Comparative full life-cycle assessment of singleuse and multi-use laryngoscopes

Emily Anderson, E. Brent Dowd, Lewis Raibley This LCA is set forth to provide an environment and human-health impact assessment of single- vs multi-use medical components as hospitals continue to move towards the former amid growing concerns over legislation and patient health. The concern is that hospitals may be doing more harm than good to the long-term health of the general population, while also contributing to growing environmental concerns. Specifically, single- and multi-use laryngoscope components have been analyzed herein. In conjunction with Yale-New Haven Hospital in New Haven, CT, the laryngoscope components are analyzed from cradle-to-grave including any sterilization and disposal phases that are applicable. It is found that when multi-use laryngoscope components are disinfected to regulations provided by the Center for Disease Control (CDC) multi-use components have far less of an impact on the environment and long-term human health. However, if these components are sterilized beyond CDC requirements the benefits of multi-use components diminish significantly to the point where single-use components become less impactful than their multi-use counterparts. Thus, decontaminating and sterilizing multi-use laryngoscope components to the regulations currently set forth by the CDC (and not beyond) creates the least amount environmental and long-term human health impacts.

Abstract

Goal This study is intended to inform hospitals, healthcare practitioners and healthcare regulators of the differences in cradle-to-grave impact between single- and multi-use laryngoscope components. Continually-evolving healthcare regulations - intended to protect patients while in the hospital - have created a culture in which it is simpler and seemingly cheaper to buy single-use, disposable laryngoscope components rather than to sterilize multi-use components. There is growing concern that the life-cycle human health impacts of this disposable culture outweigh the benefits of single-use components. This study compares the single- and multi-use laryngoscope components used by Yale-New Haven Hospital (YNHH) in New Haven, Connecticut. It is not intended to be used in brand comparative assertions, although the single-use and multi-use components are indeed made by different companies. It is assumed throughout the study that different brands of single-use or multi-use parts would have a similar impact on the environment and human health. Scope The product system studied includes six parts, three parts each for single-use and multi-use laryngoscopes: a handle, a blade, and a stylet. A stylet is not used for every laryngoscope used; however, like the laryngoscope components, it is increasingly preferred to use single-use over multiuse. The functional unit used in this study is one use of a laryngoscope. From data received from YNHH,

Goal/Scope

it was assumed that multi-use handles and stylets have conservative lifetimes of 100 uses, while a multi-use blade was estimated to last twice as long - 200 uses - due to containing fewer and more durable parts. Therefore, this study compares 1 single-use laryngoscope (all components) to 0.01 multi-use handle and stylet lifetimes and 0.005 multi-use blade lifetimes. The system includes all phases of the products lifetime, cradle to grave. The multi-use components include a use phase to incorporate sterilization; the single-use parts do not include this phase.

Methodology

Data for this study was collected primarily through manufacturer inquiries and destructive testing of components obtained from YNHH. As mentioned in the Scope section of this report, the lifetime of each multi-use component was conservatively estimated, as the hospital provided no data regarding how many times a component is used prior to disposal. The handles and stylets were estimated to last a shorter length of time than the blades due to their construction; the handles include batteries and electric lighting components, and the stylets are constructed of a thin, flexible stainless steel, which are more fragile than the more rigid stainless steel and glass fiberoptic tubing in the multi-use blades. Table 1 shows the estimated lifetime of each component of the multi-use laryngoscope. Table 1: Multi-Use Components Part Handle Blade Stylet Estimated Lifetime (# Uses) 100 200 100

This study was completed using process LCA in SimaPro. The impacts were assessed using TRACI 2.0. This report will focus on the human health impact categories of Carcinogens (CTUh), Global Warming Potential (kg CO2 eq), Respiratory Effects (kg O3 eq) and Smog Formation (kg PM10 eq). The remaining impact categories can be found in the Supplement. These impact categories were chosen in order to provide insight into both the medical and environmental community. The medical community was taken considerably into account during the formation of the study given the nature of the products being assessed. Table 2: Component Manufacturers Part Multi-Use Handle Multi-Use Blade Multi-Use Stylet Manufacturer Rusch Rusch Verathon

