The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems

Needs Assessment for the Development of a Sustainability Curriculum for Surgical Residents

INTRODUCTION

The healthcare sector accounts for 8.5% of United States (U.S.) greenhouse gas emissions, of which one-third comes from operating rooms (ORs). As a result, there is great interest in decarbonizing the OR and surgical care. However, surgical residents are not routinely educated on the negative environmental impact of surgery or how to reduce it. In this paper, we present a formal needs assessment for a sustainability curriculum geared towards surgical residents.

METHODS

Using Kern's Six-Step Framework for curriculum development, we conducted focus groups with surgical residents to perform a targeted needs assessment on 3 main topics: 1) the current state of surgical sustainability curricula; 2) resident knowledge regarding the environmental impact of surgery and barriers to sustainable practice; and 3) preferred educational methods and topics within sustainability education. We audio-recorded all focus groups and performed thematic analysis using anonymized transcripts.

RESULTS

Fourteen residents participated in 3 focus groups, from which a qualitative analysis revealed 4 themes. First, surgery residents receive limited formal teaching on the negative environmental impact of surgical care or how to reduce this impact. Second, surgery residents have variable levels of prior education about and interest in sustainability in surgery. Third, several barriers prevent the implementation of sustainable changes in surgical practice, including a lack of institutional initiative, cultural inertia, concerns about workflow efficiency, and limited formal education. Finally, residents prefer to learn about practical ways to reduce waste, specifically through interactive approaches such as quality improvement initiatives.

CONCLUSIONS

Given the increasing importance of sustainability in surgery, there is an urgent need for formal resident education on this topic. This needs assessment provides a valuable foundation for future sustainability curriculum development.

Sustainable practices in hospital and operating theaters

PURPOSE OF REVIEW

This review aims to provide an update on the results of studies published in the last two years involving the development of sustainable practices in hospital and operating theaters (OT).

RECENT FINDINGS

Recently, many studies evaluated various initiatives to better understand the environmental impact of the OT but also to minimize its environmental impact. Many trials evidenced the positive impact of the instrument's reuse using an appropriate reprocessing procedure. Better waste segregation is associated with a reduction of produced waste and contributes to a significant reduction in CO 2 equivalent emissions. Regarding anaesthetic gas, Desflurane is known to have the worst environmental impact and the majority of the study evidenced that its reduction permits to drastically reduce greenhouse gas emission of the OT.

SUMMARY

Greening the OT necessitates climate-smart actions such as waste reduction, the improvement of reusable instruments, recycling of our waste and better anaesthetic gas management. Within the last two years, many efforts have been made to reduce and better segregate waste produced in the OT and also to better understand the environmental impact of disposable and reusable devices.

Anaesthesia and climate change: time to wake up? A rapid qualitative appraisal exploring the views of anaesthetic practitioners regarding the transition to TIVA and the reduction of desflurane

BACKGROUND

The National Health Service (NHS) has pledged to reach carbon net-zero by 2040. In alignment with this goal, a London hospital's anaesthesia department is actively reducing desflurane use and transitioning towards total intravenous anaesthesia (TIVA) as a sustainable alternative, contributing to environmentally responsible practices within the healthcare sector.

METHODS

We conducted a rapid qualitative appraisal through online interviews with 17 anaesthetic practitioners to explore their perspectives regarding this climate change mitigation strategy. Data analysis was undertaken through the use of rapid appraisal sheets and a framework analysis method.

RESULTS

Participants highlighted the disadvantages of TIVA, including the increased effort, heightened monitoring requirements, operational challenges, and a lack of clinical confidence associated with its use. Despite these reservations, participants acknowledged TIVA's potential to reduce postoperative nausea. There were perceptions that senior staff members might resist this change due to habits and scepticism over its impact on climate change. To facilitate greater TIVA adoption, participants recommended enhanced training, the implementation of a dashboard to raise awareness of greenhouse gas (GHG) emissions, and the presence of strong climate change leadership within the department. Participants believed that a shift to TIVA should be followed by specific measures such as addressing waste management which is crucial for GHG reduction, emphasising the perceived link between waste and emissions.

CONCLUSIONS

The evaluation examines stakeholder attitudes, perceptions, and behaviours, focusing on transitioning from desflurane to TIVA. The study highlights the importance of staff engagement, organisational support, and underscores the crucial role that healthcare practitioners and leadership play in fostering sustainability within the healthcare sector.

Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice

BACKGROUND

Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery.

METHODS

A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics.

RESULTS

We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery.

CONCLUSION

This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

Perspectives on sustainability among surgeons: findings from the SAGES-EAES sustainability in surgical practice task force survey

BACKGROUND

Surgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability.

METHODS

Our survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts.

RESULTS

We received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes.

CONCLUSION

Surgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons' attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice.

Review of sustainable practices for the gynecology operating room

PURPOSE OF REVIEW

Climate change has immediate impacts on women's health. Hospitals and operating rooms are large contributors to greenhouse gas (GHG) emissions and waste. This article will review current green initiatives designed to minimize environmental impact in the operating room and highlight areas for future improvement.

RECENT FINDINGS

From a materials perspective, reusable goods result in less GHG emissions while being just as efficacious, well tolerated, and easy to use. Materials should be opened judiciously, only as necessary. Processing regulated medical waste produces greater GHG emissions, so waste should be properly sorted, and items which are not biohazard waste should be processed separately. Choosing appropriate anesthesia and utilizing an 'off' setting, in which operating rooms are shut down when not in use, can also drastically decrease the environmental impact of surgery. Further research is needed to determine effective implementation in hospitals.

SUMMARY

This article summarizes current attempts to make operating rooms more sustainable. Many practices result in a decreased carbon footprint and cost savings without adversely affecting patient outcomes. Gynecologic surgeons and the hospitals in which they practice need to focus on implementing these changes in a timely fashion.

