Survey of cataract surgeons' and nurses' attitudes toward operating room waste

[Sustainable development and eco-design of ophthalmology care: review of the literature]

In recent decades, medical advances in both diagnosis and treatment have led to a significant increase in the number of procedures performed. As a result, the environmental impact of medical activity continues to grow. The goal of this literature review is to examine the integration of sustainable development (SD) and eco-design of care in ophthalmology and to highlight strategies for reducing greenhouse gas (GHG) emissions. After defining the terms, issues involved, and various methods of analysis, this review will focus on the environmental impact of cataract surgery, intravitreal injections, and eye drops. It will also propose areas for improvement to minimize the ecological impact of our activity. The adoption of these practices might respond to the growing concerns of healthcare professionals in the face of climate change, while preserving the quality of care provided.

What are the Revealed and Stated Population Preferences for Environmental Sustainability in Healthcare? A Scoping Review

OBJECTIVE

Collective changes in healthcare practices are required to ensure real environmental gains. As patient-centred care is increasingly considered to enhance the ability of health systems to meet the expectations of the population, it is crucial for policymakers and health professionals to account for the preferences of the wider public regarding environmentally friendly healthcare. This article synthesises and appraises evidence from empirical studies to understand how people value environmental concerns when making decisions within medical-related or pharmaceutical sectors.

METHODS

We conducted electronic searches of the PubMed, Scopus, and Embase literature databases. Studies were eligible if they conducted a quantitative experiment to understand participants' preferences regarding sustainability and green initiatives in the medical sector or for pharmaceuticals.

RESULTS

Of the 1138 documents identified, 32 studies were deemed eligible. More than 60% were published since 2020. Different methods were used to elicit the revealed and/or stated preferences of participants. In most studies, respondents valued the environment positively and were willing to change their behaviour or practices to support sustainability. However, concerns such as disease severity or clinical effectiveness of medicines or medical interventions were often prioritised over environmental considerations. The wide heterogeneity in study participants emphasises the need to involve all stakeholders to achieve the transition to a greener and sustainable healthcare system.

CONCLUSION

The identified studies used various methods but were consistent in finding broad support for environmental considerations within the healthcare sector.

Toward a greener vision: A review on advancing sustainability in ophthalmology

The growing environmental impact from healthcare sector necessitates the adoption of sustainable strategies to reuse, recycle, reduce waste, lower carbon emissions, etc. In ophthalmology, surgical waste poses a significant environmental challenge, particularly due to the high volume of surgeries, along with single-use instruments, packaging materials and disposable surgical supplies. Examples of practical strategies to reduce surgical waste include adopting reusable surgical instruments when safe and feasible, minimizing unnecessary packaging and optimizing operating room protocols, e.g., multidose topical drops on multiple patients. An education regarding sustainability for medical personnel can further decrease waste production in the long term. Collaboration between healthcare providers, manufacturers and policymakers is essential to developing and integrating sustainability into ophthalmic practice. By implementing these strategies, ophthalmologists can contribute to a more environmentally responsible healthcare system without compromising patient safety.

Advancing sustainability in healthcare: A scoping review of global recycling practices in operating rooms

The healthcare sector, particularly operating rooms (ORs), generates significant waste, contributing to global environmental pollution. This scoping review aimed to assess global recycling practices in ORs across various surgical specialties, identifying key barriers and strategies for improvement. A comprehensive literature search using PubMed and Embase and PRISMA reporting guidelines yielded 35 studies for inclusion. The findings indicate that up to 74 ​% of OR waste, particularly preoperative waste, is recyclable. However, implementation of recycling programs is hindered by regulatory constraints, lack of education, leadership challenges, and logistical difficulties. Successful initiatives involve targeted recycling efforts, such as focusing on specific materials like blue wrap and polyethylene terephthalate plastics, supported by leadership engagement and standardized guidelines. The review highlights the necessity of a multifaceted approach, including regulatory reform, education, and strategic partnerships with manufacturers, to overcome these barriers. Incorporating robust recycling practices in ORs offers an opportunity for healthcare systems to align waste management with broader environmental sustainability goals, ultimately reducing environmental impact while enhancing resource efficiency.

Arneja J. How Can Non-Hospital Surgical Centres Improve Their Environmental Footprint (and Reduce Costs)?

Introduction

Every industry has greenhouse gas emissions, with healthcare a significant contributor. In Canada, the healthcare sector is directly and indirectly responsible for 4.6% of the country's greenhouse gas emissions. Operating rooms (ORs) are major contributors to hospital waste, making the OR low hanging fruit for analyzing environmental practices. The OR can adopt a green mindset to reduce its carbon footprint, yet barriers to going green exist. Herein we study non-hospital surgical centres in British Columbia to assess current green practices, attitudes towards environmental sustainability, and barriers to implementation.

Methods

All accredited non-hospital surgical centres in BC were invited to complete a survey on current practices and plans to reduce their environmental impact.

Results

Of 56 non-hospital surgical centres contacted, 18 responded, with 89% willing to adapt their practice to promote environmental sustainability, yet lacked current knowledge (56%) and formal plans (0%). The wide use of anesthetic gases with high global warming potential (64%) and disposable drapes/ gowns (78%/ 67%) were noted. Barriers to adopting green practices included: cost (44%), infrastructure (44%), regulatory guidelines (39%), knowledge (39%), and safety (28%).

Conclusions

Transitioning to more environmentally sustainable practices in ORs can enhance healthcare value by reducing both costs and greenhouse gas emissions. The greatest effect can be achieved through prudent choice of anesthetic gas agent, followed by reusable linens and drapes. Education and regulatory leadership were identified as crucial for overcoming these barriers. This study underscores the need for education, guidelines, and economically viable options to transition from awareness to action.

Improving Environmental Sustainability of Operating Theatres: A Systematic Review of Staff Attitudes, Barriers, and Enablers

OBJECTIVE

To understand views of staff in relation to attitudes, enablers, and barriers to implementation of environmentally sustainable surgery in operating theatres. This will ultimately help in the goal of successfully implementing more sustainable theatres.

BACKGROUND

Global health care sectors are responsible for 4.4% of greenhouse gas emissions. Surgical operating theatres are resource intensive areas and improvements will be important to meet Net-Zero carbon emissions within health care.

METHODS

Three databases were searched (Web of Science, Ovid, and PubMed), last checked January 2024. We included original manuscripts evaluating staff views regarding sustainable operating theatres. The Mixed Methods Appraisal Tool was used for quality appraisal and data analysed using thematic synthesis.