Single-Use Handle Single-Use Blade Single-Use Stylet

Flexicare Heine Rusch

Data from YNHH is taken into consideration when assessing long-term impacts outlined in this study. It is estimated that 60,000 blades and 30,000 handles and stylets are processed in the central sterilization department of YNHH each year. Sterilization inventory and impacts for the lifetime of each component are based upon this information as well as data for energy and water consumption during the sterilization process, which was also obtained directly from YNHH. According to regulations from the Center for Disease Control, multi-use laryngoscope blades are considered semi-critical, while laryngoscope handles and stylets are considered non-critical. Semicritical components must be sterilized prior to each use and non-critical components must be disinfected. YNHH disinfects non-critical components using sanitary wipes, but also sterilizes noncritical components based on doctors discretion. This study aims to set guidelines for when a component should be disinfected as opposed to sterilized. Multi-use handles and stylets are modeled in two ways; with steam sterilization and with sanitary wipe disinfection. Multi-use blades are modeled with steam sterilization only since they are semi-critical components and must be sterilized prior to each use. Full multi-use assemblies have been analyzed for the case of steam sterilization of all components, and for the case of blade sterilization and handle and stylet disinfection.

Results

Component Comparisons Two of each type of laryngoscope component (blade, handle, and stylet) are analyzed in this LCA. Single- and multi-use components are analyzed for each case. In the case of the handles and stylets, the multi-use component is analyzed with a sterilization scenario and a disinfection scenario. The multi-use blade is only analyzed under a sterilization scenario; this is because it is a semi-critical component and therefore must be sterile prior to each use. Results for the multi-use and single-use components are specific to the brands analyzed. While it is assumed that results for other laryngoscope components on the market will be similar, it should be noted that transportation impacts will vary dependent upon where each is manufactured and where it is being used. Each component studied is further detailed in Table 3: Laryngoscope Components. Further product breakdown can be found in Section 4 of the Supplement.

Table 3: Laryngoscope Components

Blades Multi or Single Use Brand Major Materials Manufacturing Location Multi Rusch Snaplight Fiber Optic Steel Israel Single Heine XP Disposable Polycarbonate Germany Multi Rusch Green Spec FibreOptic Steel Israel Handles Single Flexicare BritePro PVC, Polycarbonate Malaysia Multi Glide Rite Reusable Style Aluminium, Polypropylene Washington, USA Stylets Single Rusch FlexiSlip 14 FR Steel, Polyethylene Malaysia

Laryngoscope Blades For the multi-use blade, the majority of the impacts stem from the waste disposal scenario. The waste disposal of the multi-use blade is significant due to the disposal of the stainless steel and the sludge created during water treatment of the water used during sterilization. In the case of the single-use blade, the majority of the impacts are due to the polycarbonate and air transportation processes. A detailed breakdown of the contributing processes to each impact category can be found in the Section 4 of the Supplement. As Figure 1: Impacts From the Use of One Laryngoscope Blade indicates, the single-use blade is less impactful in terms of smog formation and respiratory effects in humans, and the multi-use blade is more impactful in terms of global warming potential and carcinogen emissions. Each figure represents the impact of the use of one laryngoscope blade. In terms of long-term health effects, if only multi-use blades were used at the rate YNHH uses laryngoscope blades, it would cause one case of cancer every 102 years. If only single-use blades were used, one case of cancer would be caused every 1,272 years. This difference is almost entirely due to the Use phase of a laryngoscope blade, which is considered to be the sterilization of the blade. Since the single-use blade does not go through any sterilization procedures, its Use phase is negligible. A laryngoscope blade is considered semi-critical and therefore must be fully sterilized if it is to be reused. Thus, disinfection techniques are not sufficient for multi-use blades between uses.

Figure 1: Impacts From the Use of One Laryngoscope Blade

Global Warming Potential

8.00E-01 7.35E-01 5.77E-01 kg O3 eq

Smog Formation
5.00E-02 4.13E-02 4.00E-02 3.00E-02 2.00E-02 1.00E-02 0.00E+00 2.53E-02

6.00E-01 kg CO2 eq

4.00E-01

2.00E-01

0.00E+00 Multi-Use Single-Use

Multi-Use

Single-Use

Carcinogens
2.00E-07 1.63E-07 1.60E-07 kg PM10 eq 1.20E-07 8.00E-08 4.00E-08 0.00E+00 Multi-Use Single-Use

Respiratory Effects
5.00E-04 4.00E-04 3.00E-04 2.00E-04 1.00E-04 0.00E+00 Multi-Use Single-Use 2.48E-04 4.75E-04