Sustainable orthopaedic surgery: Initiatives to improve our environmental, social and economic impact

In response to appeals from the WHO and The Lancet, a collaborative statement from over 200 medical journals was published in September 2021, advising international governments to combat the "catastrophic harm to health" from climate change. Healthcare, specifically surgery, constitutes a major contributor to environmental harm that remains unaddressed. This article provides practical guidance that can be instituted at a departmental, hospital and national level to institute transformative, sustainable efforts into practice. We also aim to provoke healthcare leaders to discuss policy-making with respect to this issue and highlight the necessity for sustainability to become a core domain of quality improvement. The average orthopaedic service produces 60% more waste than any other surgical specialty. Fortunately, simple measures such as a comprehensive education programme can decrease waste disposal costs by 20-fold. Other simple and effective "green" measures include integrating carbon literacy into surgical training, prioritising regional anaesthesia and conducting recycling audits. Furthermore, industry must take accountability and be incentivised to limit the use of single-item packaging and single-use items. National policymakers should consider the benefits of reusable implants, reusable surgical drapes and refurbishing crutches as these are proven cost and climate-effective interventions. It is crucial to establish a local sustainability committee to maintain these interventions and to bridge the gap between clinicians, industry and policymakers.

Balancing patient needs with environmental impacts for best practices in general anesthesia: Narrative review and clinical perspective

Discussions of the environmental impacts of general anesthetics have focused on greenhouse gas (GHG) emissions from inhaled agents, with those of total intravenous anesthesia (TIVA) recently coming to the forefront. Clinical experts are calling for the expansion of research toward life cycle assessment (LCA) to comprehensively study the impact of general anesthetics. We provide an overview of proposed environmental risks, including direct GHG emissions from inhaled anesthetics and non-GHG impacts and indirect GHG emissions from propofol. A practical description of LCA methodology is also provided, as well as how it applies to the study of general anesthesia. We describe available LCA studies comparing the environmental impacts of a lower carbon footprint inhaled anesthetic, sevoflurane, to TIVA/propofol and discuss their life cycle steps: manufacturing, transport, clinical use, and disposal. Significant hotspots of GHG emission were identified as the manufacturing and disposal of sevoflurane and use (attributed to the manufacture of the required syringes and syringe pumps) for propofol. However, the focus of these studies was solely on GHG emissions, excluding other environmental impacts of wasted propofol, such as water/soil toxicity. Other LCA gaps included a lack of comprehensive GHG emission estimates related to the manufacturing of TIVA plastic components, high-temperature incineration of propofol, and gas capture technologies for inhaled anesthetics. Considering that scarce LCA evidence does not allow for a definite conclusion to be drawn regarding the overall environmental impacts of sevoflurane and TIVA, we conclude that current anesthetic practice involving these agents should focus on patient needs and established best practices as more LCA research is accumulated.

Carbon footprint of tonsillectomy

BACKGROUND AND PURPOSE

Healthcare is responsible for 5.4% of greenhouse gas emissions in the UK. Emissions in surgery is a relatively unexplored area; in particular, this hasn't yet been looked at as a whole in ENT in the UK. The purpose of the study was to quantify the amount of greenhouse gas (GHG) emission from a tonsillectomy and assess the proportion of each source's contribution.

METHODS

Operational data from tonsillectomies performed at a large university teaching hospital in the UK were gathered and converted to global warming potential using established conversion factors and data from existing healthcare-focused carbon footprint studies. The domains considered were waste, pharmaceuticals, surgical instrument decontamination, transportation, consumables use and utilities. This study used a process-based carbon footprint approach based on the "Greenhouse Gas Protocol: Product Life Cycle Accounting and Reporting Standard".

MAIN FINDINGS

The carbon footprint of a typical case was 41 kgCO2e which is equivalent to driving a car for approximately 150 miles. Consumables were responsible for 17% of this; 14% came from transport, 5.4% from decontamination, 4.8% from pharmaceuticals and 4% from waste. However, the largest GHG was from utilities, of which heating, ventilation and air conditioning was the overwhelming contributor.

CONCLUSIONS

While the largest sources of GHG emissions require hospital-wide initiatives, there are aspects of consumables and waste streams we can improve on in ENT surgery. These include the use of disposable vs reusable instruments as well as increased availability and use of recycling waste streams in theatres. Additionally, this study provides a template that can be applied to other ENT procedures.

Interventions to Reduce Surgical Waste Burden: A Systematic Review

Background

Operating suites are significant drivers of waste, pollution, and costs. Surgeons can help fight the climate crisis by implementing innovative strategies aimed at mitigating the environmental impact of surgical procedures and decreasing operational costs, and moving toward a more sustainable healthcare system. This study aims to review the literature describing interventions that reduce surgical waste.

Methods

PubMed, Cochrane, and Embase were searched. Studies reporting interventions to reduce operative waste, including emissions, energy, trash, and other, were included. Case reports, opinion-based reports, reviews, and meta-analyses were excluded. Study quality was rated using MINORS and Jadad scales. Data were extracted from each study to calculate waste on a per case basis. Narrative review of studies was performed rather than meta-analysis.

Results

The search yielded 675 unique hits, of which 13 (level of evidence: I-III) met inclusion criteria. Included studies were categorized by intervention type in relation to the operating and procedure room. Three studies evaluated provider education initiatives, three evaluated setup of instruments, two evaluated single-use items, four evaluated technique changes, and one evaluated surgical venue. Seven studies reported significant reductions in disposable surgical waste throughput, and seven reported significant reductions in cost.

Conclusions

The results of this systemic review demonstrated the effectiveness of surgical waste reduction initiatives in reducing waste volume, cost, and carbon emissions. Within plastic surgery, minimal surgical packs resulted in reduced gross waste and cost while promoting patient satisfaction in hand surgery, supporting the continued development and implementation of such initiatives in a surgical context.

Air quality of health facilities in Spain

The present study examines indoor air pollution in health facilities, focusing on compounds from various sources, such as industrial products, healthcare activities and building materials. It assesses chemical and microbiological concentrations in two public hospitals, two public healthcare centres, and one public health laboratory in Spain. Measurements included indoor air quality, microbiological contaminants, ambient parameters and non-target analysis across ten different locations. Outdoor air quality was also assessed in the surroundings of the hospitals. The results showed that around 350 substances were tentatively identified at a high confidence level, with over 50 % of compounds classified as of high toxicological risk. Three indoor and 26 outdoor compounds were fully confirmed with standards. These confirmed substances were linked to medical, industrial and agricultural activities. Indoor Air Quality (IAQ) results revealed that CO, CO2, formaldehyde (HCHO), O3 and total volatile organic compounds (TVOCs) showed average values above the recommended guideline levels in at least one of the evaluated locations. Moreover, maximum concentrations detected for CO, HCHO, O3 and TVOCs in hospitals surpassed those previously reported in the literature. SARS-CoV-2 was detected in three air environments, corresponding to COVID-19 patient areas. Fungi and bacteria concentrations were acceptable in all assessed locations, identifying different fungi genera, such as Penicillium, Cladosporium, Aspergillus, Alternaria and Botrytis.

