Operating room greening initiatives - the old, the new, and the way forward: A narrative review

Eco-sustainability in ophthalmology

PURPOSE OF REVIEW

The purpose of this review is to evaluate the current state of eco-sustainability in ophthalmology, highlighting key practices, recent advancements, and areas requiring improvement. This review aims to provide ophthalmologists with a comprehensive overview of sustainable practices that can reduce environmental impact.

RECENT FINDINGS

Recent studies have identified several areas within ophthalmology where sustainable practices can be implemented including multidose eyedrops, adjusting surgical packs, making package inserts available electronically, and reusing surgical instruments. Moreover, there is an increasing emphasis on waste reduction both in the surgical and clinical setting, by decreasing the use of unnecessary materials and implementing more efficient use of recycling programs. Telemedicine has also emerged as a sustainable option, reducing the carbon footprint associated with patient travel. Despite these advancements, significant challenges remain, particularly in balancing the cost and accessibility of sustainable options with traditional practices.

SUMMARY

Eco-sustainability in ophthalmology is gaining momentum as the medical community aims to reduce its environmental impact. While progress has been made, further efforts are required to overcome financial and logistical barriers to widespread implementation. Continued research, education, and policy development are essential to advancing eco-sustainable practices, ensuring that environmental considerations become an integral part of ophthalmic care.

The environmental impact of hip and knee arthroplasty: An analysis of carbon emissions and disposal costs

BACKGROUND AND PURPOSE

The rise in hip and knee arthroplasty for osteoarthritis requires addressing healthcare system pollution to support Ireland's climate change goals. This research aimed to quantify waste generated and determine environmental and economic impacts to promote sustainable strategies in joint arthroplasty and shed light on the suboptimal waste management practices.

METHODS

The study was conducted at National Orthopaedic Hospital Cappagh (NOHC), measuring waste generated during hip and knee arthroplasty. Clinical, domestic, and recycled waste weights were recorded, including the segregation of Central Sterile Supply Department (CSSD) Blue Wrap waste in ten operations. Kilograms of carbon dioxide emissions (kgCO2e) and disposal costs were calculated.

RESULTS

In a sample of 100 joint arthroplasty operations, the study found that revision knees produced 23.58 ​kgCO2e per case, revision hips 23.50 ​kgCO2e, primary knees 15.82 ​kgCO2e, and primary hips 14.64 ​kgCO2e. CSSD Blue Wrap contributed on average 13.5% of OT waste. Extrapolating these findings to the estimated number of joint arthroplasties performed in 2022 ​at NOHC (1556 hip and knee joint arthroplasties), the emissions were estimated to be 24,576 kgCO2e, with the cost of disposal up to €29,228. Strategies to mitigate this waste have been identified and proposed.

CONCLUSION

The research aimed to address the environmental impact of orthopaedic joint arthroplasties, offering strategies to reduce waste generation, carbon emissions, and cost. Utilising our methodology to calculate greenhouse gas emissions will empower sustainability offices to conduct their own waste audits and implementing our strategies for waste management practices can help minimise environmental waste.

Role of green and sustainable practices in shaping the future of medical imaging technology: A cross-sectional multi-stakeholder analysis among students, radiographers, and academic experts

INTRODUCTION

The detection and treatment of diseases like COVID, diabetes, cancer, cardiovascular conditions, etc., have made medical imaging technology more necessary, so it is expected that the demands of imaging modalities are also increasing and are major contributors to carbon emissions in the healthcare industry. Hence, the Radiology departments, like the rest of the healthcare industry should adapt the procedures to become more sustainable.

METHODS

A total of 1016 respondents completed the online survey to assess the perception, current practices, and challenges in adopting green and sustainable practices in medical imaging. The radio technologists, teaching faculties, and students of medical imaging were recruited for the study. The survey tool was distributed to the closed groups through social media and emails.

RESULTS

The majority of participants (66.6%) highlighted the importance of green and sustainable practices in medical imaging whereas only 21.06% of participants seem to have implemented these practices. Most of the participants give positive responses on the use of zero-lead aprons (77%), refurbished medical systems (85.8%), and eco-friendly packaging (89.5%). The mixed response was received from waste segregation and energy-saving measures. The majority (60.3%) of them have no formal education or training. However, they have a good attitude towards the willingness to adopt green practices.

