Using Paper Soufflé Cups Instead of Plastic Medication Cups

Consider, for a moment, the lowly medication cup. Believe it or not, there is an opportunity there to move towards more sustainable healthcare.

In the hospital, a large part of a nurse’s duty is medication administration. Much time and care are spent in the rituals of withdrawing single-dose packaged medications from the automated medication dispensing device (e.g. Pyxis, Omnicell), checking the eight rights of medication administration three times (Austin Community College, 2023), dispensing the individual doses into medication cups, and giving them to patients. This is ritualized behavior (Wolf, 1988), learned first by student nurses and performed throughout a nurse’s bedside career, multiple times a day for multiple patients. A typical day shift nurse might care for five patients who receive medications at eight, nine, ten, twelve, four, and five o’clock, resulting in the use of up to 30 medication cups per day, per nurse. On a floor with 32 patients, there might be up to 192 medication cups used per day (not including night shift).

But what are nurses using as medication cups? There are two alternatives. One is the classic white paper soufflé cup, the other a plastic cup with measurements noted for dispensing liquid medication. Both are typically easily available to the nurse, whether at the bedside or by the medication dispensing device. The choice of which to use is left up to the individual nurse, which results in frequent use of the plastic cup to dispense not only liquid medications as designed, but also solid medications (pills and capsules) that do not require measurement.

How are we to get nurses to stop unnecessarily using plastic cups instead of the more recyclable and potentially compostable (depending on the manufacturer) paper soufflé cups? What is the best method of assuring that nurses have access to plastic medication cups for liquid medication but use paper soufflé cups for other oral medications?

Literature Review

I could not find any studies about the use of paper versus plastic medication cups, which is a gap in the literature that should be remedied. Wolf’s 1988 study, Nursing Rituals, included a section on the rituals surrounding medication administration. Anstey, et al. (2023) studied the amount of waste thrown away in Australian and New Zealand intensive care units; while they didn’t quantify the number or type of medication/soufflé cups, they did mention them as part of the approximately 8 kg of ICU waste per bed-day. Austin Community College’s (ACC) checkoff sheet on medication administration does not mention either type of medication/soufflé cup. When one nursing professor was questioned, she responded that it had never occurred to her to ask her students to use the paper cups instead of the plastic ones (Todd, 2024).

While there is little in the literature specifically addressing paper soufflé cups for medication administration, there is literature regarding the importance of small changes that can lead to transformation. Wright and Meadows (2009), for example, discuss the 12 ways to intervene in a system, from the least effective (numbers) to the most effective (transcending paradigms). Dorninger, et al. (2020) use this framework to discuss leverage points relating to sustainability transformation, and Edmonds (2010) discusses the impacts of small changes in sustainable behavior.

Solutions and Recommendations

            The solution to the problem seems obvious: stop using plastic medication cups for anything other than administering liquid medications that must be poured from a larger container and measured. Surely there are more complicated problems to solve! But this problem is more complex than it appears at first glance.

            As stated above, generally the choice of what type of medication cup to use is left to the individual nurse. In a typical hospital, both types are stored side by side to be utilized at the nurse’s convenience; the plastic cup may even be stored in front of the paper ones. The choice could be random, or it could be deliberate. Plastic medication cups cannot be completely eliminated, at least at this juncture, because they are required for measuring liquid oral medication, but their use can be greatly reduced.

            One solution is to educate nurses about the dangers of plastics in our environment. There is a great deal of literature that could be found to formulate an educational plan. Any plan to decrease the use of plastic medication cups should include education–but education does not have the same impact as changing the system itself.

            My first recommendation is to have the automated medication dispensing device also contain the plastic medication cups. This could easily be accomplished, as these devices frequently include items needed for medication administration such as vials of normal saline (0.9% NaCl) solution for mixing meds, pill cutters, and more. Whenever a patient has orders for a liquid medication that must be poured out and measured, the nurse could simply request this cup at the Pyxis or another such machine. This way, all areas normally stocked with both types of medication cups could switch to only carrying the paper soufflé variety. This type of change is a system change, the type that Wright and Meadows described as changing the rules of the system, which is a highly effective technique (number five in a list of twelve). Instead of just asking nurses to make the change on their own, we would be making it much more difficult to choose the plastic medication cups unless absolutely necessary. Out of convenience, nurses would simply switch to using the paper soufflé cups instead.

