A review of single-use and reusable gowns and drapes in health care

A narrative review of personal protective equipment gowns: lessons from COVID-19

This narrative review evaluates the evidence regarding the protection offered by isolation gowns, approaches to imparting antimicrobial activity to gowns, and the environmental impacts of gown use, particularly during the COVID-19 pandemic. We conducted a search of the Medline, PubMed, and Google Scholar databases for articles published between January 1, 2019 to February 20, 2024. We found that current standards pertaining to isolation gowns might be irrelevant to the protection of healthcare workers from pathogen transmission, as they focus primarily on fluid barrier resistance values that are not reflective of all transmission conditions in hospitals. Although most available isolation gowns are disposable, reusable gowns could offer greater barrier protection and are more environmentally sustainable. Several techniques have been studied for their ability to impart antimicrobial properties to isolation gowns, extending their lifespan and reducing environmental impacts. However, evidence of the effectiveness of such techniques in clinical settings is scarce. We advocate for standardised guidelines inclusive of common pathogen survival tests, comfort, and durability, which reflect the actual infection risks encountered by healthcare workers, to improve the safety and efficacy of isolation gowns in hospital settings. Further research into the clinical effectiveness of antimicrobial gowns and their long-term implications on the environment is also warranted.

Reprocessing capabilities of newly approved devices for use in surgery

INTRODUCTION

Single-use medical devices used in surgery can create environmental waste and increased costs. Reprocessed medical devices may reduce cost and environmental impact. This study investigated the reprocessing capabilities of newly FDA-approved devices in surgery.

METHODS

Devices were identified using the publicly-available FDA Releasable 510(k) Database from 2018 to 2023 using the instrument product codes for laparoscope, general, and plastic surgery (GCJ); and electrosurgical (GEI) devices. GCJ and GEI devices were categorized based on usage, and the number of devices (total, single, and reprocessed) were extracted. Costs were obtained from public websites.

RESULTS

There were 658,510(k) applications for surgical devices, representing 3.8 % (658/16723) of total applications. Reprocessing capabilities existed for 29 % of GCJ devices and 14 % of GEI devices. Among GCJ devices, 5 (56 %) laparoscopy and 16 (38 %) camera devices had reprocessing capabilities. For GEI devices, 7 (50 %) laparoscopic and 5 (50 %) cable devices had reprocessing capabilities. Only one (6 %) tissue ablation device had reprocessing capabilities. The average cost of GCJ and GEI single-use devices ($11314; $8554, respectively) was less than reprocessed counterparts ($17206; $16134, respectively).

CONCLUSION

Reprocessing capabilities for newly approved surgical devices are variable and overall limited. To enhance adoption of reprocessing in surgical practice, future efforts will likely be needed to expand the reprocessing potential of new surgical devices.

Sterile gown and drape, and bouffant cap for thyroid FNA: preventing infections or producing unnecessary medical waste?

PURPOSE

Ultrasound-guided fine needle aspiration (FNA) is a very low-risk procedure. Despite this, there remains great variability in the use of protective equipment. Given the monetary and environmental costs of protective equipment, the difference in infection rates with full versus limited protective equipment was assessed.

METHODS

A total of 857 consecutive patients were retrospectively reviewed after undergoing thyroid FNAs at the main hospital and outpatient clinic site performed from 12/1/2020 to 11/30/2023. The hospital site operated with full protective equipment (bouffant, sterile gown, sterile gloves, and full body sterile drape), and the outpatient site with limited (sterile gloves, limited sterile paper drape) protective equipment. Two patients were excluded as no procedure was performed. Review for signs of infection within 30 days of procedure was performed using medical records, which was blinded to the extent of protective equipment utilization.

RESULTS

No infections were identified in either group, with 0/629 (0%, 95%CI 0-1%) in the full protective equipment group vs. 0/226 (0%, 95%CI 0-2%) in the limited protective equipment group. There was no statistically significant difference in infection rate between full and limited protective equipment use in thyroid FNA in the included 855 procedures (95%CI 0-1%). Two patients out of 629 (0.3%) in the full protective equipment group developed mild allergic reaction to topical antiseptic. The 226 procedures with limited protective equipment represent a saving of at least 204,530 g of CO2 equivalents, equivalent to driving a car for almost 3000 miles.

CONCLUSION

Reducing the extent of protective equipment does not adversely affect the infection rate in thyroid FNAs. Given the inherent costs involved in the procurement and waste of protective equipment, reducing protective equipment use is warranted to reduce both the monetary and environmental impacts of waste.

UK national survey on surgical gowning for tonsillectomy

OBJECTIVE

Tonsillectomy is a common procedure performed nationally. The personal protective equipment and surgical gowning practices used during this procedure vary widely. We compiled a survey of ENT specialists to gain a national opinion about gowning in tonsillectomy with the aim of determining whether we could make it more environmentally friendly whilst maintaining the highest safety standards.

METHOD

We developed a nine-question survey that was piloted prior to final implementation. The questionnaire was sent to senior registrars and consultant otolaryngologists in the UK.

RESULTS

The survey was completed by a total of 63 ENT specialists. It was found that 82.54 per cent of clinicians would consider wearing a reusable gown that would be sterilised between each procedure.

CONCLUSION

Our survey suggests most ENT clinicians would consider using a more environmentally friendly surgical gown and some may even consider wearing no gown at all, although many are understandably concerned about the transmission of infection or blood splatter.

Does reusable mean green? Comparison of the environmental impact of reusable operating room bed covers and lift sheets versus single-use

INTRODUCTION

As hospitals strive to reduce their environmental footprint, there is an ongoing debate over the environmental implications of reusable versus disposable linens in operating rooms (ORs). This research aimed to compare the environmental impact of reusable versus single-use OR bed covers and lift sheets using life cycle assessment (LCA) methodology.