The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department

The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.

Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative

STUDY OBJECTIVE

To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF.

DESIGN

Prospective, single-center cohort study set in a greening initiative.

SETTING

Operating room.

PARTICIPANTS

157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists).

INTERVENTIONS

Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data.

MEASUREMENTS

The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data.

MAIN RESULTS

Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059).

CONCLUSIONS

This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

Environmental impact of anesthetic drugs

PURPOSE OF REVIEW

The environmental impact of anesthesia far exceeds that of other medical specialties due to our use of inhaled anesthetic agents (which are potent greenhouse gases) and many intravenous medications.

RECENT FINDINGS

Calls for reducing the carbon footprint of anesthesia are ubiquitous in the anesthesia societies of developed nations and are appearing in proposed changes for hospital accreditation and funding in the United States. The body of research on atmospheric, land and water impacts of anesthetic pharmaceuticals is growing and generally reinforces existing recommendations to reduce the greenhouse gas emissions of anesthesia care.

SUMMARY

The environmental impact of anesthesia care should factor into our clinical decisions. The onus is on clinicians to safely care for our patients in ways that contribute the least harm to the environment. Intravenous anesthesia and regional techniques have less environmental impact than the use of inhaled agents; efforts to reduce and properly dispose of pharmaceutical waste are central to reducing environmental burden; desflurane should not be used; nitrous oxide should be avoided except where clinically necessary; central nitrous pipelines should be abandoned; low fresh gas flows should be utilized whenever inhaled agents are used.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study

BACKGROUND

Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste.

OBJECTIVE

This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries.

STUDY DESIGN

This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital.

RESULTS

A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01).

CONCLUSION

Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Canadian Association of Radiologists Statement on Environmental Sustainability in Medical Imaging

Immediate and strategic action is needed to improve environmental sustainability and reduce the detrimental effects of climate change. Climate change is already adversely affecting the health of Canadians related to worsening air pollution and wildfire smoke, increasing frequency and intensity of extreme weather events, and expansion of vector-borne and infectious illnesses. On one hand, radiology contributes to the climate crisis by generating greenhouse gas emissions and waste during the production, manufacture, transportation, and use of medical imaging equipment and supplies. On the other hand, radiology departments are also susceptible to equipment and infrastructure damage from flooding, extreme temperatures, and power failures, as well as workforce shortages due to injury and illness, potentially disrupting radiology services and increasing costs. The Canadian Association of Radiologists' (CAR) advocacy for environmentally sustainable radiology in Canada encompasses both minimizing the detrimental effects that delivery of radiology services has on the environment and optimizing the resilience of radiology departments to increasing health needs and changing patterns of disease on imaging related to climate change. This statement provides specific recommendations and pathways to help guide radiologists, medical imaging leadership teams, industry partners, governments, and other key stakeholders to transition to environmentally sustainable, net-zero, and climate-resilient radiology organizations. Specific consideration is given to unique aspects of medical imaging in Canada. Finally, environmentally sustainable radiology programs, policies, and achievements in Canada are highlighted.

Clinician and health service interventions to reduce the greenhouse gas emissions generated by healthcare: a systematic review

OBJECTIVE

To synthesise the available evidence on the effects of interventions designed to improve the delivery of healthcare that reduces the greenhouse gas (GHG) emissions of healthcare.

DESIGN

Systematic review and structured synthesis.

SEARCH SOURCES

Cochrane Central Register of Controlled Trials, PubMed, Web of Science and Embase from inception to 3 May 2023.

SELECTION CRITERIA

Randomised, quasi-randomised and non-randomised controlled trials, interrupted time series and controlled or uncontrolled before-after studies that assessed interventions primarily designed to improve the delivery of healthcare that reduces the GHG emissions of healthcare initiated by clinicians or healthcare services within any setting.

MAIN OUTCOME MEASURES

Primary outcome was GHG emissions. Secondary outcomes were financial costs, effectiveness, harms, patient-relevant outcomes, engagement and acceptability.

DATA COLLECTION AND ANALYSIS

Paired authors independently selected studies for inclusion, extracted data, and assessed risk of bias using a modified checklist for observational studies and the certainty of the evidence using Grades of Recommendation, Assessment, Development and Evaluation. Data could not be pooled because of clinical and methodological heterogeneity, so we synthesised results in a structured summary of intervention effects with vote counting based on direction of effect.

RESULTS

21 observational studies were included. Interventions targeted delivery of anaesthesia (12 of 21), waste/recycling (5 of 21), unnecessary test requests (3 of 21) and energy (1 of 21). The primary intervention type was clinician education. Most (20 of 21) studies were judged at unclear or high risk of bias for at least one criterion. Most studies reported effect estimates favouring the intervention (GHG emissions 17 of 18, costs 13 of 15, effectiveness 18 of 20, harms 1 of 1 and staff acceptability 1 of 1 studies), but the evidence is very uncertain for all outcomes (downgraded predominantly for observational study design and risk of bias). No studies reported patient-relevant outcomes other than death or engagement with the intervention.

CONCLUSIONS

Interventions designed to improve the delivery of healthcare that reduces GHG emissions may reduce GHG emissions and costs, reduce anaesthesia use, waste and unnecessary testing, be acceptable to staff and have little to no effect on energy use or unintended harms, but the evidence is very uncertain. Rigorous studies that measure GHG emissions using gold-standard life cycle assessment are needed as well as studies in more diverse areas of healthcare. It is also important that future interventions to reduce GHG emissions evaluate the effect on beneficial and harmful patient outcomes.

