# Behavioral nudges and targeted education as sustainability strategies to reduce hazardous waste generation in intensive care and perioperative settings: a prospective interventional study

## TL;DR

A study in Italian hospitals found that combining visible waste bins and staff education significantly reduced hazardous waste in intensive care and operating rooms.

## Contribution

The study demonstrates that low-cost behavioral nudges and education can effectively reduce hazardous waste in high-resource hospital settings.

## Key findings

- Hazardous waste in ICUs decreased by 40.6% after combining behavioral nudges and education.
- Operating rooms saw a 34.4% reduction in hazardous waste following the same interventions.
- Key barriers to proper waste segregation included limited bin availability and unclear sorting rules.

## Abstract

Intensive care units (ICUs) and operating rooms (ORs) are resource-intensive hospital areas and major contributors to healthcare waste. Proper segregation of hazardous and residual waste reduces carbon-intensive disposal and supports sustainability, yet practices depend heavily on staff behavior and knowledge.

We conducted a prospective three-phase interventional study in the ICU and ORs of Merano Hospital, Italy (September 2023–May 2025). Baseline hazardous waste generation and staff knowledge/barriers were assessed (phase 1). Subsequently, low-cost behavioral nudges (enhanced bin visibility, labeling, placement–phase 2) and targeted online education on waste segregation (phase 3) were introduced in sequence. The primary outcome was the reduction in hazardous waste, normalized to ICU patient-days and surgical procedures; secondary outcomes included changes in perceived barriers and knowledge.

Hazardous waste generation declined across all phases in both ICUs and ORs. In the ICU, waste decreased from 3.31 (± 1.07) to 2.97 (± 1.40) kg/patient-day after behavioral nudges (− 10.3%, p = 0.31) and further to 1.97 (± 1.33) after education, representing a 40.6% reduction versus baseline (p < 0.001). In ORs, waste fell from 5.84 (± 1.40) to 4.38 (± 2.58) kg/procedure post-nudges (− 25.0%, p = 0.027) and to 3.84 (± 1.46) post-education, corresponding to a 34.4% reduction (p < 0.001). Structured questionnaires identified limited bin availability and unclear sorting rules as key barriers; behavioral nudges addressed structural obstacles, while education improved knowledge and confidence.

Integrating low-cost behavioral nudges with targeted education effectively reduces hazardous waste in ICU and perioperative settings. Environmental changes improve waste practices, while education enhances staff knowledge, awareness, and confidence, emphasizing that infrastructure alone is insufficient without supportive training.

The online version contains supplementary material available at 10.1186/s44158-026-00368-w.