            If it is not possible to put the plastic medication cups in the medication administration device, they could be stored separately in the supply room, instead of near the Pyxis or in individual drawers at each patient room. This would achieve the same outcome as storing them in the Pyxis, although it is possible nurses who prefer the plastic cups might take a supply with them to use instead of paper soufflé cups.

            This change could start very small, perhaps on one unit of a large hospital, then grow and spread to other parts of the hospital, the hospital system, and eventually other hospital systems. Think of the amount of plastic waste that getting rid of this one small piece could result in! Think of the impact it might have as individual nurses make the connection between saving one piece of single use plastic from the waste stream—if it works for medication cups, why not the liners for water pitchers?

And what about recycling the paper cups? I could not find any paper soufflé cups for sale that were made from recycled paper, but with the market changing to demand more of these cups, the pressure could be brought to bear to make this change, as well as ensuring that all cups are compostable.

            One way of spreading this change would be from editorials in nursing and other healthcare publications. This white paper could be adapted to use for such a purpose. Another way is through the use of green teams at individual hospitals and hospital systems. This change could motivate nurses to start green teams at hospitals that do not currently have them; some hospital systems currently only have green teams at teaching hospitals, leaving many hospitals that may wish to practice sustainability out. Green teams could bring more hospitals into networks like Practice Greenhealth, which is an organization of hospitals and health systems practicing sustainability (Practice Greenhealth, nd).

Conclusion

            When I first started working as a nursing professor, I was part of an initiative spearheaded by the Robert Wood Johnson Foundation’s Institutes for Healthcare Improvement (IHI) called Transforming Care at the Bedside (TCAB). One of the mainstays of TCAB was the power of one person to make one small change, test it, and spread it to other parts of the hospital/hospital system (Lee, et al., 2008). Piloting the placement of plastic medication cups in the automated medication dispensing device rather than at the patient’s bedside in one unit in the hospital would have been a perfect TCAB project, designed to grow and spread from that one nurse’s idea (in this case, mine). TCAB is no more, but that doesn’t mean we can’t make this change by starting small. While we don’t yet have easy solutions for replacing many of the single-use plastics utilized in healthcare today, here is one area where we can start immediately.

References

Antsey, M. H., Trent, L., Bhonagiri, D., Hammond, N. E., Knowles, S., and McGain, F. (2023). How much do we throw away in the intensive care unit? An observational point prevalence study of Australian and New Zealand ICUs. Critical Care and Resuscitation 25(2023), 78-83. https://doi.org/10.1016/j.ccrj.2023.05.004

Austin Community College (2023). Medication administration of parenteral and non-parenteral medications. https://drive.google.com/file/d/1DuvisqP5zsb3NLm729yaCcpEFlKA7dZ3/view

Edmonds, A. (2010). Resilience & engagement: some thoughts on the magnetic impact of small change. Transforming Cultures eJournal 5(1). http://epress.lib.uts.edu.au/journals/TfC

Lee B, Peck C, Rutherford P, Shannon D. (2008). Transforming Care at the Bedside How-to Guide: Developing Front-Line Nursing Managers to Lead Innovation and Improvement. Institute for Healthcare Improvement. https://tinyurl.com/5n928h59

Practice Greenhealth (nd). https://practicegreenhealth.org/

Todd, S. (2024). Personal communication.

Winkleman, R., Donges, J. F., Smith, E. K., Milkoreit, M., Eder, C., Heitzig, J., Katsanidou, A., Wiederman, M., Wunderling, N., and Lenton, T. M. (2021). Ecological Economics 192(2022), 107242. https://doi.org/10.1016/j.ecolecon.2021.107242

Wolf, Z. (1988). Nursing rituals. The Canadian Journal of Nursing Research 20(3), 59-69.

Wright, D., and Meadows, D. H. (2009). Thinking in Systems: A Primer. Routledge.