CTUh

1.31E-08

Laryngoscope Handles The process contributions to the impacts of laryngoscope handles are similar to that of laryngoscope blades in the sense that the waste scenario is significant when sterilization is used, and transportation plays a large role in single-use components. In contrast to the blades, handles are considered noncritical and do not need to be sterilized between uses. Therefore, multi-use handles were analyzed in a sterilized scenario and a disinfected scenario where sanitation wipes are used to wipe down handles between uses. As can be seen in Figure 2: Impacts From the Use of One Laryngoscope Handle, the single-use handle that is examined in this LCA is significantly more impactful in almost all of the impact categories that were analyzed. In some of the impact categories that were assessed, namely carcinogen emissions, the multi-use handle with sterilization is slightly more impactful than the single-use handle. However, in this specific impact category, the multi-use, disinfected handle has far fewer emissions. All impact category comparisons can be found in the supplement. In terms of long-term human health impacts, if all laryngoscope handles at YNHH were solely multi-use, sterilized handles, one case of cancer would be caused every 192 years. If all of the handles

at YNHH were solely single-use or multi-use, disinfected handles, one case of cancer would be caused every 209 years or 2,645 years, respectively. It is of note that the impacts of the multi-use handle (disinfected or sterilized) are greatly reliant on battery usage and disposal. If new batteries are frequently replaced in the handle, then impacts will be significantly higher. Being aware of battery usage and disposal is of major concern throughout the lifetime of the handle. Figure 2: Impacts From the Use of One Laryngoscope Handle

Global Warming Potential

2.00E+01

Smog Formation
1.50E+00 1.16E+00

kg CO2 eq

1.00E+01

kg O3 eq 8.45E-02

1.14E+01

1.00E+00

5.00E-01 2.97E-02 0.00E+00 Multi-Use Sterile Single-Use Multi-Use Disinfect

7.94E-01 0.00E+00 Multi-Use Sterile Single-Use

6.37E-03

Multi-Use Disinfect

Carcinogens
2.00E-07 1.60E-07 CTUh 1.20E-07 8.00E-08 4.00E-08 0.00E+00 Multi-Use Sterile Single-Use Multi-Use Disinfect 1.26E-08 0.00E+00 1.73E-07 1.00E-02 1.59E-07 kg PM10 eq

Respiratory Effects

6.02E-03 5.00E-03

4.57E-04 Multi-Use Sterile Single-Use

2.57E-04 Multi-Use Disinfect

Laryngoscope Stylets Laryngoscope stylets are considered non-critical and were therefore modeled in a similar fashion to the laryngoscope handles. The multi-use handle was modeled in a disinfection scenario with sanitation wipes and a sterilized scenario with steam sterilization. The significant impact from the waste scenario holds for the multi-use stylet, as does the significant transportation contributing for the single-use stylet. The stylet is the least impactful of the laryngoscope components. It is however, necessary to include in an analysis due to its frequent use in the hospital. According to data obtained from YNHH, stylets are used as often at laryngoscope handles, making then a significant impact contributor over time. As Figure 3: Impacts From the Use of One Laryngoscope Stylet shows, the multi-use, disinfected stylet is far less impactful than the other two scenarios in all of the impact categories analyzed. In

terms of long-term human health, if all of the stylets that YNHH used were multi-use, disinfected, one case of cancer would be caused every 16,665 years. If every stylet used was a multi-use, sterilized or single-use stylet, one case of cancer would be caused every 205 years or 1,165 years, respectively. Figure 3: Impacts From the Use of One Laryngoscope Stylet

Global Warming Potential

8.00E-01 7.00E-01 6.00E-01 kg CO2 eq kg O3 eq 5.00E-01 4.00E-01 3.00E-01 2.00E-01 1.00E-01 0.00E+00 Multi-Use Sterile Single-Use Multi-Use Disinfect 2.18E-02 3.19E-01 7.37E-01

Smog Formation
3.00E-02 2.50E-02 2.00E-02 1.50E-02 1.00E-02 5.00E-03 0.00E+00 Multi-Use Sterile Single-Use Multi-Use Disinfect 1.56E-03 2.52E-02 2.70E-02

Carcinogens
1.80E-07 1.60E-07 1.40E-07 kg PM10 eq 1.20E-07 CTUh 1.00E-07 8.00E-08 6.00E-08 4.00E-08 2.00E-08 0.00E+00 Multi-Use Sterile Single-Use 2.86E-08 2.00E-09 Multi-Use Disinfect 1.63E-07