PROSPERO REGISTRATION NUMBER

CRD42022309428.

The surgical outpatient clinic and the environment

Rising global temperatures will have a radical impact on the environment where global warming is associated with weather extremes such as thunderstorms and droughts which can affect the regional ecosystems. The healthcare sector is a major emitter of greenhouse gasses. Within healthcare, the outpatient clinic is responsible for a considerable sum of emissions. These can be organized under scopes 1, 2 and 3 as described in the Greenhouse Gas Protocol where scope 1 accounts for direct emissions from healthcare facilities, scope 2 is emissions from purchased electricity and scope 3 is indirect emissions including procurement and waste. Emissions and mitigation strategies from the surgical outpatient clinic are outlined under each scope of the Greenhouse Gas Protocol. These include using insulation materials, renovating or building new facilities, incorporating renewable energy sources and utilizing more efficient appliances. Telehealth and virtual clinics have been shown to be an effective method of delivering care while avoiding the combustion of fossil fuels to facilitate patient transport. In addition, virtual set-ups are cost effective and have not been proven to compromise patient safety when implemented correctly.

Handling 'carbon footprint' in orthopaedics

INTRODUCTION

The National Health Service contributes 4%-5% of England and Wales' greenhouse gases and a quarter of all public sector waste. Between 20% and 33% of healthcare waste originates from a hospital's operating room, and up to 90% of waste is sent for costly and unneeded hazardous waste processing. The goal of this study was to quantify the amount and type of waste produced during a selection of common trauma and elective orthopaedic operations, and to calculate the carbon footprint of processing the waste.

METHODS

Waste generated for both elective and trauma procedures was separated primarily into clean and contaminated, paper or plastic, and then weighed. The annual carbon footprint for each operation at each site was subsequently calculated.

RESULTS

Elective procedures can generate up to 16.5kg of plastic waste per procedure. Practices such as double-draping the patient contribute to increasing the quantity of waste. Over the procedures analysed, the mean total plastic waste at the hospital sites varied from 6 to 12kg. One hospital site undertook a pilot of switching disposable gowns for reusable ones with a subsequent reduction of 66% in the carbon footprint and a cost saving of £13,483.89.

CONCLUSIONS

This study sheds new light on the environmental impact of waste produced during trauma and elective orthopaedic procedures. Mitigating the environmental impact of the operating room requires a collective drive for a culture change to sustainability and social responsibility. Each clinician can have an impact upon the carbon footprint of their operating theatre.

A Life Cycle Assessment of Reusable and Disposable Surgical Caps

INTRODUCTION

Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps.

METHODS

ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts.

RESULTS

Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing.

CONCLUSIONS

Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.

The role of planetary health in urologic oncology

INTRODUCTION

Climate change and global warming are an omnipresent topic in our daily lives. Planetary health and oncology represent two critical domains within the broader spectrum of healthcare, each addressing distinct yet interconnected aspects of human well-being. We are encouraged to do our part in saving our planet. This should include the decisions we make in our professional life, especially in uro-oncology, as the healthcare sector significantly contributes to environmental pollution.

AREAS COVERED

There are many aspects that can be addressed in the healthcare sector in general, as there are structural problems in terms of energy consumption, water waste, therapeutic techniques, transportation and drug manufacturing, as well as in uro-oncology specific areas. For example, the use of different surgical techniques, forms of anesthesia and the use of disposable or reusable instruments, each has a different impact on our environment. The literature search was carried out using PubMed, a medical database.

EXPERT OPINION

We are used to making decisions based on the best outcome for patients without considering the impact that each decision can have on the environment. In the present article, we outline options and choices for a more climate-friendly approach in urologic oncology.

Green Hospital as a new Standard in Japan: How far can Neurosurgery go in Japan?

BACKGROUND

Climate change is a significant challenge that the medical community must address. Hospitals are large facilities with high water and energy consumption, as well as high levels of waste generation, which makes it important to pursue green hospital initiatives. Neurosurgery requires substantial energy for surgeries and tests.

METHODS

Based on the keywords "Climate change," "green hospital," "neurosurgery," "energy consumption," "environmental impact" listed in this paper, we extracted representative manuscripts, and the practices employed in the authors' hospital were assessed.

RESULTS

The "Guidelines for Environmental Consideration in Hospitals" and "Guidelines for the Sustainability of Hospital Environments" have been developed; however, they are not implemented in most hospitals in Japan. Inhalational anesthetics were found to contribute significantly to greenhouse gas emissions. Educating patients and staff and employing the "8 Rs" (rethink, refuse, reduce, reuse, recycle, research, renovation, and revolution) showed promise in achieving green hospital standards.

CONCLUSIONS

The advent of 'green hospitals' in Japan is imminent. The active participation of neurosurgeons can play a crucial role in diminishing the environmental footprint of health care while simultaneously enhancing medical standards. Given the pressing challenges posed by climate change, there is a critical need for an overhaul of medical practices. It is imperative for neurosurgeons to pioneer the adoption of new, sustainable medical methodologies.

Fostering innovation and sustainable thinking in surgery: an evaluation of a surgical hackathon

INTRODUCTION

Surgery represents a major source of carbon emissions, with numerous initiatives promoting more sustainable practices. Healthcare innovation and the development of a digitally capable workforce are fundamental in leveraging technologies to tackle challenges, including sustainability in surgery.

METHODS

A surgical hackathon was organised with three major themes: (1) how to make surgery greener, (2) the future of plastic surgery in 10 years, and (3) improving healthcare outcomes using machine learning. Lectures were given on sustainability and innovation using the problem, innovation, market size, strategy and team (PIMST) framework to support their presentations, as well as technological support to translate ideas into simulations or minimum viable products. Pre- and post-event questionnaires were circulated to participants.

RESULTS

Most attendees were medical students (65%), although doctors and engineers were also present. There was a significant increase in delegates' confidence in approaching innovation in surgery (+20%, p < 0.001). Reducing waste packaging (70%), promoting recyclable material usage (56%) and the social media dimension of public perceptions towards plastic surgery (40%) were reported as the most important issues arising from the hackathon. The top three prizes went to initiatives promoting an artificial intelligence-enhanced operative pathway, instrument sterilisation and an educational platform to teach students research and innovation skills.