METHODS

LCA is an established tool with rigorous methodology that uses science-based processes to measure environmental impact. This study compared the impacts of three independent system scenarios at a single large academic hospital: reusable bed covers with 50 laundry cycles and subsequent landfill disposal (System 1), single-use bed covers with waste landfill disposal (System 2), and single-use bed covers with waste disposal using incineration (System 3).

RESULTS

The total carbon footprint of System 1 for 50 uses was 19.83 ​kg carbon dioxide equivalents (CO2-eq). System 2 generated 64.99 ​kg CO2-eq. For System 3, the total carbon footprint was 108.98 ​kg CO2-eq. The raw material extraction for all the material to produce an equivalent 50 single-use OR bed cover kits was tenfold more carbon-intensive than the reusable bed cover. Laundering one reusable OR bed cover 50 times was more carbon intensive (12.12 ​kg CO2-eq) than landfill disposal of 50 single-use OR bed covers (2.52 ​kg CO2-eq).

DISCUSSION

Our analysis demonstrates that one reusable fabric-based OR bed cover laundered 50 times, despite the carbon and water-intensive laundering process, exhibits a markedly lower carbon footprint than its single-use counterparts. The net difference is 45.16 ​kg CO2-eq, equivalent to driving 115 miles in an average gasoline-powered passenger vehicle. This stark contrast underscores the efficacy of adopting reusable solutions to mitigate environmental impact within healthcare facilities.

Reuse of Orthopaedic Equipment: Barriers and Opportunities

» Reuse of orthopaedic equipment is one of many potential ways to minimize the negative impact of used equipment on the environment, rising healthcare costs and disparities in access to surgical care.» Barriers to widespread adoption of reuse include concerns for patient safety, exposure to unknown liability risks, negative public perceptions, and logistical barriers such as limited availability of infrastructure and quality control metrics.» Some low- and middle-income countries have existing models of equipment reuse that can be adapted through reverse innovation to high-income countries such as the United States.» Further research should be conducted to examine the safety and efficacy of reusing various orthopaedic equipment, so that standardized guidelines for reuse can be established.

Carbon Footprint of Minor Foot and Ankle Surgery: A Randomized Controlled Trial

Background

Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol.

Methods

Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated.

Results

On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group.

Conclusion

We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions.

Level of Evidence

Level I, randomized controlled trial.

Radiology Department: A Potential Source of Multidrug-Resistant Microorganisms: A Cross-Sectional Study at Tertiary Hospital, Palestine

Introduction

Globally, healthcare facilities face a great challenge in the form of hospital-acquired infections (HAIs). Aside from the morbidity and mortality they cause, these illnesses are also extremely costly. Research on infection transmission in the medical field has been considerable, but not so much in the radiology department.

Aim

This study aims to identify the presence of multidrug-resistant (MDR) microbes on surfaces that are frequently touched in computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), plain X-ray examination rooms, and portable radiography that are susceptible to contamination as well as to investigate the potential dangers of contracting MDR organisms to patients and healthcare providers. Materials and Method. In this study, 160 swab samples were collected from the radiology department during May and June 2022. Samples were obtained from 80 predefined surfaces twice within and outside of CT and MRI examination rooms as well as from US and plain X-ray machines and portable X-ray machines. Samples were taken at 7:00 a.m. using cotton swabs following the regular cleaning procedure. Bacterial colony-forming units (CFUs) per square centimeter were calculated after swabbing a 100 cm2 surface.

Results

Nearly all of the surfaces tested had bacterial CFUs. The highest contamination rate was found on keyboards ranging from (1.2-8) CFU/cm2, the sides of patient tables (1.2-20) CFU/cm2, knee coil (2.4-3) CFU/cm2, and patient leg supports (1.2-8) CFU/cm2. A noticeable increase in the contamination was noticed in June compared to May, and this was consistent with the increase in the number of isolated patients in the hospital, the workload in the radiology department, and the number of patients referred to the hospital. In our study, none of the examined sites showed contamination with MDR Gram-negative bacteria such as extended-spectrum beta-lactamases producing Enterobacterales (ESPL) or Carbapenemase-producing Enterobacterales (CPE). On the other hand, methicillin-resistant Staphylococcus (MRS), vancomycin-resistant Staphylococcus (VRS), and vancomycin-resistant Enterococcus (VRE) were detected.

Conclusion

All of the radiology department equipment and sites could be a source of bacterial infection including MDR, so the obligatory and committed disinfection protocol must be revised and implemented in the morning and between patients.

Infection Prevention, Planetary Health, and Single-Use Plastics

Authors of this Viewpoint present actionable steps for regulatory, industry, and health care organization practices to accelerate reduction of single-use plastics and help protect planetary and human health.

How Ophthalmologists Can Decarbonize Eye Care: A Review of Existing Sustainability Strategies and Steps Ophthalmologists Can Take

TOPIC

Understanding approaches to sustainability in cataract surgery and their risks and benefits.

CLINICAL RELEVANCE

In the United States, health care is responsible for approximately 8.5% of greenhouse gas (GHG), and cataract surgery is one of the most commonly performed surgical procedures. Ophthalmologists can contribute to reducing GHG emissions, which lead to a steadily increasing list of health concerns ranging from trauma to food instability.

METHODS

We conducted a literature review to identify the benefits and risks of sustainability interventions. We then organized these interventions into a decision tree for use by individual surgeons.

RESULTS

Identified sustainability interventions fall into the domains of advocacy and education, pharmaceuticals, process, and supplies and waste. Existing literature shows certain interventions may be safe, cost-effective, and environmentally friendly. These include dispensing medications at home to patients after surgery, multi-dosing appropriate medications, training staff to properly sort medical waste, reducing the number of supplies used during surgery, and implementing immediate sequential bilateral cataract surgery where clinically appropriate. The literature was lacking on the benefits or risks for some interventions, such as switching specific single-use supplies to reusables or implementing a hub-and-spoke-style operating room setup. Many of the advocacy and education interventions have inadequate literature specific to ophthalmology but are likely to have minimal risks.