CONCLUSIONS

There is a gap between perception and implementation of green and sustainable practices due to leadership and information barriers. Comprehensive training for stakeholders of medical imaging is crucial to fully integrate sustainability practices, possibly through webinars or educational modules.

IMPLICATIONS FOR PRACTICE

The study's findings shed light on how important medical imaging stakeholders view green and sustainable practices as well as potential obstacles to their implementation at the local level whilst suggesting the need for exclusive training on these practices to promote sustainability.

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

OBJECTIVE

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

DESIGN

Systematic review and structured synthesis.

SEARCH SOURCES

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

SELECTION CRITERIA

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

MAIN OUTCOME MEASURES

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

DATA COLLECTION AND ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42022309428.

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.

The surgical outpatient clinic and the environment

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Carbon Footprint of Open Carpal Tunnel Release Surgery Performed in the Procedure Room Versus Operating Room Setting

PURPOSE

Environmental sustainability is an important issue in health care because of large amounts of greenhouse gases attributable to hospitals. The operating room has been highlighted as one of the highest contributors, prompting several initiatives by organizations focused on the care of hand and upper extremity conditions. This study aimed to quantify and compare the carbon footprint of a common hand surgery in two different surgical settings, the procedure room (PR) and operating room. We hypothesized that open carpal tunnel release (oCTR) will generate a greater environmental impact in the operating room than in the PR.

METHODS

This was a retrospective review of oCTRs performed at a tertiary care medical center. Current procedural technology codes isolated a single cohort of patients who underwent bilateral oCTR, one side performed in the PR and the contralateral side in the operating room. Current published emission conversions were used to calculate carbon footprint at our institution based on energy expenditure necessary for the creation and disposal of waste and sterilization of surgical equipment. Surgery time was combined with heating, ventilation and air conditioning/lighting energy consumption to estimate facility emissions.

RESULTS

Fourteen patients had bilateral oCTR surgery performed in both settings. Open CTR performed in the operating room generated 3.7 kg more solid waste than when performed in the PR. In total, emissions from oCTR performed in the operating room generated 32.4 kg CO2, whereas oCTR in the PR emitted 13.0 kg CO2 per surgery.

CONCLUSIONS

Performing a common hand procedure (oCTR) is more environmentally sustainable in the PR than in the operating room, with a 60% reduction in carbon footprint.

CLINICAL RELEVANCE

Greater effort should be made to perform surgery in the PR instead of the operating room in appropriately indicated patients. Surgical sets should be evaluated for the necessity of included equipment and unnecessary waste.

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

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

How to choose between single-use and reusable medical materials for sustainable nursing: Methodological lessons learned from a national study

AIM

To demonstrate and reflect upon the methodological lessons by which healthcare organizations can address questions of environmental sustainability related to single-use healthcare materials.

DESIGN

A cross-sectional multi-centre study in hospitals was performed, followed by an exploratory analysis of the sustainability of commonly used healthcare materials.

METHODS

A hospital survey was conducted to collect the procurement data for single-use medical materials. Based on consumption and cost, five single-use medical materials with sustainable alternatives were selected using different reuse strategies. Single-use and reusable materials were assessed through an exploratory literature review and document study based on four parameters: environmental sustainability, safety, cost and efficiency.

RESULTS

A pragmatic method emerged from this study, providing healthcare facilities with tools to select environmentally sustainable alternatives to replace single-use options. First, an inventory of single-use medical materials consumed was collected. Next, single-use materials were prioritized for further study based on criteria such as cost, volume of the material, feasibility and input of stakeholders. We then analysed the prioritized single-use materials and their alternatives based on life cycle assessments or available information on their different life stages. Finally, we assessed safety, costs and efficiency related to the process following the use of the medical material.

CONCLUSION

This pragmatic method can guide healthcare institutions in making the most sustainable choices of medical materials and achieving sustainability goals within their institutions and nationwide.