CONCLUSIONS

Surgical hackathons can result in significant improvements in confidence in approaching innovation, as well as raising awareness of important healthcare challenges. Future innovation events may build on this to continue to empower the future workforce to leverage technologies to tackle healthcare challenges such as sustainability.

Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery

Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.

What Is the Carbon Footprint of Adult Spinal Deformity Surgery?

Background/Objectives: While the economic cost of adult spinal deformity (ASD) surgery has been studied extensively, its environmental impact is unknown. The aim of this study is to determine the carbon footprint (CF) associated with ASD surgery. Methods: ASD patients who underwent > four levels of corrective surgery between 2017 and 2021 were included. The open group included a posterior-only, single-stage technique, while the minimally invasive surgery (MIS) group was defined as the use of lateral interbody fusion and percutaneous posterior screw fixation. The two groups were propensity-score matched to adjust for baseline demographic, surgical, and radiographic characteristics. Data on all disposables and reusable instruments, anesthetic gas, and non-gas medications used during surgery were collected from medical records. The CF of transporting, using, and disposing of each product and the footprint of energy use in operating rooms were calculated. The CF produced was evaluated using the carbon dioxide equivalent (CO2e), which is relative to the amount of CO2 with an equivalent global warming potential. Results: Of the 175 eligible patients, 15 pairs (65 ± 9 years, 47% female) were properly matched and analyzed for all variables. The average CF generated per case was 147.7 ± 37.3 kg-CO2e, of which 54% was attributable to energy used to sterilize reusable instruments, followed by anesthetic gas released into the environment (17%) and operating room air conditioning (15%). Conclusions: The CF generated during ASD surgery should be reduced using a multidisciplinary approach, taking into account that different surgical procedures have different impacts on carbon emission sources.

Greener intravitreal injections: a narrative review

Healthcare services are significant contributors to climate change. Ophthalmology, by virtue of the volume of appointments and procedures it generates, is thought to play a major role in this regard. Intravitreal injections (IVI) are a commonly performed ophthalmological procedure to treat patients with conditions such as macular neovascularisation secondary to neovascular age-related macular disease or myopia, diabetic macular oedema, and retinal vein occlusions. As IVIs become more ubiquitous, addressing their environmental impact and sustainability will become increasingly important. Strategies to tackle carbon emissions from IVIs may target the following areas which align with the Greenhouse Gas Protocol scopes: building energy; water consumption; travel to appointments; manufacture and procurement of the drug and other necessary materials; and waste disposal. We propose a path towards a more sustainable approach for IVIs, and discuss its potential safety as well as the patient experience.

Assessing the Environmental and Downstream Human Health Impacts of Decentralizing Cancer Care

Importance

Greenhouse gas (GHG) emissions from health care are substantial and disproportionately harm persons with cancer. Emissions from a central component of oncology care, outpatient clinician visits, are not well described, nor are the reductions in emissions and human harms that could be obtained through decentralizing this aspect of cancer care (ie, telemedicine and local clinician care when possible).

Objective

To assess potential reductions in GHG emissions and downstream health harms associated with telemedicine and fully decentralized cancer care.

Design, Setting, and Participants

This population-based cohort study and counterfactual analyses using life cycle assessment methods analyzed persons receiving cancer care at Dana-Farber Cancer Institute between May 2015 and December 2020 as well as persons diagnosed with cancer over the same period from the Cancer in North America (CiNA) public dataset. Data were analyzed from October 2023 to April 2024.

Main Outcomes and Measures

The adjusted per-visit day difference in GHG emissions in kilograms of carbon dioxide (CO2) equivalents between 2 periods: an in-person care model period (May 2015 to February 2020; preperiod) and a telemedicine period (March to December 2020; postperiod), and the annual decrease in disability-adjusted life-years in a counterfactual model where care during the preperiod was maximally decentralized nationwide.

Results

Of 123 890 included patients, 73 988 (59.7%) were female, and the median (IQR) age at first diagnosis was 59 (48-68) years. Patients were seen over 1.6 million visit days. In mixed-effects log-linear regression, the mean absolute reduction in per-visit day CO2 equivalent emissions between the preperiod and postperiod was 36.4 kg (95% CI, 36.2-36.6), a reduction of 81.3% (95% CI, 80.8-81.7) compared with the baseline model. In a counterfactual decentralized care model of the preperiod, there was a relative emissions reduction of 33.1% (95% CI, 32.9-33.3). When demographically matched to 10.3 million persons in the CiNA dataset, decentralized care would have reduced national emissions by 75.3 million kg of CO2 equivalents annually; this corresponded to an estimated annual reduction of 15.0 to 47.7 disability-adjusted life-years.

Conclusions and Relevance

This cohort study found that using decentralization through telemedicine and local care may substantially reduce cancer care's GHG emissions; this corresponds to small reductions in human mortality.

Teleconsultation for Preoperative Anesthesia Evaluation: Identifying Environmental Potentials by Life Cycle Assessment

Introduction: Teleconsultations for preoperative evaluation in anesthesiology proved to be feasible during the COVID-19 pandemic. However, widespread implementation of teleconsultations has not yet occurred. Besides time savings and economic benefits, teleconsultations in anesthesia may have the potential to reduce CO2 emissions. Methods: We conducted a life cycle assessment based on prospective surveys to assess the potential environmental benefits of preoperative anesthesia teleconsultations in comparison to the status-quo in-person consultations. Within 1 month, all patients presenting at the preoperative anesthesia clinic at RWTH Aachen University Hospital were asked about the distance traveled and mode of transportation to the hospital. The main outcome measure was the potential environmental benefit resulting from the implementation of teleconsultations. Results: In total, 821 out of 981 patients presenting at the anesthesia clinic participated in the survey. Most patients visited on an outpatient basis (62.9%) and traveled by car (81.7%). The median travel distance was 25 km [interquartile range 12-40]. If patients who came to the hospital solely for the anesthesia appointment had scheduled virtual appointments, the emissions of 3.03-ton CO2 equivalents (CO2-eq) could be avoided in the first month after implementation. The environmental impact associated with the production of teleconsultation equipment is outweighed by the reduction in patient travel. If all outpatient appointments were performed virtually, these savings would triple. Within 10 years, more than 1,300 tons CO2-eq could be avoided. Conclusion: Teleconsultations can mitigate the environmental impact of in-person anesthesia consultations. Further research is essential to leverage teleconsultations for preoperative evaluation also across other medical specialties.

Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis

Background

General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia.

Methods

In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492).

Findings

We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients).

Interpretation

The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery.

Funding

Dutch Society for Anaesthesiology (NVA).

The impact of radical prostatectomy on global climate: a prospective multicentre study comparing laparoscopic versus robotic surgery

BACKGROUND

More than 4% of the global greenhouse gas emissions are generated by healthcare system. Focusing on the environmental impact of minimally invasive surgery, we assessed and compared the CO2 emissions between Robot-assisted (RALP) and Laparoscopic Radical Prostatectomy (LRP).

METHODS

In patients prospectively enrolled, we evaluated the age, surgical and anesthesiologic time, postoperative intensive care unit and hospital stay, blood transfusion, pre- and postoperative hemoglobin and Gleason score, open conversion need, and complications (Clavien-Dindo classification). We assessed the life cycle to estimate the energy consumption for surgical procedures and hospital stays. We reported the materials, CO2 produced, and fluid quantity infused and dispersed. Disposable and reusable materials and instruments were weighed and divided into metal, plastic, and composite fibers. The CO2 consumption for disposal and decontamination was also evaluated.

RESULTS

Of the 223 patients investigated, 119 and 104 patients underwent RALP and LRP, respectively. The two groups were comparable as regards age and preoperative Gleason score. The laparoscopic and robotic instruments weighed 1733 g and 1737 g, respectively. The CO2 emissions due to instrumentation were higher in the laparoscopic group, with the majority coming from plastic and composite fiber components. The CO2 emissions for metal components were higher in the robotic group. The robot functioned at 3.5 kW/h, producing 4 kg/h of CO2. The laparoscopic column operated at 600 W/h, emitting ~1 kg/h of CO2. The operating room operated at 3,0 kW/h. The operating time was longer in the laparoscopic group, resulting in higher CO2 emissions. CO2 emissions from hospital room energy consumption were lower in the robot-assisted group. The total CO2 emissions were ~47 kg and ~60 kg per procedure in the robot-assisted and laparoscopic groups, respectively.

CONCLUSIONS

RALP generates substantially less CO2 than LRP owing to the use of more reusable surgical supplies, shorter operative time and hospital stay.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Survey of anesthesia department chairs about the environmental sustainability initiatives of their programs

BACKGROUND

Anesthesia departments can reduce their environmental impact. Barriers exist to the promotion of individual anesthesiologists' roles in environmentally sustainable practices. We hypothesized that accountability of departmental leadership is associated with reports of practices that can encourage and sustain environmentally favorable practices.

METHODS

Invitations to complete a six-question survey were sent to academic anesthesia department chairs in the United States and Canada. Questions were presented in random sequence. We assessed the association between the sum of the answers to five questions about department- and hospital-related sustainability activities (e.g., more than one "educational session dedicated to environmental sustainability … for anesthesiology residents or other trainees?") and the sixth question ("In the past 12 months, did review of the anesthesia department chair or review of your department include" more than one "item related to promotion of environmental sustainability?").

RESULTS

Of the 138 departments receiving invitation and reminder emails, 63 departments (46%) responded to our requests. The median (interquartile range) was 1 (0,3) sustainability activity for "No" items evaluating the department chair or department (N = 43) versus 4 (2, 4.5) activities for "Yes" evaluation of department chair or department (N = 20) (Wilcoxon-Mann-Whitney test, P = 0.0021; median regression, P = 0.0002). Results were similar for sensitivity analyses (excluding one question about hospital leadership, excluding the four responding Canadian departments, controlling for time to complete the survey, and controlling for the date of completion of the survey).

CONCLUSIONS

Anesthesia department chairs and departments with annual performance evaluations that included items related to environmental sustainability reported more activities to promote sustainability. The result suggests that leadership-sponsored initiatives directed toward environmental sustainability are associated with environmental sustainability activities in anesthesia departments.

Cardiovascular Imaging, Climate Change, and Environmental Sustainability

Environmental exposures including poor air quality and extreme temperatures are exacerbated by climate change and are associated with adverse cardiovascular outcomes. Concomitantly, the delivery of health care generates substantial atmospheric greenhouse gas (GHG) emissions contributing to the climate crisis. Therefore, cardiac imaging teams must be aware not only of the adverse cardiovascular health effects of climate change, but also the downstream environmental ramifications of cardiovascular imaging. The purpose of this review is to highlight the impact of climate change on cardiovascular health, discuss the environmental impact of cardiovascular imaging, and describe opportunities to improve environmental sustainability of cardiac MRI, cardiac CT, echocardiography, cardiac nuclear imaging, and invasive cardiovascular imaging. Overarching strategies to improve environmental sustainability in cardiovascular imaging include prioritizing imaging tests with lower GHG emissions when more than one test is appropriate, reducing low-value imaging, and turning equipment off when not in use. Modality-specific opportunities include focused MRI protocols and low-field-strength applications, iodine contrast media recycling programs in cardiac CT, judicious use of US-enhancing agents in echocardiography, improved radiopharmaceutical procurement and waste management in nuclear cardiology, and use of reusable supplies in interventional suites. Finally, future directions and research are highlighted, including life cycle assessments over the lifespan of cardiac imaging equipment and the impact of artificial intelligence tools. Keywords: Heart, Safety, Sustainability, Cardiovascular Imaging Supplemental material is available for this article. © RSNA, 2024.

Effect of unidirectional airflow ventilation on surgical site infection in cardiac surgery: environmental impact as a factor in the choice for turbulent mixed air flow

BACKGROUND

Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF).

AIM

To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF.

METHODS

This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used.

FINDINGS

Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4-1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA.

CONCLUSION

Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to high electricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgery can diminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

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.