RESULTS

A total of 2933 articles were screened and 14 fulfilled inclusion criteria, using qualitative (1), quantitative (2), and mixed methods (11). Studies were undertaken in a variety of clinical (Department of Anaesthesia, Surgery, Otolaryngology, Obstetrics and Gynaecology and Ophthalmology) and geographical settings (Australia, Canada, France, Germany, New Zealand, United States, United Kingdom, and Ireland). Across studies there was a lack of evidence exploring enablers to implementation, but barriers mainly related to the following themes: education and awareness, leadership, resistance to change, facilities and equipment, time, and incentive.

CONCLUSIONS

This systematic review identified attitudes and barriers perceived by clinicians towards improving environmental sustainability within operating theatres, which may inform future strategy towards sustainable surgery. Most studies used a survey-design, whereas use of interviews may provide deeper insights. Future work should be extended to wider stakeholders influencing operating theatres. In addition, implementation studies should be carried out to examine whether barriers do change in practice.

Sustainable practices in ophthalmology-steps towards environmental stewardship in healthcare

The healthcare sector, responsible for approximately 4-5% of global carbon dioxide equivalent (CO2eq) emissions, significantly impacts the environment due to its high energy consumption and waste generation. As a specialty, ophthalmology has a disproportionately large environmental impact because of the high annual volume of ophthalmic surgeries. In recent years, significant organized efforts have focused on reducing ophthalmology's carbon footprint while maintaining quality patient care. As one example, EyeSustain is a coalition of 50 global ophthalmology societies collaborating to advance sustainability in the delivery of eye care through education, research, and advocacy. Education and advocacy are critical to raising awareness and promoting the implementation of sustainable practices among physicians. Many of these practices can and should be applied throughout the broader healthcare system, and EyeSustain is a model of how other specialties can organize education and advocacy efforts through medical societies. We review current initiatives, advocacy efforts, and waste-reduction strategies aimed at reducing the environmental footprint of ophthalmic procedures.

Reusing surgical materials for cataract surgery: an assessment of potential contamination

PURPOSE

To evaluate microbiological cultures of cataract surgical devices and products that were reused for multiple cases.

SETTING

Aravind Eye Hospital, Pondicherry, Tamil Nadu, India.

DESIGN

Prospective cohort study.

METHODS

Samples from multiple surgical instruments and products that were reused for consecutive cataract surgeries underwent bacterial and fungal cultures and were monitored alongside positive controls for 7 days. This included instruments that were processed using immediate use steam sterilization (IUSS) between cases (eg, surgical cannulas, syringes, phacoemulsification and coaxial/bimanual irrigation/aspiration [I/A] tips, phacoemulsification and I/A sleeves) (Group 1), instruments that were used without sterilization between cases (eg, phacoemulsification tubing/handpieces, coaxial I/A handpieces) (Group 2), and the residual (unused) fluid from balanced salt solution bags after being used for multiple patients (Group 3).

RESULTS

3333 discrete samples were collected from all 3 product groups that were reused across multiple patients. In all collected samples, no bacterial or fungal growth was observed. Of the 3241 cataract surgeries that used reused and IUSS-sterilized instruments alongside instrument sets cultured on the same day and balanced salt solution bags shared across multiple patients, no eyes developed endophthalmitis over a 6-week follow-up period.

CONCLUSIONS

Bacterial or fungal growth was not found in extensive microbiological cultures of IUSS-sterilized ophthalmic surgical instruments and cataract surgical products that were reused in multiple patients. This microbiological data complements clinical endophthalmitis data from 2 million consecutive cases at the Aravind Eye Hospital, suggesting that their instrument and surgical supply processing practices may allow for safe and sustainable ophthalmic care.

Investigating the sterile surgical supply waste in laparotomy surgery

BACKGROUND

Operating rooms contribute to over 40% of hospital expenses, with a portion attributed to waste from single-use, sterile surgical supplies (SUSSS). This research aimed to determine the amount of cost wastage due to not using SUSSS during laparotomy procedures.

METHODS

A descriptive-analytical investigation was conducted in two prominent teaching hospitals in Mashhad, Iran 2018. Seventy-seven laparotomy surgeries were scrutinized, documenting both used and unused disposable devices, with their respective costs being assessed. Data analysis was performed using SPSS version 16 software.

RESULTS

The study revealed that during surgery in the operating rooms, waste of SUSSS averaged 5.9%. Betadine solution and sterile Gauze types were the top two contributors to resource wastage. Sterile Gauze types incurred the highest cost loss. The study found a significant correlation between cost wastage and surgeon experience (r = 0.296, P < 0.001) as well as surgery duration (r = 0.439, P < 0.001).

CONCLUSION

Inadequate management of available and commonly used disposable supplies leads to increased hospital expenses. Enhancing the surgical team's knowledge of sterile surgical supplies usage and making thoughtful selections can play a vital role in curbing health costs by minimizing waste of SUSSS in the operating rooms.

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

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

Environmental Sustainability Initiatives in the Operating Room: A Scoping Review

The global healthcare industry has a substantial environmental footprint and therefore has a responsibility to decrease its impact. Changes to increase sustainability will only occur if healthcare providers (HCPs) and decision-makers understand and incorporate environmentally conscious practices in the operating room (OR). This scoping review aimed to assess hospital initiatives undertaken to support environmental sustainability in the OR, with a focus on HCP and hospital decision-maker beliefs and perceptions related to sustainability. A scoping review was conducted using Embase and PubMed. Searches were performed to identify relevant studies published between January 2011 and November 2022. A total of 163 publications were included: 10 systematic literature reviews and 153 original research articles. Most studies reported department-wide sustainability measures (waste reduction, staff education, etc), which were evaluated by the reduction in generated waste and energy, emission of greenhouse gasses, and costs. Despite up to 97% of HCPs noting willingness to improve sustainability within practices, up to 80.9% of HCPs stated that they lacked the necessary training and information. In conclusion, this research highlights a recent increase in interest about sustainability initiatives in the OR and that HCPs and surgical staff are not only willing to participate but also have suggestions on how to minimize the environmental impact of the OR.

Operating Room Waste Generated From Corneal and Conjunctival Surgeries

PURPOSE

The purposes of this study were to bring awareness to the surgical waste generated from corneal and conjunctival surgeries and to compare those findings with the waste generated from cataract surgeries.