Respiratory Effects
3.50E-04 3.00E-04 2.50E-04 2.00E-04 1.50E-04 1.00E-04 5.00E-05 0.00E+00 Multi-Use Sterile Single-Use Multi-Use Disinfect 4.31E-05 2.89E-04 2.49E-04

Break-Even Analysis A break-even analysis was performed in order to provide a qualitative representation of the impacts from each laryngoscope component. In the break-even analysis considered for individual parts of a laryngoscope, the amount of uses necessary to obtain an equal impact to that of the more impactful component was considered. In the case of the laryngoscope blade, the multi-use, sterilized scenario is compared with the single-use blade. In the case of the laryngoscope handle and stylets, the multi-use, disinfected case is compared with the single-use blade. The handles and stylets were handled in this manner in order to account for the fact that the disinfected multi-use component is less impactful in all of the categories of interest than its sterilized multi-use counterpart, and so will have a greater number of break-even uses. In Tables 4-6, the Break-Even Uses is the number of uses of the less impactful scenario to equal the impact of one use of the more impactful scenario. For example, from Table 4: Break-Even Uses of a Laryngoscope Blade, it would take 12.48 uses of a sterilized, multi-use blade to equal the carcinogen emissions from the use of one single-use blade. It is also significant to note that

the multi-use, disinfected handle and stylet are less impactful in all impact categories than their singleuse counterparts. Table 4: Break-Even Uses of a Laryngoscope Blade
Impact category Unit Multi-Use 3.58*10-8 0.735 0.0253 0.0745 0.0257 1.63*10-7 4.89*10-7 2.48*10-4 7.8036 Single-Use 7.04E-08 0.577 0.0413 0.1174 0.0008 1.31*10-8 5.21*10-8 4.75*10-4 0.4885 Break-Even Uses 1.96 1.27 1.63 1.57 30.87 12.48 9.38 1.91 15.98 Ozone depletion kg CFC-11 eq Global warming kg CO2 eq Smog kg O3 eq Acidification mol H+ eq Eutrophication kg N eq Carcinogens CTUh Non carcinogens CTUh Respiratory effects kg PM10 eq Ecotoxicity CTUe *Less impactful scenario bolded Table 5: Break-Even Uses of a Laryngoscope Handle Impact category Unit Multi-Use Disinfect 1.05*10-7 0.0845 0.0064 0.0557 0.0004 1.26*10-8 2.92*10-8 0.0003 0.2470 Single-Use 1.81*10-6 11.3843 1.1606 2.7990 0.0152 1.59*10-7 5.28*10-7 0.0060 3.5867 Ozone depletion kg CFC-11 eq Global warming kg CO2 eq Smog kg O3 eq Acidification mol H+ eq Eutrophication kg N eq Carcinogens CTUh Non carcinogens CTUh Respiratory effects kg PM10 eq Ecotoxicity CTUe *Less impactful scenario bolded Break-Even Uses 17.24 134.74 182.16 50.25 37.11 12.66 18.11 23.42 14.52

Table 6: Break-Even Uses of a Laryngoscope Stylet

Impact category Unit Multi-Use Disinfect 8.02*10-10 0.0218 0.0016 0.0098 8.31*10-5 2.00*10-9 5.22*10-9 4.31*10-5 0.0712 Single-Use 4.26*10-8 0.3192 0.0270 0.0761 5.71*10-4 2.86*10-8 3.69*10-8 2.89*10-4 0.3627 Ozone depletion kg CFC-11 eq Global warming kg CO2 eq Smog kg O3 eq Acidification mol H+ eq Eutrophication kg N eq Carcinogens CTUh Non carcinogens CTUh Respiratory effects kg PM10 eq Ecotoxicity CTUe *Less impactful scenario bolded Break-Even Uses 53.20 14.64 17.28 7.76 6.87 14.30 7.06 6.71 5.09

