Sustainability Initiatives in the Operating Room

Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change.

Anesthetics drug wastage and preventive strategies: Systematic review

BACKGROUND

Surgical Patients and hospitals are now facing financial strain due to direct anesthetic demand as a result of the development of new anesthetic drugs, equipment, and techniques. Up to 15% of a hospital's pharmacy budget is currently allocated to anesthetic drug expenses. Drug wastage during anesthesia practice is a widespread hidden source of healthcare waste that leads to anesthetic drug shortages as well as poor operating room efficiency. On the other hand, despite the fact that it is preventable in the vast majority of cases, it is well described that drug wastage is routinely observed, including in developing countries where the consequences significantly affect both hospitals and patients.

METHODS

This review aims to review the prevalence of anesthetic drug waste across the world and systematically formulate and describe preventive strategies. Relevant publications were identified using systematic searches on databases including Google Scholar, Medline (PubMed), the Cochrane Library, and Embase. In addition, papers were detected and then selected through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria guidelines and the inclusion and exclusion criteria. Using the predetermined terms and dates from the searching databases, a total of 504 articles were identified. Based on the screening criteria, 16 papers were considered eligible and included in the final review. In addition, the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis was used for evaluating the quality of selected articles. This study is registered on PROSPERO, number CRD42024497044.

RESULTS

Of the sixteen publications from eleven different nations that were considered suitable for inclusion, only two of them addressed the waste of inhalational anesthetics. In more than half of eligible articles, propofol was the frequently wasted drug that contributed to increased financial loss through drug waste. The first most significant factor contributing to the waste of intravenous and inhalational anesthetics was the disposal of multidrug vials following their use for a single patient and high fresh gas flow, respectively.

CONCLUSION

Anesthetic medication waste is a common occurrence worldwide, despite the fact that it is expensive and has a significant negative impact on operating room efficiency. Because the majority of drug waste is avoidable, preventive measures may lower drug waste and improve patient and hospital efficiency.

How we can reduce the environmental impact of our operating theatres: a narrative review

Climate change is projected to become the leading cause of adverse health outcomes globally, and the healthcare system is a key contributor. Surgical theatres are three to six times more pollutant than other hospital areas, and produce anywhere from a fifth to a third of total hospital waste. Hospitals are increasingly expected to make operating theatres more sustainable, however guidelines to improve environmental sustainability are lacking, and previous research takes a narrow approach to operative sustainability. This paper presents a narrative review that, following a 'review of reviews' approach, aims to summarize the key recommendations to improve the environmental sustainability of surgical theatres. Key domains of discussion identified across the literature included minimisation of volatile anaesthetics, reduction of operating theatre power consumption, optimisation of surgical approach, re-use and re-processing of surgical instruments, waste management, and research, education and leadership. Implementation of individual items in these domains has seen significant reductions in the environmental impact of operative practice. This comprehensive summary of recommendations lays the framework from which providers can assess the sustainability of their practice and for the development of encompassing guidelines to build an environmentally sustainable surgical service.

The Use of Disposable Supplies: Measuring Suburethral Sling Surgical Waste by Cost and Weight

IMPORTANCE

The health care industry is a leading contributor to solid waste in the United States, and two thirds of a hospital's regulated medical waste is produced from surgery.

OBJECTIVE

The primary objective was to assess the utilization of single-use disposable supplies during suburethral sling cases.

STUDY DESIGN

We observed suburethral sling plus cystoscopy procedures at an academic medical center. Cases with concomitant procedures were excluded. Our primary outcome was the quantity of wasted supplies, defined as disposable supplies that were opened at the start of the procedure and were unused. Secondarily, we quantified those supplies in both weight and United States dollars. In a subset of cases, we obtained the weight of the total amount of trash generated from the procedure.

RESULTS

A total of 20 cases were observed. Most frequently wasted items included an emesis basin, large ring basin, and rectangle plastic tray. Redundant supplies wasted included a 1-L sterile water bottle and, on average, 2.73 (SD, 2.34) blue towels. The sum of the weight of the wasted items among cases was 1.33 lb, associated with $9.50. The average total amount of trash produced from 11 cases was 14.13 lb (SD, 2.27). Removal of the most frequently wasted items would achieve a 9.4% reduction in solid waste produced by the case.

CONCLUSIONS

A large waste burden per surgical case was produced by a minor procedure. Removal of frequently wasted items, a reduced number of towels, and smaller cystoscopy fluid bags are simple strategies that would decrease overall waste production.

Optimising Complex Surgical Trays Based on PDSA Cycles

Objective

To investigate the application of a multidisciplinary collaboration model to optimise the configuration management of orthopaedic external device sets in general hospitals.

Methods

A pretest-post-test study design was used. Sixty patients who underwent unilateral total knee arthroplasty and 60 patients who underwent posterior lumbar interbody fusion between March and May 2022 were recruited as the control stage. Additionally, a total of 120 patients, 60 of each, who underwent the two procedures between September and November 2022, were recruited as the experimental stage. For the control stage, conventional external equipment management was used, and for the experimental stage, an external device management programme was implemented based on multidisciplinary collaboration with the control stage. Based on the PDSA cycle, the configuration management of orthopaedic external device sets was optimised, and the differences in collating and counting external devices, nurses' overtime in the external device stage and orthopaedic surgeon satisfaction were compared between the two stages.