METHODS

This was an observational prospective pilot cohort study at a tertiary corneal/anterior segment private practice. All waste related to cataract, cornea, and conjunctival surgical procedures (including anesthesia waste and corneal tissue storage) was weighed. The primary outcome was total waste generated while other outcomes included surgical setting (ambulatory surgical center, hospital, and minor operating room) and comparison of corneal/conjunctival surgeries with cataract surgery.

RESULTS

Surgical waste data were collected from 119 surgeries (82 corneal/conjunctival surgeries and 37 cataract surgeries). Hospital surgeries produced more waste than ambulatory surgical center and minor operating room surgeries. Penetrating keratoplasty (2.22 kg, P = 0.483) and Descemet stripping only (2.11 kg, P = 0.326) procedures generated comparable mean waste with cataract surgery (2.07 kg) while endothelial keratoplasties produced more ( P < 0.001, 0.002). (Deep) anterior lamellar keratoplasty results depended on the surgical setting. All conjunctival surgeries produced less waste than cataract surgery.

CONCLUSIONS

In comparison with cataract surgery, keratoplasties overall produced comparable or more waste while conjunctival surgeries produced less waste. The surgical setting and type of anesthesia played a substantial role in the amount of waste generated. Assessing waste production from different ophthalmic surgeries may increase awareness of the negative environmental impact of surgical waste and promote practice or legal changes to improve environmental sustainability.

Expiry dates in surgical equipment: What are the options?

INTRODUCTION

Hospitals and the healthcare system contribute significantly to global warming, due to the energy use, water use and waste produce going directly to landfill. The operating theatre environment contributes to 70% of all hospital waste, and a proportion of this is due to unused surgical supplies, such as those stocked but never used as they go past their use-by date.

AIM

To evaluate how use-by dates are identified and assigned to surgical equipment, and if there are opportunities to re-use, or re-sterilise this equipment in order to reduce waste from the operating theatre environment.

RESULTS

Use-by dates are assigned to ensure sterility and longevity of the device, and are assigned based on risk analysis, retrospective and prospective assessment. Incineration is the mainstay of disposal of unused medical devices, but there are alternative options such as re-processing in specific circumstances.

CONCLUSION

A large volume of hospital waste is due to operating theatres, and there is movement towards developing more sustainable methods of dealing with expired surgical equipment. This is however in the early stages, with further research required to confirm if these methods will be safe for patients, and beneficial to the environment.

Systematic review of carbon footprint of surgical procedures

The ecological sustainability of the operating room (OR) is a matter of recent interest. The present systematic review aimed to review the current literature assessing the carbon footprint of surgical procedures in different surgical fields. Following to the PRISMA statement checklist, three databases (MEDLINE, EMBASE, Cochrane Library) were searched by independent reviewers, who screened records on title and abstract first, and then on the full text. Risk of bias was evaluated using the MINORS system. Over the 878 articles initially identified, 36 original studies were included. They considered ophthalmologic surgical procedures (30.5%), general/digestive surgery (19.4%), gynecologic procedures (13.9%), orthopedic procedures (8.3%), neurosurgery (5.5%), otolaryngology/head and neck surgery (5.5%), plastic/dermatological surgery (5.5%), and cardiac surgery (2.8%). Despite a great methodological heterogeneity, data showed that a single surgical procedure emits 4-814 kgCO2e, with anesthetic gases and energy consumption representing the largest sources of greenhouse gas emission. Minimally invasive surgical techniques may require more resources than conventional open surgery, particularly for packaging and plastics, energy use, and waste production. Each OR has the potential to produce from 0.2 to 4kg of waste per case with substantial differences depending on the type of intervention, hospital setting, and geographic area. Overall, the selected studies were found to be of moderate quality. Based on a qualitative synthesis of the available literature, the OR can be targeted by programs and protocols implemented to reduce the carbon footprint and improve the waste stream of the OR.

Reducing ophthalmic surgical waste through electronic instructions for use: a multisociety position paper

Every ophthalmic surgical supply, including intraocular lenses (IOLs), IOL cartridges, and ophthalmic viscosurgical device syringes, is packaged with instructions for use (IFU). These pamphlets are printed in multiple languages and, in the case of an IOL, significantly increase the size and weight of the packaging. To eliminate this significant and unnecessary source of waste, we recommend that manufacturers move to Quick Response codes that link to online electronic IFU (e-IFU) as a sensible alternative. In addition to reducing carbon emissions and manufacturing costs, e-IFU can be updated more easily and accessed by surgeons in the clinic, where IOL models and powers are selected. Varying and inconsistent IFU requirements between different countries are a barrier to wider adoption of e-IFU by the ophthalmic surgical industry. Regulatory agencies in every country should allow and encourage e-IFU. This position paper has been endorsed by the 3 major societies that sponsor EyeSustain, a consortium of global societies dedicated to advancing sustainability in ophthalmology.

Tracing the barriers to decarbonising ophthalmology: A review

As climate change demands increasingly urgent mitigation of greenhouse gas emissions, the health sector needs to do its part to decarbonise. Ophthalmologists share concerns about climate change and seek opportunities to reduce their environmental impact. When measuring the footprint of ophthalmology, major contributions are from patient travel to clinics, and from the large amounts of single-use disposable materials that are consumed during surgeries and sterile procedures. Ophthalmic services in India have already demonstrated systems that consume far fewer of these products through efficient throughput of patients and the safe reuse of many items, while maintaining equivalent safety and quality outcomes. Choosing these low-cost low-emission options would seem obvious, but many ophthalmologists experience barriers that prevent them operating as Indian surgeons do. Understanding these barriers to change is a crucial step in the decarbonisation of ophthalmology and the health sector more broadly.

Paper waste from instructions for use brochures in cataract surgery implant packaging in Europe and the United States

PURPOSE

To assess the extent of paper waste generated per year by instructions for use (IFUs) brochures included in intraocular lens (IOL) packaging in Europe and the U.S.

SETTING

Rothschild Foundation Hospital, Paris, France; Royal Free London NHS Foundation Trust; Center for Sight, London, United Kingdom.

DESIGN

Experimental study.

METHODS

A sample of IOLs were collected and each IFU was weighed. In addition, the cumulative weight of these brochures used in cataract surgeries performed annually in Europe and the U.S. was estimated, and the potential annual paper conservation that could be achieved if all manufacturers adopted electronic IFUs (e-IFUs) in Europe and the U.S. was determined.