Healthcare sustainability in cardiothoracic surgery

BACKGROUND

Climate change is the greatest threat to human health. Cardiothoracic patients suffer direct consequences from poor environmental health and we have a vested interest to address this in our practice. As leaders of complex high-end surgery, we are uniquely positioned to effect practical and immediate changes to significantly pare down emissions within the operating theatre, outside the operating theatre and beyond the confines of the hospital.

METHODS

We aim to spotlight this pressing issue, take stock of our current efforts, and encourage fellow specialists to drive this agenda.

RESULTS

Sustainability in healthcare needs to be formalized as part of the core curriculum in surgical training and awareness generated via carbon audits and life cycle analyses. Practical actions such as reducing unnecessary equipment usage, choosing reusable equipment over single use disposables, judicious use of investigations rooted in clinical reasoning and sharing of resources across services and health systems help reduce the carbon output of our specialty.

CONCLUSION

The 'Triple Bottom Line' serves as a good template to calibrate efforts that balance quality against environmental costs. More can be done to advocate for and find solutions for sustainable healthcare with cardiothoracic surgery.

Average total weight of surgical waste and CO2 carbon footprint of orthopedic surgery in France, estimated on the basis of a representative panel

BACKGROUND

Reduction of waste and carbon footprint can be optimized. Awareness of carbon sources and quantification of the waste are two key parameters. To our knowledge, there is no study in France on waste production by the surgical team during the operation in orthopedic surgery, in a global scope. Therefore, we performed an observational investigation aiming to: (1) quantify and characterize the weight of the wastes generated after a panel of orthopedic procedures, (2) calculate the CO2 footprint generated by these wastes and extrapolate the figure at the national scale.

HYPOTHESIS

Waste production is highly variable according to the types of procedures and infectious clinical waste is still a predominant source of waste and CO2 emission.

MATERIALS AND METHODS

It is a comparative and prospective study in which a total of 14 procedures were selected as a representative panel: arthroplasties (hip, knee), spine fusions, arthroscopic procedures (shoulder, knee), nerve release, forefoot osteotomies, trauma procedures. The main outcome was the average total weight of waste for each of the fourteen categories (280 measurements: 140 times 2, at the end of each procedure), expressed in kilograms (kg), and the proportions of infectious clinical waste (ICW) and household wastes (HW), expressed in percentages. Ten measures were prospectively recorded for each type of procedure in a single teaching hospital from January to September 2022. The theoretical carbon footprint generated by the treatment of the wastes was estimated in kilograms of CO2 equivalent (KgEqCO2). The national extrapolation of the carbon footprint was performed by collecting the total number of procedures in France in 2021 using the VisuChir tool.

RESULTS

A total of 937kg of waste were produced for the 140 procedures, amongst which 514kg of ICW (54.8%) and 423kg of HW (45.2%). The overall median waste weight was 5.9kg (Q1: 4.4, Q3: 8.1), ranging from 1.8kg to 18.3kg. The overall median waste weight for HW was 2.8kg (Q1: 2.5, Q3: 3.4), ranging from 1.8kg to 17.8kg. The overall median waste weight for ICW was 3.8kg (Q1: 2.7, Q3: 4.8), ranging from 0.8kg to 7.2kg. The knee surgeries were responsible for the heaviest waste weight; the least waste-productive procedures were the foot and the carpal tunnel release. The median proportions of ICW varied from 39% for the total knee replacements to 72% for the femoral nails. There was a significant inverse correlation between the total waste weight and the proportion of ICW: r=-0.47, p<10-4. The total median estimated carbon footprint was 4.3KgCO2Eq (Q1: 3.1, Q3: 5.8), ranging from 1.59KgCO2Eq (Q1: 1.5, Q3: 1.8) and 7.07KgCO2Eq (Q1: 6.7, Q3: 8.17). The total median estimated carbon footprint was 3.5KgCO2Eq for ICW (Q1: 2.5, Q3: 4.5) and 0.76KgCO2Eq (Q1: 0.54, Q3: 1.3) for HW. The national median estimated carbon footprint was 10.1 million KgEqCO2 in 2021 for orthopedic surgery.

CONCLUSION

Our study revealed that in most cases more than half of the wastes were ICW. The total estimated national carbon footprint for orthopedic procedures was 10 million kilograms. The reduction of the ICW constitutes a cornerstone, as they are responsible for more carbon emissions.

LEVEL OF EVIDENCE

III; prospective comparative observational in vivo study.

Carbon footprint of a laser unit: a study of two centres in the UK

PURPOSE

Climate change has serious consequences for our wellbeing. Healthcare systems themselves contribute significantly to our total carbon footprint, of which emissions from surgical practice are a major component. The primary sources of emissions identified are anaesthetic gases, disposal of single-use equipment, energy usage, and travel to and from clinical areas. We sought to quantify the waste generated by laser surgery which, to our knowledge, has not been previously reported.

METHODS

The carbon footprint of two laser centres operating within the United Kingdom were measured. The internationally recognised Greenhouse Gas Protocol was used as a guiding framework to classify sources of waste and conversion factors issued by the UK government were used to quantify emissions.

RESULTS

The total carbon footprints per day at each unit were 299.181 carbon dioxide equivalents (kgCo2eq) and 121.512 kgCO2eq, respectively. We found the carbon footprint of individual laser treatments to be approximately 15 kgCO2eq per procedure. The biggest overall contributor to the carbon footprint was found to be the emissions generated from staff, patient and visitor travel. This was followed by electricity usage, and indirect emissions from physical waste and laundry.

CONCLUSIONS

The carbon footprint of laser procedures was considerably less than the average surgical operation in the UK. This initial study measures the carbon footprint of a laser center in a clinical setting and allows us to identify where improvements can be made to eventually achieve a net carbon zero health care system.

Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022.

REVIEW METHODS

Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed.

RESULTS

The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases.

CONCLUSION

The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

What is the effect of reducing the air change rate on the ventilation effectiveness in ultra-clean operating rooms?

BACKGROUND

The operating room (OR) department is one of the most energy-intensive departments of a hospital. The majority of ORs in the Netherlands have an air-handling installation with an ultra-clean ventilation system. However, not all surgeries require an ultra-clean OR.

AIM

To determine the effect of reducing the air change rate on the ventilation effectiveness in ultra-clean ORs.