Results

Compared with the control stage, the collation count took less time (8.65 ± 0.25 min vs 5.37 ± 0.13 min; 13.55 ± 1.10 min vs 7.85 ± 0.82 min), the number of overtime hours was shorter (175.80 ± 12.19 min vs 96.68 ± 13.66 min) and orthopaedic surgeon satisfaction was improved (4.58 ± 0.62 vs 4.10 ± 0.68; 4.33 ± 0.73 vs 3.87 ± 0.77; 4.20 ± 0.71 vs 3.82 ± 0.71; 4.12 ± 0.69 vs 3.87 ± 0.72; 4.05 ± 0.68 vs 3.79 ± 0.68) in the experimental stage (all P < 0.05).

Conclusion

Multidisciplinary collaboration offers various benefits for optimising the configuration of external device sets, such as reducing the time taken for the preoperative sorting and counting of external devices, enhancing nurses' work efficiency and improving surgeons' job satisfaction; therefore, it is worthy of reference in clinical practice.

Stakeholder perspectives on scaling up medical device reprocessing: A qualitative study

BACKGROUND

The United States health care sector is one of the largest polluting industries, which has significant adverse effects on human health. Medical device reprocessing (MDR) is a sustainability solution that has the potential to decrease hospital waste, cut carbon emissions, reduce spending, and improve supply chain resiliency; however, only a small proportion of FDA-approved devices are actually reprocessed. Thus, we conducted a qualitative study to understand barriers and facilitators of scaling up MDR.

METHODS AND FINDINGS

We conducted in-depth interviews with 17 stakeholders (exceeding thematic saturation) at a large academic health system in New England and national MDR organizations. We also collected observations through site visits at the health system. We recruited participants from June 2021 to April 2022 through purposive sampling. Using an analytic approach guided by the Consolidated Framework for Implementation Research, we applied inductive and deductive codes related to key implementation constructs. We then conducted a thematic analysis and identified five overarching themes related to barriers and facilitators of MDR. First, respondents explained that regulatory bodies and original equipment manufacturers determine which devices can be reprocessed. For example, some respondents described that original equipment manufacturers use tactics of forced obsolescence that prevent their devices from being reprocessed. Second, respondents explained that MDR has variable compatibility with hospital priorities; for example, the potential cost savings of MDR is compatible with their priorities, while the perception of decreased functionality of reprocessed medical devices is incompatible. Third, respondents described that physician preferences influence which reprocessed devices get ordered. Fourth, respondents explained that variable staff knowledge and beliefs about MDR influence their motivations to select and collect reprocessable devices. Lastly, respondents emphasized that there was a lack of infrastructure for evaluating and maintaining MDR programs within their health system.

CONCLUSIONS

Based on our findings, we have outlined a number of recommendations that target these barriers and facilitators so that the environmental and financial benefits of MDR can be realized at this health system and nationally. For example, implementing federal policies that prevent original equipment manufacturers from using tactics of forced obsolescence can facilitate the scale-up of MDR nationally. Additionally, providing life cycle assessments that compare the environmental effects of single-use disposable, reprocessable disposable, and reusable devices could facilitate health systems' purchasing decisions. Creating and disseminating audit and feedback reports to hospital staff might also facilitate their continued engagement in the program. Lastly, hiring a full-time program manager that leads MDR programs within health systems could improve program sustainability.

Waste Management and the Perspective of a Green Hospital-A Systematic Narrative Review

The concept of a "green hospital" is used in reference to a hospital that includes the environment as part of its quality services and one that pays attention to the sustainable design of buildings. Waste disposal represents a potential risk for the environment; therefore, waste collection from healthcare centers is a key environmental issue. Our study aims to systematically review the experiences acquired in worldwide nosocomial settings related to the management of healthcare waste. Nineteen studies, selected between January 2020 and April 2022 on Scopus, MEDLINE/PubMed and Web of Science databases were included in our systematic narrative review. Operating room and hemodialysis activities seem to be the procedures most associated with waste production. To deal with waste production, the 5Rs rule (reduce, reuse, recycle, rethink and research) was a common suggested strategy to derive the maximum practical benefit while generating the minimum amount of waste. In this context, the COVID-19 pandemic slowed down the greening process of nosocomial environments. Waste management requires a multifactorial approach to deal with medical waste management, even considering the climate change that the world is experiencing. Education of health personnel and managers, regulation by governmental institutions, creation of an "environmental greening team", and awareness of stakeholders and policymakers are some of the measures needed for the greening of healthcare facilities.

The environmental impact of health care for musculoskeletal conditions: A scoping review

BACKGROUND

Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions.

METHODS

We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed.

RESULTS

Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1).

CONCLUSION

Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.