IMPACT

Patient care involves a large consumption of single-use medical materials with considerable environmental impact. A pragmatic method was developed to guide healthcare institutions in making the most sustainable choices regarding the use of single-use healthcare materials. Healthcare institutions, ideally represented by a green team including nurses and other relevant professionals, can use this method to reduce the use of single-use medical materials, thereby yielding positive outcomes for the entire population.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Toward Environmentally sustainable surgery: Waste recycling in general surgery operating room. Preliminary cognitive audit

BACKGROUND

It is common practice to classify waste from the operating theater as "clinical". The development of sustainable policies could have a significant impact. In the first phase, our study aims to measure general surgery waste and to assess the potential financial and carbon savings of appropriate recycling. Based on this information, we will plan for a second phase in which educational interventions will be put in place to promote waste segregation in surgical environments.

METHODS

We conducted a preliminary cognitive audit of the most common general surgery procedures to examine the types and quantity of waste produced. We calculated the economic and environmental impacts of disposing of waste treated as clinical or general, and we measured how much of it could actually be recycled. Then, we attempted a projection of the savings we could expect if recycling policies were implemented.

RESULTS

We found that more than 30% of total waste was actually recyclable. Considering a projection based on annual procedures performed in our hospital, we estimated that for each kind of surgical procedure, we could expect a reduction of the carbon footprint by approximately 6%, and an average 3% reduction in costs every year, only by improving waste segregation in the general surgery operating rooms.

CONCLUSION

There could be a great potential for reducing environmental and economic footprint of the operating rooms by promoting waste recycling protocols. Surgeons are in a unique position to implement for these protocols. Interventions should be codesigned with theater staff to create a "green culture".

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

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

Healthcare in the era of climate change and the need for environmental sustainability

ABSTRACT

Climate change is an existential threat to humanity. While the healthcare sector must manage the health-related consequences of climate change, it is a significant contributor to greenhouse gas emissions, responsible for up to 4.6% of global emission, aggravating global warming. Within the hospital environment, the three largest contributors to greenhouse gas emissions are the operating theatre, intensive care unit and gastrointestinal endoscopy. Knowledge of the health-related burden of climate change and the potential transformative health benefits of climate action is important to all health professionals, as they play crucial roles in effecting change. This article summarises the available literature on the impact of healthcare on climate change and efforts in mitigation, focusing on the intrinsic differences and similarities across the operating theatre complex, intensive care unit and gastrointestinal endoscopy unit. It also discusses strategies to reduce carbon footprint.

Environmental Sustainability and MRI: Challenges, Opportunities, and a Call for Action

The environmental impact of magnetic resonance imaging (MRI) has recently come into focus. This includes its enormous demand for electricity compared to other imaging modalities and contamination of water bodies with anthropogenic gadolinium related to contrast administration. Given the pressing threat of climate change, addressing these challenges to improve the environmental sustainability of MRI is imperative. The purpose of this review is to discuss the challenges, opportunities, and the need for action to reduce the environmental impact of MRI and prepare for the effects of climate change. The approaches outlined are categorized as strategies to reduce greenhouse gas (GHG) emissions from MRI during production and use phases, approaches to reduce the environmental impact of MRI including the preservation of finite resources, and development of adaption plans to prepare for the impact of climate change. Co-benefits of these strategies are emphasized including lower GHG emission and reduced cost along with improved heath and patient satisfaction. Although MRI is energy-intensive, there are many steps that can be taken now to improve the environmental sustainability of MRI and prepare for the effects of climate change. On-going research, technical development, and collaboration with industry partners are needed to achieve further reductions in MRI-related GHG emissions and to decrease the reliance on finite resources. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 6.

Go Green in Neuroradiology: towards reducing the environmental impact of its practice

Raising public awareness about the relevance of supporting sustainable practices is required owing to the phenomena of global warming caused by the rising production of greenhouse gases. The healthcare sector generates a relevant proportion of the total carbon emissions in developed countries, and radiology is estimated to be a major contributor to this carbon footprint. Neuroradiology markedly contributes to this negative environmental effect, as this radiological subspecialty generates a high proportion of diagnostic and interventional imaging procedures, the majority of them requiring high energy-intensive equipment. Therefore, neuroradiologists and neuroradiological departments are especially responsible for implementing decisions and initiatives able to reduce the unfavourable environmental effects of their activities, by focusing on four strategic pillars-reducing energy, water, and helium use; properly recycling and/or disposing of waste and residues (including contrast media); encouraging environmentally friendly behaviour; and reducing the effects of ionizing radiation on the environment. The purpose of this article is to alert neuroradiologists about their environmental responsibilities and to analyse the most productive strategic axes, goals, and lines of action that contribute to reducing the environmental impact associated with their professional activities.