RESULTS

The mean and standard deviation of the weight for overall IFUs, classic IFUs, and e-IFUs were 17.6 ± 13.8 g, 23.5 ± 13.2 g, and 2.9 ± 1.9 g, respectively. The estimated cumulative weight of paper generated from the IFUs accompanying implants used in European and U.S. cataract surgeries is 153 tons. If all manufacturers transition to e-IFUs, the cumulative weight saved would be 128 tons (-84%), equivalent to 120 tons of carbon dioxide equivalent and the preservation of more than 2000 trees annually.

CONCLUSIONS

The classic IFUs in IOL packaging result in a significant amount of paper waste annually. Therefore, there is an urgent need for a rapid transition to e-IFU technology. The adoption of e-IFUs has already been authorized in Europe and the U.S., and it is crucial to expedite this process.

A Mini-review on New Developments in Nanocarriers and Polymers for Ophthalmic Drug Delivery Strategies

The eye is an important and vital organ of the human body consisting of two segments - anterior and posterior segments and these segments are associated with many diseases. This review elaborates upon the various eye-related diseases with their medications and carriers used to deliver them. Delivery strategies include drugs encapsulated into liposomes, polymeric micelles of drugs, solid lipid nanoparticles, nanostructured lipid carriers, nano emulsions, and Nanosuspension used to improve penetrating properties, bioavailability, and residence time of the drugs as examples available in the literature. With regard to this, different forms of ocular drug delivery are classified and elaborated. Additionally, the possibility of addressing the physical and chemical complexities of ocular diseases and how they could be overcome with environmentally stable nanoformulations are briefly discussed. Enhanced drug delivery efficiency with various novel pharmaceuticals along with enhanced uptake by different routes/modes of drug administration. Current advancements in drug carrier systems, i.e., nanocarriers, have shown promise for improving the retention time, drug permeation and prolonging the duration of release of the drug in the ocular site. Bio-degradable polymers investigated for the preparation of nanocarriers for the entrapment of drugs and to enhance the efficacy through improved adherence of tissue in the eye, sustained release measures, enhanced bioavailability, lower toxicity, and targeted delivery is applicable. This review covers the introduction of various nanocarriers and polymers for ocular drug delivery with the purpose of enhancing the absorption, retention and bioavailability of medications in the eye.

Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework

BACKGROUND

The health sector contributes significantly to the climate crisis. Operating theatres (OTs) in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. The authors systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in OTs, categorising these using the Theoretical Domains Framework (TDF).

MATERIALS AND METHODS

Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 and June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines.

RESULTS

Twenty-one studies were selected for analysis and assessment (17 surveys and four interview studies) comprising 8286 participants, including surgeons, nurses, and anaesthetists. Eighteen themes across 10 TDF domains were identified. The most common barriers to adoption of green behaviours in OTs were in domains of: 'knowledge' ( N =18), for example knowledge of sustainable practices; 'environmental context and resources' ( N =16) for example personnel shortage and workload and inadequate recycling facilities; 'social influences' ( N =9) for example lack of leadership/organisational mandate or support; 'beliefs about consequences' ( N =9) for example concerns regarding safety. Intention was the most common facilitator, with 11 studies citing it.

CONCLUSIONS

Despite intentions to adopt sustainable practices in OTs, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the hospital and trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise OTs.

Exploring Barriers and Facilitators to Reducing the Environmental Impact of the Operating Room

INTRODUCTION

The operating room (OR) is a major contributor to greenhouse gas emissions both nationally and globally. Successful implementation of quality improvement initiatives requires understanding of key stakeholders' perspectives of the issues at hand. Our aim was to explore surgical, anesthesia, and OR staff member perspectives on barriers and facilitators to reducing OR waste.

MATERIALS AND METHODS

Identified stakeholders from a single academic medical center were interviewed to identify important barriers and facilitators to reducing surgical waste. Two team members with qualitative research experience used deductive logic guided by the Theoretical Domains Framework of behavior change to identify themes within transcripts.

RESULTS

Nineteen participants including surgeons (n = 3, 15.8%), surgical residents (n = 5, 26.3%), an anesthesiologist (n = 1, 5.3%), anesthesia residents (n = 2, 10.5%), nurse anesthetists (n = 2, 10.5%), nurses (n = 5, 26.3%), and a surgical technologist (n = 1, 5.3%) were interviewed. Twelve of the 14 themes within the Theoretical Domains Framework were discovered in transcripts. Barriers within these themes included lack of resources to pursue environmental sustainability in the OR and the necessity of maintaining sterility for patient safety. Facilitators included emphasizing surgeon leadership within the OR to reduce unused supplies and spreading awareness of the environmental and economic impact of surgical waste.

CONCLUSIONS

Interviewed stakeholders were able to identify areas where improvements around surgical waste reduction and management could be made at the institution by describing barriers and facilitators to sustainability-driven interventions. Future surgical waste reduction initiatives at this institution will be guided by these important perspectives.

Pediatric Surgeon Perceptions on Operating Room Environmental Stewardship and Current Institutional Climate-Smart Actions

BACKGROUND

Operating rooms generate significant greenhouse gas emissions. Our objective was to assess current institutional climate-smart actions and pediatric surgeon perceptions regarding environmental stewardship efforts in the operating room.

METHODS

A survey was distributed to members of the American Pediatric Surgical Association in June 2022. The survey was piloted among ten general surgery residents and two professional society cohorts of pediatric surgeons. Comparisons were made by demographic and practice characteristics.

RESULTS

Survey response rate was 15.9% (n = 160/1009) and included surgeons predominantly from urban (n = 93/122, 76.2%) and academic (n = 84/122, 68.9%) institutions. Only 9.8% (n = 12/122) of pediatric surgeons were currently involved in operating room environmental initiatives. The most common climate-smart actions were reusable materials and equipment (n = 120/159, 75.5%) and reprocessing of medical devices (n = 111/160, 69.4%). Most surgeons either strongly agreed (n = 48/121, 39.7%) or agreed (n = 62/121, 51.2%) that incorporation of environmental stewardship practices at work was important. Surgeons identified reusable materials/equipment (extremely important: n = 61/129, 47.3%, important: n = 38/129, 29.5%) and recycling (extremely important: n = 68/129, 52.7%, important: n = 29/129, 22.5%) as the most important climate-smart actions. Commonly perceived barriers were financial (extremely likely: n = 47/123, 38.2%, likely: n = 50/123, 40.7%) and staff resistance to change (extremely likely: n = 29/123, 23.6%, likely: n = 60/123, 48.8%). Regional differences included low adoption of energy efficiency strategies among respondents from southern states (n = 0/26, p = 0.01) despite high perceived importance relative to other regions (median: 5, IQR: 4-5 vs median: 4, IQR 4-5, p = 0.04).