CONCLUSIONS

Ophthalmologists can engage in a variety of safe and effective approaches to reduce or eliminate dangerous GHG emissions associated with cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Research progress in preparation, properties, and applications of medical protective fiber materials

A variety of public health events seriously threaten human life and health, especially the outbreak of COVID-19 at the end of 2019 has caused a serious impact on human production and life. Wearing personal protective equipment (PPE) is one of the most effective ways to prevent infection and stop the spread of the virus. Medical protective fiber materials have become the first choice for PPE because of their excellent barrier properties and breathability. In this article, we systematically review the latest progress in preparation technologies, properties, and applications of medical protective fiber materials. We first summarize the technological characteristics of different fiber preparation methods and compare their advantages and disadvantages. Then the barrier properties, comfort, and mechanical properties of the medical protective fiber materials used in PPE are discussed. After that, the applications of medical protective fibers in PPE are introduced, and protective clothing and masks are discussed in detail. Finally, the current status, future development trend, and existing challenges of medical protective fiber materials are summarized.

Novel Designed Surgical Drapes Reducing Fluid Permeability in the Surgical Critical Area of a Sterile Operation Interface: A Randomized Controlled Trial

Aim. To compare the impact and cost effects of medical long fiber polyester drapes and cotton fabric drapes on operative sterile operation interfaces. Background. The comparison of the properties of the commonly used surgical drapes materials in terms of leakage, device slip, and prevention of intraoperative adverse events is not clear. Method. A prospective randomized controlled study was conducted in the operating room of a tertiary hospital in Chengdu, China. A total of 400 patients who underwent urology surgery were enrolled and randomly divided into two groups by computer, the study group (200 cases) selected the new long-fiber polyester cloth, while the control group (200 cases) selected conventional cotton fabric surgical drapes during the operation to maintain a sterile operating interface. The impermeability and water absorption of surgical drapes, the rate of device slip and skin scald in surgical patients, and the cost effect of the two kinds of surgical drapes were compared. Results. The long fiber polyester surgical drapes were superior to conventional cotton cloth in water absorption (g/m2) (835 ± 15.8 VS 225 ± 21.0, t = 328.261, $P<0.001$ ), preventing surgical site infections (2.5% VS 8.0%, χ2 = 6.081, $P=0.014$ ), device slip (7.5% VS 17.0%, χ2 = 8.396, $P=0.004$ ), patients from burning (0 VS 1, Fisher $P=1.0$ ), and total cost per use ($) (0.83 VS 0.96–1.09). Conclusion. Long fiber polyester fabric has a stronger antipenetration ability of fluid and microorganisms thus forming an effective protective barrier. It also has strong hygroscopicity, and its special design can prevent the occurrence of sliding of surface instruments and skin scald in patients. In addition, its cost effect is superior. Implications for Nursing Management. Operating room nursing managers can introduce long fiber polyester drapes into the selection of medical textiles to construct aseptic surgical barriers and prevent surgical site infection.

Implementation of an Environmental Cleaning Protocol in Hospital Critical Areas Using a UV-C Disinfection Robot

Improving the cleaning and disinfection of high-touch surfaces is one of the core components of reducing healthcare-associated infections. The effectiveness of an enhanced protocol applying UV-C irradiation for terminal room disinfection between two successive patients was evaluated. Twenty high-touch surfaces in different critical areas were sampled according to ISO 14698-1, both immediately pre- and post-cleaning and disinfection standard operating protocol (SOP) and after UV-C disinfection (160 sampling sites in each condition, 480 in total). Dosimeters were applied at the sites to assess the dose emitted. A total of 64.3% (103/160) of the sampling sites tested after SOP were positive, whereas only 17.5% (28/160) were positive after UV-C. According to the national hygienic standards for health-care setting, 9.3% (15/160) resulted in being non-compliant after SOP and only 1.2% (2/160) were non-compliant after UV-C disinfection. Operation theaters was the setting that resulted in being less compliant with the standard limit (≤15 colony-forming unit/24 cm2) after SOP (12%, 14/120 sampling sites) and where the UV-C treatment showed the highest effectiveness (1.6%, 2/120). The addition of UV-C disinfection to the standard cleaning and disinfection procedure had effective results in reducing hygiene failures.

The Role and Duty of Global Surgery in Increasing Sustainability and Improving Patient Care in Low and Middle-Income Countries

Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energy-intensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts. Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces 'informal recycling' schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from high-income countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.

Guidelines for clothing in the operating theatre, 2021

OBJECTIVE

To provide guidelines for the choice of items of clothing (except sterile surgical gown) for staff working in the operating theatre.

DESIGN

A committee of nine experts from SFAR and the SF2H learned societies was convened. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The authors were required to follow the rules of the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: operating theatre suits, operating theatre hats, masks, and shoes/over-shoes. Each question was formulated according to the PICO format (Patient, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 13 recommendations. As the GRADE® method could not be integrally applied to all questions, some recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we produced 13 recommendations to guide the choice of operating theatre attire.