Knowledge of surgeons and practical stances of healthcare institutions in the Ile-de-France region toward sustainable development: A cross-sectional study

PURPOSE OF THE STUDY

Climate change represents one of the gravest threats to health. Surgical activities mobilize a large number of resources which contribute to increased emission of CO2 and anesthetic gases in the environment. The objective of this study was to assess the level of knowledge of surgeons and the practical stances of healthcare establishments toward sustainable development.

METHODS

This was a descriptive cross-sectional study, lasting 2 months. From 1 May 2021 to 30 June 2021, surgeons were asked via an online questionnaire to participate.

RESULTS

A total of 131 out of the 457 contacted surgeons responded. A majority practiced in the private sector, 48.9% knew little about the rules of sustainable development in operating theaters, and 43.5% had an average level. The sustainable development charter was available in only 23% of establishments, while 19% had a sustainable development committee, and specific sustainable development actions were carried out in 27%.

CONCLUSION

The level of knowledge of surgeons in Île-de-France on sustainable development was low. In general, surgical units were not complying with the rules of good practice on CO2 reduction. It is necessary to find strategies to reduce the impact of operating theaters on the environment.

"O.R. GOES GREEN": a first step toward reducing our carbon footprint in the operating room and hospital

Hospitals in Europe produce approximately 6 million tons of medical waste annually, about one-third of this originating in operating rooms. Most of it is solid waste, which can be recycled if bodily fluids do not contaminate it. Only 2-3% of hospital waste must be disposed of as infectious waste, and this is much lower than the 50-70% of garbage in the biohazard waste stream. In June 2021, at the main operating room of the Department of General Surgery of the University of Turin, we began a separate collection program for materials consisting of plastic, paper, TNT (material not contaminated by bodily fluids), and biohazardous waste. We calculated the number of boxes and the weight of special waste disposed produced every month in one operating room for 18 months. The monthly number of Sanibox and the monthly weight of biohazardous waste decreased during the observation period. The reduction trend was not constant but showed variations during the 18 months. Direct proportionality between number of low-complexity procedures and production of biohazardous waste was found (p = 0.050). We observed an optimization in the collection and filling of plastic, paper and TNT boxes separated and sent for recycling. One of the barriers to recycling hospital waste, and surgical waste in particular, is the failure to separate infectious waste from clean waste. A careful separate collection of waste in the operating room is the first step in reducing environmental pollution and management costs for the disposal of hospital waste.

Carbon Neutral Hand Surgery: Simple Changes to Reduce Carbon Footprint

Introduction: Rapid climate change poses a major challenge to healthcare. The operating room is especially responsible for carbon emission, with 20% to 70% of hospital waste traced back to the operating room. This literature review aims to suggest changes that can be made in hand surgery for a more sustainable practice. Methods: A literature search was conducted from PubMed, Medline, and other online search engines with the keywords "carbon footprint, environmental health, carbon neutral, plastic surgery, hand surgery, surgery." Results: "Reduce, Reuse, Recycle, Research, Rethink and Culture" was the framework used to recommend a more carbon neutral practice. In reduction, techniques such as cutting down oversupply of materials, adopting protocols to perform cases in ambulatory settings, and simple measures to reduce energy were identified as valuable methods. Modified sterilization techniques and reprocessing single-use devices were techniques identified for reuse and recycling involved single-stream recycling, staff training, and donation of basic surgical supplies. Research involved adopting data-driven programs for life cycle assessment of all equipment in the operating room, while the use of telemedicine and "green meetings' were suggested for rethinking. Finally, strategies to encourage a team approach to environmental responsibility were discussed. Conclusion: Carbon neutral practice must be implemented to safeguard sustainable and cost-effective operating rooms and healthcare systems. Hand surgery can pave the way for other specialties through the use of available resources to develop guidelines for carbon neutral practice. This requires active effort from hand surgeons to act as role models for other healthcare professionals.