CONCLUSIONS

While most pediatric surgeons agreed that environmental stewardship was important, less than 10% are currently involved in initiatives at their institutions. Opportunities exist for surgical leadership surrounding implementation of climate-smart actions.

LEVEL OF EVIDENCE

Level III.

Assessing Strategies to Reduce the Carbon Footprint of the Annual Meeting of the American Academy of Ophthalmology

Importance

Greenhouse gas emissions associated with medical conferences have been associated with climate change, and the effects of climate change have been associated with an increased incidence of ophthalmic diseases. Identifying practical strategies associated with reducing these emissions may be warranted.

Objective

To assess greenhouse gas emissions associated with in-person and virtual meetings of the American Academy of Ophthalmology (AAO) and to conduct mitigation analyses to suggest strategies to reduce future emissions.

Design, Setting, and Participants

Quality improvement study in which attendee and conference data were used to estimate emissions from in-person (October 12 to October 15, 2019, San Francisco, California) and virtual (November 13 to November 15, 2020) AAO annual meetings for 35 104 attendees. The data were also used to perform mitigation analyses to assess whether meeting format alterations could be used to reduce future emissions. Data were analyzed from December 21, 2021, to April 18, 2022.

Exposures

Attendance at a selected meeting. Total attendance was 23 190 participants in 2019 and 11 914 participants in 2020.

Main Outcomes and Measures

Greenhouse gas emissions produced by the in-person meeting were estimated by calculating the equivalent metric tons of carbon dioxide (CO2) associated with attendee transportation, attendee accommodations, and the conference venue. Emissions produced by the virtual meeting were estimated by calculating the equivalent metric tons of CO2 associated with attendees' computer use, network data transfer, and video-conferencing server use. Mitigation analyses simulated the association of changing the meeting location and format with reductions in emissions.

Results

In this analysis, the 2019 in-person meeting produced 39 910 metric tons of CO2 (1.73 metric tons of CO2 per capita), and the 2020 virtual meeting produced 38.6 metric tons of CO2 (0.003 metric tons of CO2 per capita). Mitigation analyses showed that holding a single in-person meeting in Chicago, Illinois, rather than San Francisco, California, could be associated with transportation-related emissions reductions of 19% (emissions for the San Francisco meeting, 38 993 metric tons of CO2; for the Chicago meeting, 31 616 metric tons of CO2). Holding multiple in-person meetings in separate regions could be associated with transportation-related emissions reductions of as much as 38% (emissions for the San Francisco meeting, 38 993 metric tons of CO2; for multiple meeting scenario 2, 24 165 metric tons of CO2).

Conclusions and Relevance

This study found that the AAO's 2019 in-person meeting was associated with substantially higher greenhouse gas emissions compared with the 2020 virtual meeting, primarily due to transportation-related emissions. Increasing the proportion of virtual participants, holding the meeting in locations chosen to minimize transportation-related emissions, or offering multiple regional meeting locations may reduce the carbon footprint of future meetings.

[Survey and reduction of waste production from eye surgery]

BACKGROUND

The health sector is facing new challenges due to the impact of climate change on health. At the same time, it significantly contributes to our society's climate footprint. Hospitals producing considerable amounts of waste are an important aspect of this burden. The aim of this work was to quantify the amount of waste produced by eye surgery and, as an optimization measure, to evaluate the effect of glass separation from residual waste.

MATERIAL AND METHODS

Over a 2-week period, the waste generated by eye operations in the surgical theater of our university hospital was measured. Another 2‑week long measurement was conducted after the initiation of glass separation from general waste. The data obtained allowed a comparison of the two periods, the type of waste (residual and recyclable) as well as the type of operation (intraocular, extraocular). Considering regional waste disposal costs, an economic comparison was also performed.

RESULTS

In the first measurement period (196 operations), a total of 549.6 kg of waste was generated, 87% (478.3 kg) of which was residual waste, corresponding to 14.3 tons of total waste annually. Intraocular procedures generated on average 80% more waste than extraocular procedures: 18.1 ± 3.9 kg and 11.4 ± 4.0 kg, respectively, per day and theater. Separation of glass from residual waste reduced its quantity by 7.2% in the second measurement period (197 procedures). As the disposal of glass is free of charge in the city of Essen, this resulted in a small economic advantage (extrapolated to 112 € per year).

CONCLUSION

The amount of waste generated by ophthalmic surgery is substantial, with a predominant proportion of non-recyclable residual waste. Intraocular operations are the cause of the majority of the waste produced. Simple measures, such as disposing of glass separately, are helpful and inexpensive to reduce the quantity of residual waste.

Sterile surgical supply waste identification using asynchronous analysis: Pediatric surgery QI pilot

Background

The operating room (OR) is a major cost and revenue center for a hospital. One of the few modifiable costs in the OR is single-use, sterile surgical supplies (SUSSS). If SUSSS are opened on the scrub table and not used, then they are wasted. High-fidelity SUSSS usage data is important to strategically implement solutions to reduce waste of SUSSS in the OR. OR waste reduction may decrease health systems' carbon footprints and reduce spending.

Methods

A convenience sample of general pediatric surgical cases was observed in summer 2021. HIPAA-free images of the surgical scrub table were acquired every 2 s with minimal impact on pediatric OR workflow. These images were asynchronously analyzed to obtain SUSSS usage data for each case.

Results

Image data from three pediatric surgeons performing 41 pediatric surgeries was reviewed. The median cost of unused SUSSS was $13.10 (IQR = $2.73-$47.97) with a range of $0.07 to $489.08 wasted in a single surgery. The mean number of items wasted was 9.3 ± 6.4. The most frequently wasted items were sutures, syringes, towels, paper rulers, and specimen cups. The most expensive sources of waste were laparoscopic trocars, sutures, insufflation needles, drapes, and guidewires.

Conclusions

SUSSS that were discarded without being used were successfully identified through the asynchronous analysis of HIPAA-free OR scrub table image data. This may be an opportunity to identify SUSSS waste efficiently without an observer in the OR.