Discordance among Belief, Practice, and the Literature in Infection Prevention in the NICU

This study evaluates practices of infection control in the NICU as compared with the available literature. We aimed to assess providers’ awareness of their institutional policies, how strongly they believed in those policies, the correlation between institution size and policies adopted, years of experience and belief in a policy’s efficacy, and methods employed in the existing literature. An IRB-approved survey was distributed to members of the AAP Neonatal Section. A systematic review of the literature provided the domains of the survey questions. Data was analyzed as appropriate. A total of 364 providers responded. While larger NICUs were more likely to have policies, their providers are less likely to know them. When a policy is in place and it is known, providers believe in the effectiveness of that policy suggesting consensus or, at its worst, groupthink. Ultimately, practice across the US is non-uniform and policies are not always consistent with best available literature. The strength of available literature is adequate enough to provide grade B recommendations in many aspects of infection prevention. A more standardized approach to infection prevention in the NICU would be beneficial and is needed.

Environmental Impacts of Personal Protective Clothing Used to Combat COVID- 19

Personal protective clothing is critical to shield users from highly infectious diseases including COVID-19. Such clothing is predominantly single-use, made of plastic-based synthetic fibers such as polypropylene and polyester, low cost and able to provide protection against pathogens. However, the environmental impacts of synthetic fiber-based clothing are significant and well-documented. Despite growing environmental concerns with single-use plastic-based protective clothing, the recent COVID-19 pandemic has seen a significant increase in their use, which could result in a further surge of oceanic plastic pollution, adding to the mass of plastic waste that already threatens marine life. In this review, the nature of the raw materials involved in the production of such clothing, as well as manufacturing techniques and the personal protective equipment supply chain are briefly discussed. The environmental impacts at critical points in the protective clothing value chain are identified from production to consumption, focusing on water use, chemical pollution, CO2 emissions, and waste. On the basis of these environmental impacts, the need for fundamental changes in the business model is outlined, including increased usage of reusable protective clothing, addressing supply chain "bottlenecks", establishing better waste management, and the use of sustainable materials and processes without associated environmental problems.

Advanced materials for personal thermal and moisture management of health care workers wearing PPE

In recent years, the development of personal protective equipment (PPE) for health care workers (HCWs) attracted enormous attention, especially during the pandemic of COVID-19. The semi-permeable protective clothing and the prolonged working hours make the thermal comfort a critical issue for HCWs. Although there are many commercially available personal cooling products for PPE systems, they are either heavy in weight or have limited durability. Besides, most of the existing solutions cannot relieve the perspiration efficiently within the insolation gowns. To avoid heat strain and ensure a longtime thermal comfort, new strategies that provide efficient personal thermal and moisture management without compromising health protection are required. This paper reviews the emerging materials for protective gown layers and advanced technologies for personal thermal and moisture management of PPE systems. These materials and strategies are examined in detail with respect to their fundamental working principles, thermal and mechanical properties, fabrication methods as well as advantages and limitations in their prospective applications, aiming at stimulating creative thinking and multidisciplinary collaboration to improve the thermal comfort of PPEs.

Anesthesia screen use may impact operating room communication practices in otolaryngology

OBJECTIVES

Failures in communication are a leading contributor to medical error. There is increasing attention on cultivating robust communication practices in the Operating Room (OR) to mitigate against patient injury and optimize efficient patient care. Few studies have evaluated how surgical equipment may introduce barriers to team dynamics.

DESIGN

We conducted a pilot observational study to examine the relationship between anesthesia screen drapes (which are used inconsistently) and the frequency of verbal exchanges between surgical and anesthesia members. 25 procedures spanning various procedures in Otolaryngology were covertly observed, 12 of which employed a screen. Verbal exchanges were recorded across three stages of the surgery: pre-procedure (before the draping), procedure (drapes placed throughout) and post-procedure (after the removal of the draping). Speaker and content of the exchange was noted as well as various features about the procedure.

RESULTS

Decreases in rates of exchanges were most pronounced during the procedure stage, although they did not reach significance on T-testing (p = 0.0719). After controlling for attending, table orientation and number of professionals, regression analysis did reveal a statistically significant decrease in rates of verbal exchanges during the procedure in the presence of the anesthesia screen (7.17 (± 6.33) versus 2.23 (± 1.00), p = 0.0318). Differences were also significant among surgeon-initiated and patient-care-related exchanges (p = 0.0168 and p = 0.0432, respectively). Decreases in anesthesiologist-initiated and non-clinical exchanges did not reach significance (p = 0.1530 and p = 0.5120, respectively).

CONCLUSION

This pilot study suggests that anesthesia screens may negatively impact communication practices in the OR.

Effect of opaque eye coverage on anxiety in candidates for surgical removal of impacted third molars: a randomized clinical trial

OBJECTIVE

To assess the effects of opaque eye coverage on anxiety in candidates for surgical removal of impacted third molars.

STUDY DESIGN

This randomized clinical trial was conducted in candidates for surgical extraction of bilateral, vertical, class IC impacted maxillary third molars or bilateral, mesioangular class IC impacted mandibular third molars. Patients with moderate anxiety (dental anxiety scale range, 9-14) were selected. Surgical extraction of the bilateral third molars was performed in 2 separate visits with and without covering the eyes using surgical drapes. Pulse rate (PR), systolic and diastolic blood pressure (BP), and respiratory rate (RR) were measured immediately after surgery. Moreover, after surgery, the patients were asked to rate their dental anxiety on a visual analog scale (VAS) from 0 to 10. The collected data were used for statistical analysis.

RESULTS

Sixty patients with a mean age of 21.31 years participated in the study. PR, systolic BP, RR, and VAS were significantly higher with eye coverage (P < .001). Diastolic BP was not significantly different between the 2 surgical sessions (with or without eye coverage) (P = .157).

CONCLUSION

In patients with moderate dental anxiety, covering the eyes during surgical extraction of third molars may contribute to the increase of dental anxiety.