Recycling facemasks into civil construction material to manage waste generated during COVID-19

Growing plastic pollution in the context of COVID-19 has caused significant challenges, exacerbating this already out-of-control issue. The pandemic has considerably boosted the demand for personal protective equipment (PPE), such as facemasks and gloves, all over the globe, and mismanaging this growing plastic pollution has harmed the environment and wildlife significantly. To mitigate negative environmental impacts, it is necessary to develop and implement effective waste management strategies. This present study estimated the daily facemask generation throughout the pandemic in Iran based on the distribution of urban and rural populations and, likewise, the daily generation of hand gloves in the COVID-19 era and the amount of medical waste generated by COVID-19 patients were calculated. In the next step, the quantities of discarded facemasks dumped into the Caspian Sea, the Persian Gulf, and the Gulf of Oman from the coastal cities were determined. Finally, the innovative alternatives for repurposing discarded facemasks in civil construction materials such as concrete, pavement, and partition wall panel were discussed.

Greening Hand Surgery: Targeted Measures to Reduce Waste in Ambulatory Trigger Finger and Carpal Tunnel Decompression

BACKGROUND

Operating rooms (ORs) produce approximately 70% of hospital waste. Greening strategies in the OR aim to reduce the environmental impact of surgery while maintaining patient safety and outcomes. The aim of this study was to strategically reduce waste and cost associated with common ambulatory hand procedures by implementing a 3-stage "green case" plan over a 1-year period in a high-volume tertiary referral hand surgery division.

METHODS

A 3-stage greening initiative for hand surgery was designed and implemented in ambulatory open carpal tunnel release (CTR) and trigger finger release (TFR) cases, including: (1) introduction of minor field sterility; (2) implementation of a lean and green minor hand surgery pack and reduced instrument set; and (3) elimination of gown use by surgeons and OR staff. Surgical supply usage and costs were tracked during the study period and compared with control.

RESULTS

Each "green case" resulted in savings of $105 compared with the control cases from the preceding year, excluding cost savings associated with reduced waste processing. There was a 64% and 75% reduction in waste and costs after greening, respectively. This equates to a minimum institutional annual savings of $51 000 when used for CTR and TFR. There was no observed increase in surgical site infections or complications after the introduction of greening.

CONCLUSION

Greening initiatives can be successfully implemented by surgeons to reduce waste and costs. With targeted greening of CTR and TFR procedures, we significantly reduced waste and decreased costs while maintaining patient safety and outcomes.

Barriers and enablers to implementing environmentally sustainable practices in healthcare: A scoping review and proposed roadmap

This scoping review sought to identify the barriers and enablers to implementing environmentally sustainable practices in healthcare, as well as propose a multi-phased approach to enable such implementation. The three concepts guiding the search were (1) environmental sustainability; (2) healthcare; and (3) barriers or enablers. The PRISMA checklist for scoping reviews was used to guide this search. A total of 16 articles were included and reviewed for data extraction. While most articles focused on healthcare in general, dentistry and surgery were the most recurring clinical areas of focus. Barriers and enablers were related to the individual (e.g. knowledge, skills, and attitude), institutional (e.g. budget, strategy, and readiness), geographical/infrastructural (e.g. infrastructure and public awareness), political (e.g. regulations and incentives), and other (e.g. patient awareness and knowledge). A key enabler identified was having transformational leadership with a clear vision and collaborative approach.

Focus on reuse: reducing waste associated with topical preoperative antiseptics

PURPOSE

To outline the environmental and financial costs associated with single-use topical antiseptic (5% povidone-iodine [PVI] solution) in the ophthalmology theatre setting and explore potential methods of repurposing topical antiseptics.

SETTING

Large tertiary referral center (Flinders Medical Centre, Adelaide, Australia).

DESIGN

Single-center prospective observational study.

METHODS

Dedicated containers placed in the ophthalmology theatre of the participating institution were used to collect the number of disposed PVI bottles over the 3-week study period. Descriptive statistics were employed to determine the associated packaging bottle weight, mean unused quantity (mL) and cost of the single-use topical PVI solution and costs of unused antiseptic.

RESULTS

The total amount of waste generated from the use of single-use PVI bottles during the surveillance period was 10.823 kg, of which 21.9% was preventable; 72% of unused PVI by weight were discarded during the study period, equating to approximately $21 857.60 in wasted pharmaceutical content per year. 100% of the discarded PVI was successfully redirected and reused at a local wildlife rescue organisation and diverted from landfill.

