Comment on ‘Reducing plastic in single-use central line insertion packs: a mixed methods observational study’

I read with interest the article by Seville et al. on reducing plastic in single-use central line insertion packs. ¹ While the study addresses an important sustainability issue, I wish to highlight several significant limitations not discussed by the authors.

The study relied on clinician surveys and interviews to identify ‘non-essential’ items, but it did not include any procedural audit or direct observation of pack use. This is a critical shortcoming: staff perceptions can be biased, and only an objective audit can confirm which items truly go unused. Best practices in waste reduction recommend monitoring actual pack utilisation—for example, by tracking unused items over a trial period.^2,3 Indeed, a recent initiative in a children’s hospital eliminated items used in less than 85% of cases from packs, yielding a 2-ton annual plastic waste reduction and more than US$27,000 savings. ² Seville et al. did not perform such an observational audit to validate their claims. Without real-use data, the recommendation to remove five items rests on self-reported habits and may not reflect all clinical scenarios.

The authors propose removing infrequently used items (and using a ‘trolley’ for optional supplies) to streamline packs. However, they fail to discuss infection control implications. A key benefit of comprehensive custom kits is that all necessary equipment is pre-packaged sterile, minimising additional handling and opening of separate packages.^4,5 In emergency or high-acuity situations, having to retrieve a now-omitted item could introduce delays or breaks in aseptic technique. Opening extra sterile packages ‘on the fly’ can increase contamination risk, undermining patient safety. Seville et al. did not perform any infection control risk analysis of their intervention. There is no consideration of whether removing certain ‘just-in-case’ items might compromise sterility or preparedness when an unforeseen need arises. This omission is concerning given that central line insertion is an invasive procedure in which infection prevention is paramount.

The financial analysis in the paper focuses only on the direct cost of eliminated items (an estimated annual saving of AUD$1400 across two hospitals). This simplistic approach ignores indirect costs and potential trade-offs. The authors did not account for staff time and workflow impacts—for instance, if a missing item must be fetched from stock during a procedure, incurring delay and labour cost. They also excluded the costs of retraining staff to use a new pack configuration or maintaining a supplemental item trolley. In practice, poorly optimised custom packs can inadvertently increase costs if additional supplies must be opened to compensate. ⁶ For example, if a standard pack lacks an appropriately sized drape or device, staff will open a separate item, adding approximately US$5–7 per case. ⁴ Seville et al. did not discuss such scenarios. A more comprehensive cost–benefit analysis (including potential costs of procedural delays, wastage when an omitted item is needed, and staff adaptation) is necessary to evaluate fully the economic impact of pack changes.

The study’s environmental benefit calculation was limited to the embodied carbon of the removed items (230 kg CO₂e per year). This partial life cycle assessment (LCA) overlooks other stages of the product life cycle. The authors did not account for upstream and downstream impacts such as manufacturing transportation, additional packaging, or end-of-life disposal of the medical waste. In healthcare, supply-chain logistics and waste disposal contribute significantly to carbon emissions. ² Furthermore, prior LCA research on central line kits emphasises factors such as sterilisation energy, water use, and waste processing in determining the overall environmental footprint. ⁷ By ignoring transport and disposal pathways, Seville et al. likely overstate the net ecological benefit. For instance, removing an item might necessitate separate procurement (with its own transport packaging) on the occasions it is needed, shifting rather than eliminating environmental costs. A fuller LCA, encompassing all stages from production to disposal, is needed to substantiate the claimed sustainability gains.

The article overlooks how pack refinements could be scaled across institutions. Changing a custom procedure pack requires procurement, supply chain, and regulatory coordination. Their two-hospital pilot offers no clarity on whether expansion is feasible. Would vendors adjust packs for just a few hospitals, and how would this align with broader contracts or policies? These practical issues remain unaddressed. Notably, other successful waste reduction initiatives have engaged supply managers and procurement staff in the process. ⁶ In addition, published reviews suggest that pack optimisation strategies should be applied widely across healthcare settings, not just in one unit. ⁸ The lack of discussion on integration into institutional policy, and on the coordination needed for system-wide adoption, is a significant shortcoming of the paper.

Finally, Seville et al. concentrate solely on pack contents, with no mention of parallel strategies to change clinician behaviour or culture around waste. This is a missed opportunity. Redesigning a kit can reduce waste, but sustainable practice typically also requires educating staff and modifying routine habits. For example, simply encouraging clinicians not to open items unless needed or to use alternatives (like reusables) can substantially cut waste. ⁹ Guidelines for greener operating rooms advocate multi-faceted interventions—educating personnel, auditing usage regularly, and reinforcing waste-conscious practices alongside product changes. Seville et al. did not consider any educational or behavioural component to complement the pack modification. By omitting this, they overlook well-recognised human factors in waste generation. A combined approach (pack redesign plus staff engagement and training) could likely amplify the benefits, and its absence in the discussion is a notable gap.

In conclusion, Seville et al. have highlighted an important issue of unnecessary plastic waste in central line packs, but their study’s unacknowledged limitations temper the strength and applicability of their findings. Broadening the scope to incorporate objective usage data and infection control review, and addressing economic, environmental, and operational complexities would provide a more robust foundation for change. I urge that future efforts to reduce medical waste adopt a comprehensive strategy—one that couples pack optimisation with policy support and staff education—to ensure both safety and sustainability in critical care practice.