Sustainable surgery: in and out of the operating theatre

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.

Delivering a net zero National Health Service: where does otorhinolaryngology - head and neck surgery stand?

OBJECTIVE

The National Health Service (NHS) recognised the risk to public health brought by climate change by launching the Greener NHS National Programme in 2020. These organisational changes aim to attain net zero direct carbon emissions. This article reviews the literature on initiatives aimed at mitigating the environmental impact of ENT practice.

METHOD

Systematic review of the literature using scientific, healthcare and general interest (public domain) databases.

RESULTS

The initiatives reviewed can be broken down into strategies for mitigating the carbon footprint of long patient stay, use of operative theatres and healthcare travel. The carbon footprint of in-patient stay can be mitigated by a shift towards day-case surgery. The ENT community is currently focused on the reduction of theatre waste and the use of disposable instruments. Furthermore, supply chains and healthcare delivery models are being redesigned to reduce travel.

CONCLUSION

Future areas of development include designing waterless theatre scrubs, waste-trapping technologies for anaesthetic gases and a continuing investment in virtual healthcare.

Reducing greenhouse gas emissions in a bariatric surgical unit is a complex but feasible project

Obesity is a growing issue worldwide, whose causes and consequences are linked to the environment and which therefore has a high carbon footprint. On the other hand, obesity surgery, along with other procedures in surgical suites, entails environmental consequences and responsibilities. We conducted a prospective comparative study on two groups of bariatric interventions (N = 59 and 56, respectively) during two consecutive periods of time (Oct 2021-March 2022), first without and then with specific measures aimed at reducing greenhouse gas emissions related to bariatric procedures by approximately 18%. These measures included recycling of disposable surgical equipment, minimizing its use, and curbing anesthetic gas emissions. Further and continuous efforts/incentives are warranted, including reframing the surgical strategies. Instead of comparing measurements, which is difficult at the present time, we suggest defining an ECO-SCORE in operating rooms, among other healthcare facilities.

Sustainable Healthcare to Provide Quality Care in the Surgical Industry in the United Kingdom

The surgical industry makes a major contribution to sustainable healthcare. This article aims to critically evaluate sustainable healthcare to provide quality surgical care in the United Kingdom. For this study, a systematic review was conducted using peer-reviewed studies and articles from the United Kingdom related to surgical and anesthetic fields that were published within the last five years. The journal articles were selected based on their relevance to the sustainability and performance of the healthcare system, including risks, and subsequently screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 model screening approach. The findings of the relevant journal articles were then critically evaluated for each theme. A total of 79 studies were retrieved, and 15 of the retrieved studies met the inclusion criteria. Of those, 10 articles evaluated existing sustainability practices, only seven articles discussed significant determinants of quality healthcare, and only 86.67% of the articles highlighted the implications of sustainability. The key predictors of high-quality medical care are effective resource management, the acquisition of a moral surgical team, the provision of professional services, integration, short hospital stays, and low mortality and morbidity rates. Conserving water, optimizing treatment routes and transportation, and creating cultural change were found to be the pillars of high-quality, sustainable healthcare. The concept of sustainability varied between these studies, and limitations on sustainability as a result of reduced mortality, morbidity, and business services were observed. Anesthetic gas emissions from operating rooms continue to have the most detrimental effect on the sustainability of the surgical industry. A significant gap was noted between the available data and their implications.

Knowledge, attitude, and practices of operating theatre staff towards environmentally sustainable practices in the operating theatres

BACKGROUND

Successful implementation of environmentally sustainable practices in the operating theatre (OT) requires stakeholder engagement. We evaluate the knowledge, attitudes, and practices of OT users in our institution towards sustainable practices in the OT.

METHODS

A survey was conducted among OT users in August 2022. Respondents completed a 44-question anonymised online survey covering sustainability in (1) knowledge, (2) attitude, (3) practice, and (4) proposed changes to current practices. Points were assigned to knowledge (15 points) and attitude (40 points) sections. Practice was evaluated based on proportion of measures practiced. Appropriate statistical tests were used, with significance p < 0.05. Data are presented as mean ± standard deviation (SD) or proportion (%).

RESULTS

Among 149 respondents were doctors (n = 76), non-doctors (n = 45), and medical students (n = 28). Doctors scored highest in knowledge of sustainability (8.58 ± 1.83) compared to non-doctors and medical students (7.62 ± 1.75, 8.39 ± 1.87). Positive attitudes towards sustainability correlated with years of experience (p < 0.01). Non-doctors were more likely to practice sustainable measures, versus doctors (61 vs 52%, p < 0.01). Most (69%) respondents were unwilling to adopt any practice changes. The least popular measure was replacement of standard hand scrubbing with alcohol-based hand rub, considered unsafe by 74% of respondents.

CONCLUSION

Despite positive attitudes towards sustainable measures, there remains wariness of practice changes, which should be addressed by educational campaigns.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Environmental sustainability in orthopaedic surgery

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Methods

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.

Results

A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.

Conclusion

Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary.

Cite this article: Bone Jt Open 2022;3(8):628–640.