CONCLUSIONS

This study has demonstrated that the utilization of single-use topical preoperative PVI preparations is associated with significant financial, pharmaceutical and environmental waste. Future studies examining the recyclability of single-use PVI bottles and investigating systematic strategies to recycle and repurpose this waste are required.

Sustainability in Urology: Ideas for a Greener Future

Sustainability in urology can be achieved via conscientious practices that minimize the negative impact of our services while achieving ethical and responsible patient care. We highlight novel and actionable ideas that could pave the path towards healthier, greener urological practice.

Strategies for efficient management of microplastics to achieve life cycle assessment and circular economy

The anticipated increase in the influx of plastic waste into aquatic environments has propelled the identification and elimination of plastic waste into the global agenda. The plastics sector generates a significant volume of materials, which, due to their extended durability, accumulate rapidly in natural ecosystems. Consequently, this indiscriminate utilization, along with the deposition of plastic waste (PW) in landfills and inadequate recycling practices, leads to diverse economic, social, and environmental consequences. Microplastics (MPs) are a type of PW that has been fragmented into particles measuring less than 5 mm. These particles have been found in several environments, including the air, soil, freshwater, and ocean ecosystems, where they accumulate in large quantities. In order to gain insight into the ecological risks and resource implications associated with a plastic product, it is strongly advised to conduct life cycle and sustainability analyses. Therefore, this paper examines various strategies aimed at achieving effective management of MP waste in order to develop a conceptual framework for MPs in circular economy and life cycle assessment (LCA). The findings of this study provides a new avenue for future research and contribution to manage MP waste as well as reduce their environmentally hazardous impact.

Sustainable surgical practices: A comprehensive approach to reducing environmental impact

This paper presents a comprehensive overview of the environmental impact of surgical procedures and highlights potential strategies to reduce the associated greenhouse gas emissions. We discuss procurement, waste management, and energy consumption, providing examples of successful interventions in each area. We also emphasize the importance of adopting the Green Theatre Checklist as a useful tool for clinicians aiming to implement sustainable surgical practices.

Evaluating the Environmental Impact of Single-Use and Multi-Use Surgical Staplers with Staple Line Buttressing in Laparoscopic Bariatric Surgery

PURPOSE

Operation rooms have a large environmental impact. Single-use staplers (SUS) are widely used surgical instruments that contribute to resource consumption and waste generation, whereas multi-use staplers (MUS) can greatly reduce the environmental impact of surgery. The staple lines are often reinforced with buttressing material to prevent leaks and bleeding. We explore current clinical practice and environmental concerns regarding stapling and buttressing, as well as the environmental impact of staple line buttressing in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, we extend this analysis by taking packaging material and the lithium in power supplies into consideration.

MATERIALS AND METHODS

A survey of bariatric surgeons was conducted to assess stapler and buttressing use in clinical practice. We deconstructed and analyzed the product and packaging composition of a commonly used SUS with separate staple line reinforcement (Echelon Flex™ with Echelon Endopath™, Ethicon) and MUS (Signia™ with Tri-Staple™ reinforced reloads, Medtronic), where the buttressing material was delivered separately or already incorporated in the reload cartridge, respectively. Both systems were compared regarding total waste generation, resource use (determined as total material requirement), and greenhouse gas emission caused by their lithium content.

RESULTS

60 mm cartridges were most frequently used in bariatric surgery, and 67% of surveyed surgeons applied staple line reinforcement. MUS with pre-attached buttressing resulted in a reduction of waste, material consumption, and greenhouse gas emissions compared to SUS with separate buttressing: they reduced product waste by 40% (SG and RYBG), packaging waste by 60% (SG) and 57% (RYGB), resource consumption by more than 90%, and greenhouse gas emissions related to the lithium in the batteries by 99.7%. Preloaded buttressing produced less waste than separate buttressing per stapler firing.

CONCLUSION

The environmental impact of surgery can be greatly reduced by using MUS with pre-attached buttressing rather than SUS with separate buttressing.

[Recycling of Disposable Surgical Instruments - Is It Worth It?]