Phase Results Manufacturing The largest Manufacturing impact is from the single-use handles, notably in the human health categories. Each of the handles contains three lithium ion button cell batteries and an LED bulb, which are rather resource intensive products to manufacture. These components are discarded with each use, while the multi-use handles contain a similar bulb and C batteries, but can be used many more times. Transportation The impact of the Transportation phase also shows the greatest proportional effect in the life cycle of the single-use handles, and is relatively minor in every impact category for the multi-use items. This is due to the fact that a full delivery is required for every use of the single-use components, whereas the multi-use products distribute the effects one delivery over the entire lifetime (100-200 years). As expected, the Transportation phase proved to have a much larger influence on the air quality impact categories, such as global warming potential and smog formation, in which contributions to the total CO2e emissions of a single use assembly are 89% and 95%, respectively. This effect is due to the emission of carbon dioxide and carbon monoxide. Sterilization and End of Life The sterilization of the multi-use components is shown in the Use phase. The single-use products do not require disinfection or sterilization, so the impact of each component due to the Use phase is zero. Although the impacts do not appear to have much direct effect on the life cycle of the multi-use products, an important aspect to note is the considerable increase in waste generated by the sterilization process, allocated to the End of Life category. Washing and sterilizing the components requires a great deal of water, which must be treated after use. As shown, the impacts of the multi-use handle and stylet are significantly larger when a full steam sterilization process is incorporated, particularly concerning the human health and water quality categories. Avoiding this process with instruments that do not require full sterilization has a considerable effect on the overall impact.

Figure 4a: Impacts by Life-Cycle Phase

Global Warming Potential

11.384

GWP (kg CO2e)

End-of-Life 0.794 0.577 0.735 0.331 0.737 Use 0.022 Transport Manufacturing

0.084

Smog Formation
1.16 Smog Formation (kg O3e)

End-of-Life Use 2.97E-02 6.37E-03 4.13E-02 2.53E-02 2.78E-02 2.52E-02 7.12E-02 Transport Manufacturing

Figure 4b: Impacts by Life-Cycle Phase

1.73E-07

Carcinogens
1.63E-07 1.63E-07

1.59E-07

Carcinogens (CTUh)

End-of-Life 2.93E-08 1.26E-08 1.31E-08 2.00E-09 Use Transport Manufacturing

Respiratory Effects
Respiratory Effects (kg PM10e) 6.02E-03

4.57E-04 2.57E-04 4.75E-04 2.48E-04 3.02E-04 2.49E-04 4.31E-05

End-of-Life Use Transport Manufacturing

Full Assembly Comparison The impact categories of Global Warming Potential, Smog Formation, Carcinogens and Respiratory Effects are included in this report. The remaining impact categories are included in Section 2 of the Supplement. As shown in Figure 5: Comparison of Full Assemblies, the single-use assembly has a greater impact in three of the four chosen categories, generally by a large margin. As a breakeven analysis, Table 7 shows the number of uses it would take for the impacts to be even in each category, when comparing each of the multi-use assemblies to the single-use assembly. Figure 5: Comparison of Full Assemblies

Global Warming Potential

14.000 12.000 10.000 kg CO2 eq 8.000 6.000 4.000 2.000 0.000 Multi-Use with Sani Wipes Multi-Use Sterile Single-Use 0.842 2.268 kg O3 eq 12.294 1.400 1.200 1.000 0.800 0.600 0.400 0.200 0.000

Smog Formation
1.230

0.033 Multi-Use with Sani Wipes

0.081 Multi-Use Sterile Single-Use

Carcinogens
6.00E-07 5.00E-07 4.00E-07 CTUh 3.00E-07 2.00E-07 1.00E-07 0.00E+00 Multi-Use with Sani Wipes Multi-Use Sterile Single-Use 1.78E-07 2.02E-07 5.00E-07 kg PM10 eq

Respiratory Effects
8.00E-03 7.00E-03 6.00E-03 5.00E-03 4.00E-03 3.00E-03 2.00E-03 1.00E-03 0.00E+00 Multi-Use with Sani Wipes Multi-Use Sterile Single-Use 5.48E-04 9.56E-04 6.79E-03

Table 7: Break-Even Uses of Full Assemblies

Impact category Global Warming Potential Smog Carcinogens Respiratory Effects Multi-Use Sterilization vs. Single-Use Unit Multi-Use Single-Use BreakEven Uses Multi-Use Sani Wipes vs. Single-Use Multi-Use Single-Use BreakEven Uses