A Combined Tie-Fastening Method for the Reusable Surgical Gown with Two Neck Tie Belts to Improve Wearing Comfort

The reusable surgical gowns made of slippery materials have the tendency to slip down as they are being worn. The rear neck tie(s) can sometimes loosen, and this causes the surgical gown to slip down somewhat, making the surgical staff members feel uncomfortable. If the gowns have two rear neck ties with a tendency of loosening and allowing the gowns to slip down, the surgical staff members feel more uncomfortable when there is only one tie loosening but the other tie is tethering. To fasten the neck ties of the surgical gown with two neck tie belts, we propose a simplified method of fastening the two sets of tie belts together as one tie, instead of fastening them separately. The object of this study is to evaluate this combined tying method for its ability to secure the gown and its wearing comfort. We enrolled five volunteers to evaluate the tie loosening condition of the reusable surgical gowns with two sets of rear neck tie belts after a series of upper limb motion exercises while wearing and not wearing the X-ray protective apron beneath the gown. The amount of uppermost rear neck cloth edge separation was recorded before and after the exercise. We also evaluated the wearing comfort of five enrolled operating surgeons for comparing the original and this modified tying method while wearing and not wearing the X-ray protective apron. In the results, we found that combined tying tends to have significantly more rear gown separation (0.94 cm) than separate tying (0.27 cm) after vigorous upper extremities exercise. However, during the actual performance of the surgeries, the rear neck tie(s) loosening and wearing discomfort of the combined tying method was significantly less than using the separate tying method (loosening: 0% vs. 30%) (discomfort: 0% vs. 35%) while the X-ray protective apron was not worn. For reusable surgical gowns that have two rear neck ties, we suggest the two sets of rear neck ties could be fastened together as one combined tie in routine surgical practice. With this, tying could be performed easier and faster, and wearing comfort could be improved.

Sustainable Personal Protective Clothing for Healthcare Applications: A Review

Personal protective equipment (PPE) is critical to protect healthcare workers (HCWs) from highly infectious diseases such as COVID-19. However, hospitals have been at risk of running out of the safe and effective PPE including personal protective clothing needed to treat patients with COVID-19, due to unprecedented global demand. In addition, there are only limited manufacturing facilities of such clothing available worldwide, due to a lack of available knowledge about relevant technologies, ineffective supply chains, and stringent regulatory requirements. Therefore, there remains a clear unmet need for coordinating the actions and efforts from scientists, engineers, manufacturers, suppliers, and regulatory bodies to develop and produce safe and effective protective clothing using the technologies that are locally available around the world. In this review, we discuss currently used PPE, their quality, and the associated regulatory standards. We survey the current state-of-the-art antimicrobial functional finishes on fabrics to protect the wearer against viruses and bacteria and provide an overview of protective medical fabric manufacturing techniques, their supply chains, and the environmental impacts of current single-use synthetic fiber-based protective clothing. Finally, we discuss future research directions, which include increasing efficiency, safety, and availability of personal protective clothing worldwide without conferring environmental problems.

Microbial Barrier Properties of Cotton Fabric-Influence of Weave Architecture

The subject of the paper focuses on the effect of weave architecture on microbial barrier properties of woven fabrics or more precisely on identifying crucial elements of weave architecture that dominantly influence bacteria penetration in dry condition. For that purpose, 12 samples of cotton fabrics were woven and examined. In their structure, all samples had the same yarns (36 tex) in warp and weft, same densities of warp (24 yarns/cm), two weft densities (24 and 20 yarns/cm) and six different basic weave structures. Microbial barrier permeability was determined according to a previously developed test method in cooperation with University Hospital Center Zagreb. Bacterial endospores of apathogenic species of the genus Bacillus: Geobacillusstearothermophilus and Bacillus atrophaeus were used. The effect of weave pattern on microbial barrier properties was significant. Weave patterns, decisively determined the number of influencing pores and its sizes in woven fabrics, as well as the yarn floating which jointly almost perfectly correlated with bacteria penetration through the woven fabric. Multiple linear regression of pore numbers and floating threads produced equations which correspond in 99% to the measuring results for densities 24/24 and 24/20, and more than 98% considering both densities of the set. Among compared weave patterns, satin weave had significantly lower permeability of microorganisms (six–seven times) than basket weave (the highest), for both densities.

[Factors associated with the quality of sterilization of surgical drapes at the National Hospital University Hubert Koutoukou Maga of Cotonou]

Introduction

La stérilisation des linges opératoires joue un rôle important dans la prévention des infections associées aux soins. Au Centre National Hospitalier Universitaire Hubert Koutoukou MAGA (CNHU-HKM), le processus de stérilisation des linges rencontre des problèmes. La présente étude avait pour objectif d’étudier les facteurs associés à la qualité de stérilisation du linge opératoire au CNHU-HKM.

Méthodes

Il s’agissait d’une étude transversale, descriptive et analytique qui avait porté sur 20 linges opératoires stérilisés, 41 agents impliqués dans la gestion des linges et 55 membres de l’équipe chirurgicale. La méthode avait été probabiliste pour les linges opératoires stérilisés et non probabiliste pour les autres. Le test de Khi carré de Pearson et la régression logistique ont été utilisés pour rechercher l’association avec un seuil significatif et un p <0,05.

Résultats

Quatre-vingt-six virgule quarante-six pourcent des sujets étaient de sexe masculin avec un âge médian de 42 ans. La qualité du processus de stérilisation du linge opératoire n’était pas bonne dans les deux services en charge de traiter les linges. Le contrôle bactériologique avait montré que sur les 20 linges opératoires stérilisés, 9 portaient Acinetobacter spp. un germe d’infection nosocomiale multi résistant. L’analyse multivariée avait montré que l’expérience professionnelle (p=0,015) et le contrôle de qualité dans le processus de traitement (p=0,034) sont statistiquement associés à la qualité de la stérilisation.

Conclusion

Acinetobacter spp. trouvé sur des linges stérilisés montre que la stérilisation des linges au CNHU-HKM n’est pas de qualité. Un renforcement des compétences des prestataires est nécessaire pour l’amélioration de la qualité du processus de stérilisation.

