automatically open red bags. For the majority of simple cases (breast lumpectomy, skin wide local excision, lymph node excision, robotic small bowel and adrenal cases), they reminded the team that red bags would likely not be needed. For larger, typically bloody cases (exploratory laparotomy, radical resection of tumors, Hyperthermic Intraperitoneal Chemotherapy (HIPEC), red bags were opened.

Overall Results and Analysis

Dr. Gabriel and his team reduced inappropriate red bag use from 96.5% to 17.5% over six months using these interventions, with the 17.5% reflecting all post-intervention cases, including those where biohazard waste was expected (see Figure 3 below).

The data collection start date for the first post-intervention measurement of the improvement measures was December 1, 2025. The data collection end date was May 24, 2026. The sample size (number of cases in Dr. Gabriel’s OR) was 138.

Lumpectomies and laparoscopic or robotic GI cases would still be expected to sit near 0%, while bloodier cases justifiably call for red bag use; HIPECs, being always bloody, continued to use red bags routinely. To date in Dr. Gabriel's OR, red bags have been seen to stay unopened until needed in every case except HIPECs, where they remain routinely used.

At Mayo Clinic Jacksonville, clear-bag waste disposal costs $0.024/lb against $0.22/lb for red-bag waste, a differential of $0.196/lb. Bags were not weighed in this project, but at an assumed 3–5 lbs per bag, the savings would compound considerably across an entire hospital system.

There were three inappropriate balancing measure events, meaning that biohazard waste was placed in non-biohazard bags, which was inappropriate. These events were able to be detected and corrected at the end of the procedure before inappropriate disposal. The identified reason was that the circulating nurse thought that Dr. Gabriel had instructed all waste to go into clear bags, so this was an issue of communication.

Limitations

This initial QI project was limited to a single operating room, and that room belonged to Dr. Gabriel. If the approach could be scaled slowly to (1) the Division of Surgical Oncology, (2) the Department of Surgery, (3) the House of Surgery at Mayo Clinic Florida, (4) the entire Mayo Clinic Enterprise, and (5) nationwide hospitals as part of a sustainability toolkit in reducing red bag waste, then it could have a substantial impact on the environment and on cost savings to hospitals. The main limitation was obtaining buy-in from other surgeons and creating a sense of urgency and commitment in others to implement these strategies.

Lessons Learned

Several lessons emerged from this project. Custodial staff had been trained to open biohazard bags before the start of each case, regardless of the expected amount of soiled surgical materials with biohazard waste. Circulating nurses, scrub technicians, and surgeons (faculty, residents, PA/NP) were not educated on OSHA-defined guidelines for what materials should be disposed of in red bags. These included items visibly saturated with blood, used PPE visibly contaminated, soaked gauze or drapes, IV tubing and blood bags, containers with unfixed human tissue, and sharps. Team changes and shifts during the day often brought in new team members who also were not educated on these first two points. Overall, there was not a high level of motivation or understanding of why minimizing red bag waste was important to our environment.