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.

Reuse of shipping materials in the intravitreal bevacizumab supply chain: feasibility, cost, and environmental impact

BACKGROUND

Intravitreal injections are the most common ophthalmic procedure worldwide and are also a prime opportunity for waste reduction. This study analyzes the feasibility, environmental impact, and cost of reusing shipping materials for intravitreal injection medications, as compared to wasting coolers and cold packs after single-use.

METHODS

In this prospective pilot study, shipping materials (cardboard boxes, polystyrene foam coolers, and cold packs) from repackaged bevacizumab delivered to our clinic (500 doses per week) were saved and reused over a 10-week study period. The shipping supplies were photographed and inspected for defects at point of care (Twin Cities, MN), and returned via standard ground shipping to the outsourcing facility (Tonawanda, NY).

RESULTS

Polystyrene foam coolers (n = 3) survived 10 roundtrips between the outsourcing facility and retina clinic (600 mi each way), although wear-and-tear was visible in the form of marks and dents. Cold packs (n = 35) were less durable, lasting 3.1 ± 2.0 roundtrips. Total carbon dioxide equivalent (CO₂e) emissions were reduced 43%, by reusing shipping materials (12.88 kgCO₂e per 1000 bevacizumab doses), as compared to the standard practice of disposing containers after single-use (22.70 kgCO₂e per 1000 bevacizumab doses), and landfill volume was reduced by 89%. Cost savings from reusing containers offset expenses incurred with return shipping and extra handling in the reuse cohort (net savings: $0.52 per 1000 bevacizumab doses).

CONCLUSIONS

Reusing shipping supplies can be cost neutral, with less CO₂e emissions and reduced landfill. Robust environmental benefit is possible if retina clinics partner with manufacturers to reuse shipping containers.

Potential environmental effect of reducing the variation of disposable materials used for cataract surgery

PURPOSE

To analyze the cataract package variability in 1 country, Austria.

SETTING

Austrian Departments of Ophthalmology.

DESIGN

Cross-sectional study.

METHODS

The cataract package components of 3 different Austrian hospitals were weighed and life cycle assessment on each product performed. This data was then extrapolated to the sales figures of the main Austrian cataract package suppliers to estimate the carbon footprint of all cataract packages used in Austria in 2021.

RESULTS

There were 55 different cataract package compositions in use with an average weight of 0.7 kg. These compositions differ significantly in weight and composition considering that the smallest package was 57% lighter than the largest package. The size of the surgical drapes also showed considerable variation, with a difference of up to 71%. This is substantial, considering that drapes and covers account for about 53% of the package weight.

CONCLUSIONS

There was a considerable variation in package composition and product size, which could provide opportunities to save carbon dioxide emissions in cataract surgery. If all Austrian eye departments were to reduce the material quantities and drape sizes to the lower third of the cataract packages used in the Austria in 2021, cataract package associated CO 2 emissions could be reduced by 34%.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Sustainability in interventional radiology: are we doing enough to save the environment?

Background

Healthcare waste contributes substantially to the world’s carbon footprint. Our aims are to review the current knowledge of Interventional Radiology (IR) waste generation and ways of reducing waste in practice, to quantify the environmental and financial impact of waste generated and address green initiatives to improve IR waste management.

Methods

A systematic literature search was conducted in July 2022 using the Medline and Embase literature databases. The scope of the search included the field of IR as well as operating theatre literature, where relevant to IR practice.

Results

One-hundred articles were reviewed and 68 studies met the inclusion criteria. Greening initiatives include reducing, reusing and recycling waste, as well as strict waste segregation. Interventional radiologists can engage with suppliers to reformulate procedure packs to minimize unnecessary items and packaging. Opened but unused equipment can be prevented if there is better communication within the team and increased staff awareness of wasted equipment cost. Incentives to use soon-to-expire equipment can be offered. Power consumption can be reduced by powering down operating room lights and workstations when not in use, changing to Light Emitting Diode (LED) and motion sensor lightings. Surgical hand wash can be replaced with alcohol-based hand rubs to reduce water usage. Common barriers to improving waste management include the lack of leadership, misconceptions regarding infectious risk, lack of data, concerns about increased workload, negative staff attitudes and resistance to change. Education remains a top priority to engage all staff in sustainable healthcare practices.

Conclusion

Interventional radiologists have a crucial role to play in improving healthcare sustainability. By implementing small, iterative changes to our practice, financial savings, greater efficiency and improved environmental sustainability can be achieved.

Recycling, responsible consumption and nursing: A qualitative study of surgical nurses' recycling and medical waste management

AIM

This study was conducted to examine the opinions of nurses working in surgical wards on recycling and medical waste management.

BACKGROUND

Surgical services and operating rooms are the most waste-generating parts of health institutions. The primary purpose of waste management is to ensure waste minimization and increase recycling.

METHOD

In this qualitative study, in-depth interviews were conducted with 15 nurses. The data were analysed by the content analysis method. The COREQ checklist was used in the study.

RESULTS

As a result of the study, four main themes were determined: Barriers in medical waste and recycling management, solution suggestions in medical waste and recycling management, waste of medical and consumable materials and the effect of the pandemic process on medical waste and recycling management.

CONCLUSION

Medical waste and recycling management was interrupted due to lack of education, emergencies, hiring of untrained personnel and workload. During the pandemic, medical waste increased, and it could not be recycled. The solution suggestions are training at frequent intervals, monitoring by the responsible nurses and imposing sanctions on those who do not comply.

IMPLICATIONS FOR NURSING MANAGEMENT

Knowing nurses' obstacles in managing medical waste and recycling and putting forward solutions in this regard affects sustainability. Knowing the obstacles to the management of medical waste and recycling by nurses could help in solutions.

The carbon footprint of the operating room related to infection prevention measures: a scoping review

BACKGROUND

Infection prevention measures are widely used in operating rooms (ORs). However, the extent to which they are at odds with ambitions to reduce the health sector's carbon footprint remains unclear.

AIM

To synthesize the evidence base for the carbon footprint of commonly used infection prevention measures in the OR, namely medical devices and instruments, surgical attire and air treatment systems.

METHODS

A scoping review of the international scientific literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search was performed in PubMed and Google Scholar. Articles published between 2010 and June 2021 on infection prevention measures, their impact on the health sector's carbon footprint, and risk for surgical site infections (SSIs) were included.