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery

OBJECTIVE

To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.

DESIGN

Uncontrolled before-and-after study.

SETTING

Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.

PATIENTS

Patients undergoing surgery between January 2016 and April 2018.

INTERVENTION

A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.

RESULTS

Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%-65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31-5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.

CONCLUSIONS

This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.

Biocide Resistance and Transmission of Clostridium difficile Spores Spiked onto Clinical Surfaces from an American Health Care Facility

Clostridium difficile is the primary cause of antibiotic-associated diarrhea globally. In unfavorable environments, the organism produces highly resistant spores which can survive microbicidal insult. Our previous research determined the ability of C. difficile spores to adhere to clinical surfaces, finding that spores had markedly different hydrophobic properties and adherence abilities. Investigation into the effect of the microbicide sodium dichloroisocyanurate on C. difficile spore transmission revealed that sublethal concentrations increased spore adherence without reducing viability. The present study examined the ability of spores to transmit across clinical surfaces and their response to an in-use disinfection concentration of 1,000 ppm of chlorine-releasing agent sodium dichloroisocyanurate. In an effort to understand if these surfaces contribute to nosocomial spore transmission, surgical isolation gowns, hospital-grade stainless steel, and floor vinyl were spiked with 1 × 10⁶ spores/ml of two types of C. difficile spore preparations: crude spores and purified spores. The hydrophobicity of each spore type versus clinical surface was examined via plate transfer assay and scanning electron microscopy. The experiment was repeated, and spiked clinical surfaces were exposed to 1,000 ppm sodium dichloroisocyanurate at the recommended 10-min contact time. Results revealed that the hydrophobicity and structure of clinical surfaces can influence spore transmission and that outer spore surface structures may play a part in spore adhesion. Spores remained viable on clinical surfaces after microbicide exposure at the recommended disinfection concentration, demonstrating ineffectual sporicidal action. This study showed that C. difficile spores can transmit and survive between various clinical surfaces despite appropriate use of microbicides.IMPORTANCE Clostridium difficile is a health care-acquired organism and the causative agent of antibiotic-associated diarrhea. Its spores are implicated in fecal to oral transmission from contaminated surfaces in the health care environment due to their adherent nature. Contaminated surfaces are cleaned using high-strength chemicals to remove and kill the spores; however, despite appropriate infection control measures, there is still high incidence of C. difficile infection in patients in the United States. Our research examined the effect of a high-strength biocide on spores of C. difficile which had been spiked onto a range of clinically relevant surfaces, including isolation gowns, stainless steel, and floor vinyl. This study found that C. difficile spores were able to survive exposure to appropriate concentrations of biocide, highlighting the need to examine the effectiveness of infection control measures to prevent spore transmission and to consider the prevalence of biocide resistance when decontaminating health care surfaces.

Does the type of surgical drape (disposable versus non-disposable) affect the risk of subsequent surgical site infection?

Aims

Determine whether disposable or reusable drapes are better at reducing surgical site infection (SSI) rates.

Methods

A systematic review of the English literature from inception to 2018 with search terms relating to infection and drapes in orthopaedic and spine surgery.

Results

No orthopaedic or spinal surgery studies assessed the risk of SSI between reusable or disposable drapes. However, two articles, with conflicting results, compared current reusable and disposable drapes in other surgical disciplines.

Conclusion

There is no evidence to support a difference between reusable or disposable drapes to reduce the risk of SSI in orthopaedic and spinal surgery.

Break Scrub to Take That Phone Call?

BACKGROUND

The American College of Surgeons reports that 60% of the hundreds of thousands of surgical site infections occurring annually are preventable. The practice of surgeons taking phone calls while remaining sterile in the operating field is often accomplished by interposing a sterile disposable towel between the phone and their glove. After completing the call, surgeons resume operating. The purpose of our study was to test the conceptual idea of whether bacteria transmit from an inanimate object, such as a telephone, to the gloves of a surgeon through a sterile disposable towel.

STUDY DESIGN

Glo Germ (Glo Germ Co), an ultraviolet light-enhanced particle powder sized to mimic bacteria, was placed on an inanimate surface and held with a sterile disposable operating room towel covering a sterile surgical glove. The glove was then inspected for Glo Germ using an ultraviolet light. Additionally, 18 operating room telephones were cultured and then held with a Sterile Disposable OR Towel (Medline Industries Inc) covering a sterile surgical glove. The surgical gloves were then cultured to determine if bacteria had transmitted from the telephone through the towel and onto the sterile glove.

RESULTS

The Glo Germ powder readily transmitted through the towel to the gloves. Median colony-forming units (CFU) on the cultured telephones for the 17 samples was 10, ranging from 1 to 35 CFUs. Of these 17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI 26% to 69%, p < 0.001).

CONCLUSIONS

Sterile disposable operating room towels do not provide an effective barrier between bacteria present on operating room telephones and the otherwise sterile gloves of a surgeon.

Evaluation of gowns and coveralls used by medical personnel working with Ebola patients against simulated bodily fluids using an Elbow Lean Test

Gowns and coveralls are important components of protective ensembles used during the management of known or suspected Ebola patients. In this study, an Elbow Lean Test was used to obtain a visual semi-quantitative measure of the resistance of medical protective garments to the penetration of two bodily fluid simulants. Tests were done on swatches of continuous and discontinuous regions of fabrics cut from five gowns and four coveralls at multiple elbow pressure levels (2-44 PSI). Swatches cut from the continuous regions of one gown and two coveralls did not have any strike-through. For discontinuous regions, only the same gown consistently resisted fluid strike-through. As hypothesized, with the exception of one garment, fluid strike-through increased with higher applied elbow pressure, was higher for lower fluid surface tension, and was higher for the discontinuous regions of the protective garments.