METHODS

Lower air volume ventilation effectiveness (VELv) of conventional ventilation (CV), controlled dilution ventilation (cDV), temperature-controlled airflow (TcAF) and unidirectional airflow (UDAF) systems were evaluated within a 4 × 4 m measuring grid of 1 × 1 m. The VELv was defined as the recovery degree (RD), cleanliness recovery rate (CRR) and air change effectiveness (ACE).

FINDINGS

The CV, cDVLv and TcAFLv ventilation systems showed a comparable mixing character in all areas (A, B and AB) when reducing the air change rate to 20/h. Ventilation effectiveness decreased when the air change rate was reduced, with the exception of the ACE. At all points for the UDAF-2Lv and at the centre point (C3) of the TcAFLv, higher RD10Lv and CRRLv were measured when compared with the other examined ventilation systems.

CONCLUSIONS

The ventilation effectiveness decreased when an ultra-clean OR with an ultra-clean ventilation air-supply system was switched to an air change rate of 20/h. Reducing the air change rate in the OR from an ultra-clean OR to a generic OR will reduce the recovery degree (RD10) by a factor of 10-100 and the local air change rate (CRR) by between 42% and 81%.

The role of the health sector in tackling climate change: A narrative review

Climate change is one of the largest threats to population health and has already affected the ecosystem, food production, and health and wellbeing of populations all over the world. The healthcare sector is responsible for around 5 % of greenhouse gas emissions worldwide and can play a key role in reducing global warming. This narrative review summarized the information on the role of healthcare systems in addressing climate change and strategies for reducing its negative impact to illustrate different types of actions that can support the ecological transformation of healthcare systems to help reaching sustainable development goals. A wide range of green interventions are shown to be effective to reduce the carbon footprint of healthcare and can have a meaningful impact if implemented systematically. However, these would not suffice unless accompanied by systemic mitigation strategies altering how healthcare is provided and consumed. Sustainable healthcare strategies such as reducing waste and low-value care will have direct benefits for the environment while improving economic and health outcomes. The healthcare sector has a unique opportunity to leverage its position and resources to provide a comprehensive strategy for fighting climate change and improving population health and the environment on which it depends.

Global warming impact of fluorinated gases in ophthalmic surgeries at a tertiary eye center in India

PURPOSE

Global warming is one of the greatest health threats of the 21 st century. The ophthalmic sector contributes to the emission of greenhouse gases, thus altering the natural environment. There is currently no data on global emissions of fluorinated gases in ophthalmic surgery. This retrospective study from 2017 to 2021 aims to report the carbon dioxide (CO 2 ) equivalence of sulfur hexafluoride (SF 6 ), hexafluoroethane (C 2 F 6 ), and octafluoropropane (C 3 F 8 ) at a tertiary eye center.

METHODS

Data collected from 1842 surgical procedures that used injections of fluorinated gases were analyzed. Environmental impact (global warming potential over 100 years) was calculated by converting milliliters to grams by using modified ideal gas law at standard temperature and pressure for the canisters and then to their CO 2 equivalence.

RESULTS

Though 70% of surgeries used C 3 F 8 , the least greenhouse effect causing fluorinated gas, the total carbon emission was 1.4 metric tons. The most common indication was macular hole surgery (36.86%).

CONCLUSION

This study paves a step toward analyzing the problem statement, thus awakening us to contemplate options to make ophthalmic surgeries greener.

Establishing and Defining an Approach to Climate Conscious Clinical Medical Ethics

An anthropocentric scope for clinical medical ethics (CME) has largely separated this area of bioethics from environmental concerns. In this article, we first identify and reconcile the ethical issues imposed on CME by climate change including the dispersion of related causes and effects, the transdisciplinary and transhuman nature of climate change, and the historic divorce of CME from the environment. We then establish how several moral theories undergirding modern CME, such as virtue ethics, feminist ethics, and several theories of justice, promote both a flourishing of human medical practice and the environment. We conclude by defining an expanded the scope of CME as inclusive of not only patients, families, physicians, and other health professionals but other humans, non-humans, and their shared environment. We then apply this scope and theory to a widely used framework for applying CME, the Four Topics model, to construct a climate conscious approach to CME.

Climate change and human health: Last call to arms for us

Climate change, now the foremost global health hazard, poses multifaceted challenges to human health. This editorial elucidates the extensive impact of climate change on health, emphasising the increasing burden of diseases and the exacerbation of health disparities. It highlights the critical role of the healthcare sector, particularly anaesthesia, in both contributing to and mitigating climate change. It is a call to action for the medical community to recognise and respond to the health challenges posed by climate change.

Environmental sustainability and gynaecological surgery: Which factors influence behaviour? An interview study

OBJECTIVE

To assess the various factors that influence environmentally sustainable behaviour in gynaecological surgery and examine the differences between gynaecologists and residents.

DESIGN

An interview study.

SETTING

Academic and non-academic hospitals in the Netherlands.

POPULATION

Gynaecologists (n = 10) and residents (n = 6).

METHODS

Thematic analysis of semi-structured interviews to determine the various factors that influence environmentally sustainable behaviour in gynaecological surgery and to examine the differences between gynaecologists and residents. By using the Desmond framework and the COM-B BCW, both organisational and individual factors related to behaviour were considered.

MAIN OUTCOME MEASURES

Factors that influence environmentally sustainable behaviour.

RESULTS

Awareness is increasing but practical knowledge is insufficient. It is crucial to integrate education on the environmental impact of everyday decisions for residents and gynaecologists. Gynaecologists make their own choices but residents' autonomy is limited. There is the necessity to provide environmentally sustainable surgical equipment without compromising other standards. There is a need for a societal change that encourages safe and open communication about environmental sustainability. To transition to environmentally sustainable practices, leadership, time, collaboration with the industry and supportive regulatory changes are essential.

CONCLUSION

This study lays the groundwork for promoting more environmentally sustainable behaviour in gynaecological surgery. The key recommendations, addressing hospital regulations, leadership, policy revisions, collaboration with the industry, guideline development and education, offer practical steps towards a more sustainable healthcare system. Encouraging environmentally sustainable practices should be embraced to enhance the well-being of both our planet and our population, driving us closer to a more environmentally sustainable future in healthcare.