FINDINGS

Although hospitals strive to reduce their carbon footprint, many infection prevention measures result in increased emissions. Evidence suggests that the use of disposable items instead of reusable items generally increases the carbon footprint, depending on sources of electricity. Controversy exists regarding the correlation between air treatment systems, contamination and the incidence of SSIs. The literature indicates that new air treatment systems consume more energy and do not necessarily reduce SSIs compared with conventional systems.

CONCLUSION

Infection prevention measures in ORs can be at odds with sustainability. The use of new air treatment systems and disposable items generally leads to significant greenhouse gas emissions, and does not necessarily reduce the incidence of SSIs. Alternative infection prevention measures with less environmental impact are available. Implementation could be facilitated by embracing environmental impact as an additional dimension of quality of care, which should change current risk-based approaches for the prevention of SSIs.

Reducing topical drug waste in ophthalmic surgery: multisociety position paper

This position article on reducing topical drug waste with ophthalmic surgery was written by the Ophthalmic Instrument Cleaning and Sterilization Task Force, comprising representatives of the ASCRS, American Academy of Ophthalmology, American Glaucoma Society, and Outpatient Ophthalmic Surgery Society. Drug waste significantly increases the costs and carbon footprint of ophthalmic surgery. Surgical facilities should be permitted to use topical drugs in multidose containers on multiple patients until the manufacturer's labeled date of expiration, if proper guidelines are followed. Surgical patients requiring a topical medication not used for other patients should be allowed to bring that partially used medication home for postoperative use. These recommendations are based on published evidence and clarification of policies from multiple regulatory and accrediting agencies with jurisdiction over surgical facilities. Surveys suggest that most ambulatory surgery centers and hospitals performing cataract surgery are wasting topical drugs unnecessarily.

Carbon Emissions from Overuse of U.S. Health Care: Medical and Ethical Problems

The United States health care industry is the second largest in the world, expending an estimated 479 million metric tons (MMT) of carbon dioxide per year, nearly 8 percent of the country's total emissions. The importance of carbon reduction in health care is slowly being accepted. However, efforts to "green" health care are incomplete since they generally focus on buildings and structures. Yet hospital care and clinical service sectors contribute the most carbon dioxide within the U.S. health care industry, with structures/equipment and pharmaceuticals ranking as the third and fourth highest emitters in the industry. Given the magnitude of health care carbon emissions-and the paucity of attention to the carbon of hospital care and clinical services-this essay identifies overuse of health care as a health threat with serious ethical implications, offers a data-driven action plan for carbon reduction in health care, and provides practical suggestions for more sustainable health care delivery in the United States.

Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol

OBJECTIVE

Calculate the cost savings associated with a multiuse preoperative and preinjection eyedrop protocol.

DESIGN

Economic analysis PARTICIPANTS: Adults undergoing ophthalmic surgical procedures requiring preoperative dilation and intravitreal injections.

METHODS

Economic modeling with scenario analysis was used to derive the value for cost-savings attributable to a protocol where perioperative mydriatic eyedrop bottles are used across multiple patients versus the current protocol where drop bottles are wasted after single patient use. Similar analyses were performed for a multiuse povidone-iodine protocol for intravitreal injections. Sensitivity analyses were used to test baseline model assumptions with varying degrees of waste and patient volume.

RESULTS

The multi-use mydriatic protocol allowed for a 97.1% reduction in the number of eyedrop bottles required for the single-use protocol (1037 bottles vs. 35850 bottles). This led to an estimated five year cost savings of approximately $240,000 (nominal) per institution (performing an average of 1434 cases/year) in the base case. This savings varied minimally in sensitivity analyses accounting for practical limitations (loss, expiration, or contamination) of multi-use containers, with savings of 97.54-95.00% for excess supply ranges from 0%-100% in the multiuse protocol. Likewise, the cost savings varied minimally in sensitivity analyses for eye drop sizes, with savings of 99.23-96.69% for mydriatic eye drop sizes of 15 microliter per drop to 65 microliter per drop, respectively, in the multi-use protocol. Over a five-year period, for povidone-iodine drops prior to performing intravitreal injection, the multi-use protocol required 153 bottles compared to 41,954 bottles (99.6% reduction) for the current single-use protocol, resulting in a nominal cost savings of $41,801, which varied minimally in sensitivity analyses.

CONCLUSIONS

Multiuse perioperative mydriatic eyedrops are a viable option for cost and environmental waste reduction for ophthalmologic procedures and surgeries requiring dilation. Likewise, multiuse povidone-iodine may allow for large relative cost reduction for in office procedures. The total potential savings over five years was estimated greater than $280,000 before adjusting for inflation.

Addressing the environmental sustainability of eye health-care delivery: a scoping review

The demand for eye care-the most common medical speciality in some countries-is increasing globally due to both demographic change and the development of eye health-care services in low-income and middle-income countries. This expansion of service provision needs to be environmentally sustainable. We conducted a scoping review to establish the nature and extent of the literature describing the environmental costs of delivering eye-care services, identify interventions to diminish the environmental impact of eye care, and identify key sustainability themes that are not yet being addressed. We identified 16 peer-reviewed articles for analysis, all published since 2009. Despite a paucity of research evidence, there is a need for the measurement of environmental impacts associated with eye care to be standardised along with the methodological tools to assess these impacts. The vastly different environmental costs of delivering clinical services with similar clinical outcomes in different regulatory settings is striking; in one example, a phacoemulsification cataract extraction in a UK hospital produced more than 20 times the greenhouse gas emission of the same procedure in an Indian hospital. The environmental costs must be systematically included when evaluating the risks and benefits of new interventions or policies aimed at promoting safety in high-income countries.

[Use of resources in cataract surgery-More waste is (not) always possible]

BACKGROUND

Aspects of ecological sustainability are becoming more important in the healthcare system. The use of resources is particularly high in the operating theater. Cataract surgery is one of the most frequent procedures in ophthalmology and even in medicine overall. Its CO₂ footprint is therefore quantitatively relevant. Approaches to conserve resources can be implemented at the levels of production and transport of materials and also in the form of reduction and management of waste.

MATERIAL AND METHODS

In this paper the sources of the waste load, the management of waste separation, the implementation of single-use instruments and the influence of innovative technologies during cataract surgery are presented based on the current literature.

RESULTS

Particularly the use of plastic materials for packaging and single-use instruments, also for reasons of hygiene, lead to an increased waste production. The simple separation of compound materials is difficult and only meaningful if the materials used in eye operations can be recycled; however, international comparisons show that cataract surgery can be performed with the same quality of results while conserving resources. Measures in organization and infrastructure are presented.