Isolation gowns in health care settings: Laboratory studies, regulations and standards, and potential barriers of gown selection and use

Although they play an important role in infection prevention and control, textile materials and personal protective equipment (PPE) used in health care settings are known to be one of the sources of cross-infection. Gowns are recommended to prevent transmission of infectious diseases in certain settings; however, laboratory and field studies have produced mixed results of their efficacy. PPE used in health care is regulated as either class I (low risk) or class II (intermediate risk) devices in the United States. Many organizations have published guidelines for the use of PPE, including isolation gowns, in health care settings. In addition, the Association for the Advancement of Medical Instrumentation published a guidance document on the selection of gowns and a classification standard on liquid barrier performance for both surgical and isolation gowns. However, there is currently no existing standard specific to isolation gowns that considers not only the barrier resistance but also a wide array of end user desired attributes. As a result, infection preventionists and purchasing agents face several difficulties in the selection process, and end users have limited or no information on the levels of protection provided by isolation gowns. Lack of knowledge about the performance of protective clothing used in health care became more apparent during the 2014 Ebola epidemic. This article reviews laboratory studies, regulations, guidelines and standards pertaining to isolation gowns, characterization problems, and other potential barriers of isolation gown selection and use.

Is non-woven fabric a useful method of packaging instruments for operation theatres in resource constrained settings?

INTRODUCTION

Studies have highlighted the advantages and disadvantages of woven and non-woven fabrics. The present study assessed the change in resterilisation proportion after introduction of non-woven fabric for packaging of instruments and to evaluate the cost-effectiveness of non-woven fabrics compared with woven fabrics.

MATERIALS AND METHODS

The present study is a secondary data analysis of resterilisation data collected from November 2009 to August 2013. We calculated the proportions (and their 95% confidence intervals) of resterilisation done every month. The proportion over time was compared using a Chi-square test for trend. We used linear regression analysis to adjust for the number of surgeries performed every month. We also compared the cost of woven and non-woven fabrics.

RESULTS

Of the total 117,335 surgical packets prepared during the study period, 1900 were resterilised; thus, the overall proportion was 1.62% (95% CI: 1.55% to 1.69%). The resterilisation proportion was 8.95% (95% CI: 7.73% to 10.17%) in November 2009 and was 0.38% (95% CI: 0.16% to 0.62%) in August 2013 (P < 0.001). After adjusting for the total number of surgeries conducted every month, we found that the number of packets resterilised reduced every month (per month reduction: -1.97, 95% CI: -2.76 to -1.18). The total cost (initial preparation and resterilisation) for 100 units of woven fabric is INR 6359.41 per month (confidence limit estimates: 6228.20 to 6430.62) and for non-woven fabric was INR 6208.50 (confidence limit estimate: INR 6194.90 to 6223.35) (P < 0.01).

CONCLUSIONS

The introduction of non-woven spunbond-meltblown-spunbond fabrics did reduce the proportion of resterilisation of packaged instruments. The decline was sharp and sustained over time, even after accounting for the change in the number of procedures. Furthermore, though the switch from woven to non-woven fabric was cost-effective in our situation, it may not be directly translated to other scenarios.

Clinical challenges in isolation care

OVERVIEW

In 2014, the authors published the results of a study investigating nurses' use of personal protective equipment (PPE) in the care of a live simulated patient requiring contact and airborne precautions. The 24 participants were video-recorded as they donned and doffed PPE. Variations in practices that had the potential to cause contamination were noted. In this article, the authors comment on those variations, analyzing each element of proper PPE protocols and examining why the behaviors are a safety concern for the nurse and a potential risk for disease transmission in the hospital or other clinical area. The authors note that making use of reflective practice for complicated care situations such as infection control may help nurses improve decision making in isolation care.

Costs of reusable and disposable aprons in a public teaching hospital

Objective To analyze the direct cost of reusable and disposable aprons in a public teaching hospital. Method Cross-sectional study of quantitative approach, focusing on the direct cost of reusable and disposable aprons at a teaching hospital in northern Paraná. The study population consisted of secondary data collected in reports of the cost of services, laundry, materials and supplies division of the institution for the year 2012 Results We identified a lower average cost of using disposable apron when compared to the reusable apron. The direct cost of reusable apron was R$ 3.06, and the steps of preparation and washing were mainly responsible for the high cost, and disposable apron cost was R$ 0.94. Conclusion The results presented are important for hospital managers properly allocate resources and manage costs in hospitals
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Prevention of surgical site infections

In the current era of pay-for-performance standards, the incidence of surgical site infections is increasingly becoming an institutional marker of quality assurance. Surgical site infections lead to increased morbidity and mortality in the surgical population and contribute to an already rising healthcare cost. As a result, the surgical community goes to great lengths to prevent this costly and occasionally lethal complication. Many practices are evidence based, however, many are not. In this article, the most commonly used preventive strategies in practice today and the evidence behind each are reviewed. In addition, an overview of the epidemiology, pathophysiology and microbiology of surgical site infections will be provided.

Surgical attire, practices and their perception in the prevention of surgical site infection

INTRODUCTION

Clean surgical scrubs, surgical gowns and headgear are worn by operative teams to decrease bacterial contamination and lower surgical site infection (SSI) rates.

METHODS

A detailed review was undertaken of peer-reviewed publications and other sources of material in the English language over the last 50 years included.

RESULTS

Surgical scrubs should be clean and made of tightly woven material. Studies investigating single-use gowns and drapes versus reusable gowns report conflicting evidence. Double gloving may reduce SSI rates in procedures where no antibiotic prophylaxis was administered. Bacterial contamination of the operative field has been shown to be decreased by the wearing of surgical headgear by the operating team.