kg CO2 eq kg O3 eq CTUh kg PM10 eq

2.266 0.080 4.998*10 0.0010

-7

12.281 1.229 2.008*10 0.0068

-7

5.419 15.298 2.489 7.104

0.842 0.033 1.779*10 0.0005

-7

12.281 1.229 2.008*10 0.0068

-7

14.589 36.942 1.129 12.367

*Less impactful scenarios are shown in bold When comparing the multi-use assembly that uses sterilization to the single-use assembly, the multiuse performs better in all categories except Carcinogens, where it has an impact more than twice that of the single-use assembly. However, in the other three impact categories, it performs significantly better than the single-use assembly. For example, it would take more than 15 uses of a reusable handle to match the impacts of one single-use handle in terms of carcinogen emissions. At first glance this value could seem rather low. However, it means that over the lifetime of one reusable handle (100 uses), if the hospital wished to keep the impact level consistent, only 6.67 single-use handles could be used if the carcinogenic impact were to be conserved. Impacts of the sterile, multi-use assembly can be attributed mainly to the sterilization process itself. Water and electricity consumption during the sterilization process produce a significant amount of waste and emissions that are taken into account in the waste scenarios detailed throughout this report. The use of disinfecting sanitation wipes greatly diminishes the impacts in all of the impact categories analyzed. This plays a significant role when comparing the sterile, multi-use handles and blades to their disinfected counterparts. In each case, the majority of the impacts come from the laryngoscope handle. The handle is typically the heaviest component of the assembly and also includes batteries. In the case of the disposable handle, the batteries are three (3) lithium-ion batteries and in the case of the multi-use handle the batteries are comprised of two (2) nickel-cadmium batteries. Reusing these batteries greatly influences the overall impact of each assembly. For the purposes of this study, it is assumed that the same batteries are replaced into the handle after each sterilization or disinfection for the entire lifetime of the device.

Sensitivity

The multi-use assembly was used for a sensitivity analysis in each of the impact categories. Variables considered were: the number of uses in the products lifetime, the amount of water, steam, and electricity used for sterilization, and transportation distance. Each variable was changed by 10%, and the effect that the change has on the overall impact was calculated. Figure 6 shows the sensitivity analysis for GWP, Smog Formation, Carcinogens and Respiratory Effects. The sensitivity analysis of the remaining impact categories is displayed in Section 7 of the Supplement.

Figure 6: Impact Category Sensitivity

GWP (kg CO2e) Smog Formation (O3)

Number of Uses

Number of Uses

Sterilization

+10% -10%

Sterilization

+10% -10%

Transportation 2 2.25 2.5

Transportation 0.072 0.08 0.088

Carcinogens (CTUh)
Number of Uses

Respiratory Effects (kg PM10e)

Number of Uses Sterilization Transportation +10% -10% Sterilization Transportation +10% -10%

Number of Uses - In each category, the number of uses per lifetime has a very direct effect; a 10% change in the number of uses causes approximately a 10% change in the total impact. Thus, extending the lifetime of the laryngoscopes through proper care is very beneficial to overall environmental impact. Sterilization Requirements - The amount of resources used for the sterilization process also affects the overall impact. A 10% change in materials used for sterilization results in a 6-11% change in overall impact, depending on the category. Transportation Distance The distance of transportation from manufacturing to the hospital has very low sensitivity. A 10% change in transportation causes a change of less than 1% in each overall impact category.

This study recommends that YNHH move away from single-use laryngoscope components in favor of multi-use components utilizing sanitary wipe disinfection techniques where industry regulations warrant disinfection appropriate. When taking a full assembly of laryngoscope components (blade, handle, and stylet) into consideration, the assembly of multi-use components that are disinfected with sanitation wipes prove less impactful per use than steam sterilized components in all of the impact categories analyzed during this study. An assembly of multi-use, disinfected components also proves less impactful than an assembly of single-use components in all impact categories analyzed, the the exception of ecotoxicity and eutrophication. However, given that the number of uses of a multi-use component during its lifetime has been conservatively estimated, it is likely that multi-use, disinfected components have less of an impact in these categories when taking into consideration their actual lifetimes.

Recommendations

The authors of this study would like to thank Dr. Jodi Sherman and Walter Hall at Yale-New Haven Hospital for data and their invaluable help, as well as Dr. Matthew Eckleman for his guidance and support.

Acknowledgements

References

[1] Consolidated Edison Company of New York, Inc. "General Steam Service Historical Rates." <http://www.coned.com/documents/steam/Historical-Rates/Tariff_LeavesSCs_20131001.pdf>. [2] Rutala, Ph.D., M.P.H., William A., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC) United States Department of Health and Human Services. Guideline for Disinfection and Sterilization in Healthcare Facilities. 2008. <http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf>. [3] The United Illuminating Company. "General Service Time-of-Day Rate." <http://www.uinet.com/wps/wcm/connect/ead3bb0040d86745a885bbd2ce51850f/694_General Service Time of Day Rate GST.pdf?MOD=AJPERES&CACHEID=ead3bb0040d86745a885bbd2ce51850f>.