CONCLUSION

In the future, innovative strategies should be developed and the use of resources in Germany should also be critically questioned in order to reduce the CO₂ footprint of cataract surgery.

[Current and future effects of climate change on ophthalmology]

BACKGROUND AND OBJECTIVES

Climate change is also an increasingly important issue in the healthcare system. Due to its anatomical and physiological nature, the eye is directly exposed to environmental influences and changes in a special way.

METHODS

The current literature is used to illustrate the effects of climate-induced changes and the respective influences on the eye. A PubMed search (cut-off date 3 October 2021) using the search terms "climate change" or "planetary health" or "global health" and in each case "ophthalmology" or "eye" or "ocular" was used to determine the development of the number of publications between 2011 and 2021.

RESULTS

Measurable effects of climate change are already evident in a wide variety of ophthalmological fields. The significance of this topic, for instance, is reflected in a relatively constant increase in the number of publications and an almost tenfold increase in the number of publications per year from 2011 to 2021.

CONCLUSION

The impact of climate change on eye diseases and on the field of ophthalmology is multifaceted and could be expected to intensify in the coming years. Therefore, the interrelationships need to be further investigated in future studies, preferably on a large scale.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery

PURPOSE

To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE).

DESIGN

Retrospective, sequential, clinical registry study.

METHODS

85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR.

RESULTS

Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups.

CONCLUSIONS

Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Pharmaceutical and Supply Waste in Oculofacial Plastic Surgery at a Hospital-Based Outpatient Surgery Center

PURPOSE

To investigate the financial and environmental waste burden of unused disposable surgical supplies and pharmaceutical products in oculofacial plastic surgery at a hospital-based outpatient surgery center.

METHODS

This descriptive study was performed at a single academic hospital-based outpatient surgery center. Unused pharmaceuticals and disposable surgical materials were recorded for each of 34 consecutive oculofacial plastic surgeries performed by the same surgical team. Pharmaceutical products were grouped as local anesthetic (tetracaine, bupivacaine, lidocaine, and sodium bicarbonate), intraoperative (basic saline solution, methylene blue, and oxymetazoline hydrochloride), or antiseptic/antimicrobial (erythromycin ointment and hydrogen peroxide). Percentage of unused pharmaceutical product and disposable surgical material were calculated and extrapolated to direct costs to the institution and greenhouse gas emissions.

RESULTS

The mean percentage of disposable surgical supply waste per case was 11.6% ($29.32). The mean percentage of pharmaceutical waste was 96.1% ($271.84) for local anesthetic, 71.0% ($163.47) for intraoperative medications, and 26.7% ($2.19) for antiseptic medication. The mean emissions per surgical case for unused disposable surgical equipment and unused pharmaceutical product were 10 and 103 kg of carbon equivalent gases (kg CO2-e), respectively.

CONCLUSIONS

Surgical supply waste was nominal, but pharmaceutical waste was considerable in this single hospital-based outpatient surgery center study. There may exist opportunities for quality improvement in waste, especially pharmacologic burden, in oculofacial plastic surgery.

Sustainability Initiatives in the Operating Room

BACKGROUND

Operating rooms (ORs) contribute up to 30% of a hospital's waste, are very resource-intensive, and thus provide an opportunity for improvement.

METHODS

A narrative review was conducted, searching MEDLINE, EMBASE, and ProQuest databases. The study included 78 of the 108 published articles.

RESULTS

The researchers identified and categorized articles according to the following major themes: Committee and Leadership; Waste Reduction; Segregating OR waste; Minimizing unnecessary devices and packaging; Reducing energy consumption; Choosing anesthetic gases; Education; Reducing water consumption; Different surgical venues; Donating medical supplies. Formation of an OR committee or a hospital Green Team dedicated to environmentally sustainable initiatives can significantly improve health care's impact on the environment while saving money. Changes in supply chain with preferences for reusable devices, effective recycling, repurposing instruments, and donating items can all be effective means of diverting waste away from landfills. Reducing unnecessary packaging and instruments would eliminate excess in the waste stream. Curtailing energy and water usage results in cost and environmental savings. Surgical venue (inpatient vs. outpatient surgical center) can also contribute to waste. Transitioning away from certain inhaled anesthetics can minimize greenhouse gas impact. Education to all levels in the health care system is important to drive change and maintain change.

CONCLUSION

Optimizing efficiency and decreasing waste generation can have a positive impact on the environment and can be accompanied by cost reduction. Because the field of sustainability in health care is young but burgeoning, increased research is needed to support evidence-based approaches.

Improving productivity, costs and environmental impact in International Eye Health Services: using the 'Eyefficiency' cataract surgical services auditing tool to assess the value of cataract surgical services

Objective

Though one of the most common surgeries, there is limited information on variability of practices in cataract surgeries. ‘Eyefficiency’ is a cataract surgical services auditing tool to help global units improve their surgical productivity and reduce their costs, waste generation and carbon footprint. The aim of the present research is to identify variability and efficiency opportunities in cataract surgical practices globally.

Methods and Analysis

9 global cataract surgical facilities used the Eyefficiency tool to collect facility-level data (staffing, pathway steps, costs of supplies and energy use), and live time-and-motion data. A point person from each site gathered and reported data on 1 week or 30 consecutive cataract surgeries. Environmental life cycle assessment and descriptive statistics were used to quantify productivity, costs and carbon footprint. The main outcomes were estimates of productivity, costs, greenhouse gas emissions, and solid waste generation per-case at each site.

Results

Nine participating sites recorded 475 cataract extractions (a mix of phacoemulsification and manual small incision). Cases per hour ranged from 1.7 to 4.48 at single-bed sites and 1.47 to 4.25 at dual-bed sites. Average per-case expenditures ranged between £31.55 and £399.34, with a majority of costs attributable to medical equipment and supplies. Average solid waste ranged between 0.19 kg and 4.27 kg per phacoemulsification, and greenhouse gases ranged from 41 kg carbon dioxide equivalents (CO2e) to 130 kg CO2e per phacoemulsification.

Conclusion

Results demonstrate the global diversity of cataract surgical services and non-clinical metrics. Eyefficiency supports local decision-making for resource efficiency and could help identify regional or global best practices for optimising productivity, costs and environmental impact of cataract surgery.