CONCLUSIONS

Further consideration and better trials are required to determine the impact of different theatre clothing on SSI rates.

Effect of disposable barriers, disinfection, and cleaning on controlling methicillin-resistant Staphylococcus aureus environmental contamination

BACKGROUND

Environmental contamination and transmission of methicillin-resistant Staphylococcus aureus (MRSA) have been reported in dental health care settings. National professional dental associations recommend controlling surface contamination using disposable barriers or disinfection. Because these procedures may be costly, impractical, and/or toxic, we compared their effect against traditional detergent-based cleaning for decontaminating a dental chair sprayed with MRSA.

METHODS

Five MRSA strain suspensions were aerosolized to give a density of approximately 10 colony-forming units/cm(2) MRSA on the dental chair 5 minutes after dispersal. Three different decontamination protocols were applied: protocol 1: disposable barriers positioned before aerosol production and removed after 5 minutes; protocol 2: disinfection (wipe-rinse method) with 1:10 dilution of 5.25% to 6.15% sodium hypochlorite solution; protocol 3: cleaning (wipe-rinse method) with a sodium-lauryl-sulphate-based detergent. Contact plates containing Mannitol Salt Agar were used to assess the level of MRSA contamination.

RESULTS

All 3 protocols decreased MRSA surface load by >99%. Residual densities on the dental chair were 0.030 ± 0.010 (protocol 1), 0.029 ± 0.09 (protocol 2), and 0.030 ± 0.011 (protocol 3) colony-forming units/cm(2).

CONCLUSION

Cleaning (wipe-rinse method) using a sodium-lauryl-sulphate-based detergent demonstrated equivalence with disposable barrier placement or disinfection-based protocol for reducing MRSA contamination on dental chairs. This has practical and cost implications for controlling MRSA transmission in dental health care settings.

Developing antiviral surgical gown using nonwoven fabrics for health care sector

BACKGROUND

Healthcare workers' uniforms including surgical gowns are used as barriers to eliminate the risk of infection for both doctor and patient. The prevalence of human immunodeficiency virus, hepatitis B and C viruses in the patient population is very common.

OBJECTIVES

To develop antiviral surgical gown comprising of Polypropylene nonwoven as outer layer, Polytetrafluroethylene (PTFE) film as middle layer and polyester nonwoven as inner layer and the surgical gown with a basic weight of 70 g/m(2).

METHODS

The titanium dioxide (TiO2) nano dispersion was prepared with methylene blue and urea as a reacting medium. These nano particles have an average size of 9 nm which was revealed by High resolution transmission electron microscope. The nonwoven fabric pore size was characterised by using digital image analyzer. The polypropylene nonwoven fabrics were treated with nano dispersion by pad-dry-cure method and trilaminate fabric was formed using fusing machine. The presence of nano particle on the surface of the non woven fabric was confirmed by Scanning Electron microscope.

RESULTS

The trilaminate surgical gown has passed ASTM 1671 viral penetration test which is mandatory for healthcare facilities. The average pore size of inner, middle and outer layer were found as 0.187, 0.4 and 0.147 micron respectively. The tensile strength of the trilaminate fabric in both machine and cross direction was 145 N and 94 N respectively. The tearing strength of the trilaminate fabric in direction I and II was 10 N and 4 N respectively. The hydrostatic and index puncture resistance of the trilaminate fabric was 2930 mmwc and 58.8 N respectively. The moisture vapour permeability of the fabric was exhibited as 585.7 g/m(2)/day.

CONCLUSIONS

The surgical gown exhibits antiviral property which can protect the health care people from human immunodeficiency virus.

Medical textiles that suit the user: predicting health care workers' preference for disposable versus reusable surgical gowns

Administrators need to balance a variety of factors when purchasing products for a health care facility, including user preference. The objectives of this study were to determine which variables were significantly related to gown preference and then to create a multivariate model to determine the best set of variables for predicting user preference for reusable versus disposable gowns. When "no preference" was included in the multivariate analysis, both occupational group and years employed at the hospital where they currently worked were significant. When no preference data were removed, years employed at the current hospital became the only significant predictor of preference.

Surgical waste audit of 5 total knee arthroplasties

BACKGROUND

Operating rooms (ORs) are estimated to generate up to one-third of hospital waste. At the London Health Sciences Centre, prosthetics and implants represent 17% of the institution's ecological footprint. To investigate waste production associated with total knee arthroplasties (TKAs), we performed a surgical waste audit to gauge the environmental impact of this procedure and generate strategies to improve waste management.

METHODS

We conducted a waste audit of 5 primary TKAs performed by a single surgeon in February 2010. Waste was categorized into 6 streams: regular solid waste, recyclable plastics, biohazard waste, laundered linens, sharps and blue sterile wrap. Volume and weight of each stream was quantified. We used Canadian Joint Replacement Registry data (2008-2009) to estimate annual weight and volume totals of waste from all TKAs performed in Canada.

RESULTS

The average surgical waste (excluding laundered linens) per TKA was 13.3 kg, of which 8.6 kg (64.5%) was normal solid waste, 2.5 kg (19.2%) was biohazard waste, 1.6 kg (12.1%) was blue sterile wrap, 0.3 kg (2.2%) was recyclables and 0.3 kg (2.2%) was sharps. Plastic wrappers, disposable surgical linens and personal protective equipment contributed considerably to total waste. We estimated that landfill waste from all 47 429 TKAs performed in Canada in 2008-2009 was 407 889 kg by weight and 15 272 m3 by volume.

CONCLUSION

Total knee arthroplasties produce substantial amounts of surgical waste. Environmentally friendly surgical products and waste management strategies may allow ORs to reduce the negative impacts of waste production without compromising patient care.

LEVEL OF EVIDENCE

Level IV, case series.