The German healthcare sector is responsible for 5.2% of the country's greenhouse gas emissions. One contributing factor is the enormous amount of waste generated daily in German hospitals, making them the fifth largest waste producer in Germany. Despite the potential for recycling, a significant portion of hospital waste is incinerated, as mandated by current regulations. This results in high levels of noxious CO2 emissions and the loss of valuable resources. The goal of this project was to demonstrate the feasibility of recycling complex, contaminated disposable surgical instruments.The study included frequently used disposable surgical instruments that could potentially be recycled as electronic waste. The instruments were wipe-disinfected and sterilised internally within the hospital. After sterilisation, the devices could be classified as electronic waste in consultation with the environmental authorities and then machine-recycled externally by a waste disposal company. Sorting machines shredded and separated the instruments into individual fractions of cables, plastics, different metals, and circuit boards, which were further processed into secondary raw materials.In the first six months (09/2022-03/2023), 239 kg of material were recycled instead of being incinerated. This resulted in a reduction of 545 kg CO2e. The metal content was estimated as 50% of the total weight; 30% were recyclable plastics, resulting in an 80% recycling rate. The ongoing recycling costs were 1.90 €/kg after deducting revenues. Thus, recycling in this model was approximately 3.9 times as expensive as incineration. A survey of the operating theatre personnel found high satisfaction with the recycling project and a minimal additional workload of less than five minutes.We demonstrated that recycling of contaminated disposable surgical instruments is possible in coordination with government authorities. This approach avoids waste incineration and leads to a reduction in CO2-equivalent emissions. However, the higher costs of recycling and the requirement for in-house decontamination pose limitations on the implementation of such projects. To address this, it is necessary for lawmakers to reconsider current regulations and involve manufacturers in recycling costs to fully exploit the enormous recycling potential.

Assessing the environmental impact of an anastomotic leak care pathway

Background

The healthcare sector faces increasing pressure to improve environmental sustainability whilst continuing to meet the needs of patients. One strategy is to lower the avoidable demand on healthcare services, by reducing the number of surgical complications, such as anastomotic leak (AL). The aim of this study was to assess the environmental impact associated with the care pathway of AL.

Methods

An environmental impact assessment was performed according to the Sustainable Healthcare Coalition (SHC) guidelines. A care pathway, describing the typical steps involved in the diagnosis and treatment of AL was developed. Activity and emission data for each stage of the care pathway were used to calculate the climate, water and waste impact of the treatment of AL patients.

Results

The environmental impact assessment shows that AL is associated with an average climate, water and waste impact per patient of 1303 kg CO₂-eq, 1803 m³ of water and 123 kg waste, respectively. Grade C leaks are associated with the greatest environmental impact, contributing to 89.3 %, 79.4 % and 97.9 % of each impact, respectively. A breakdown of the environmental impact of each activity shows that stoma home management is the largest contributor to the total climate (46.6 %) and waste (47.3 %) impact of AL patients, whilst in-patient hospital stay contributes greatest to the total water impact (46.7 %).

Conclusions

The treatment of AL is associated with a substantial environmental impact. This study is, to our knowledge, the first to assess the environmental impact associated with the treatment of AL.

The Green Maternity project: A midwife-led initiative to promote correct waste segregation on an Australian postnatal ward

AIMS

Healthcare waste production is a significant contributor to carbon emissions, negatively impacting the environment. Ineffective healthcare waste disposal results in greater measures to manage it which is costly to both the environment and healthcare organizations. This study aimed to improve waste management in a tertiary maternity hospital. Specifically, the impact of a midwife-led intervention to improve waste segregation, staff knowledge and attitudes and waste management-related costs was investigated.

DESIGN

A multi-method study including pre- and post-intervention staff waste management knowledge and attitude surveys and waste audits of bins located on the postnatal ward.

METHODS

The intervention included education sessions, posters and signage by waste bins and monthly newsletters distributed throughout 2021 to raise staff awareness of correct waste segregation processes. Pre- and post-intervention surveys were distributed in early 2021 and early 2022, respectively. The waste audits occurred on three occasions, January, July and December of 2021. The waste audit included total waste in kilograms (kg), waste in kg by segregation and identification of correct and incorrect segregation. Waste audit and quantitative staff survey data were analysed using descriptive statistics and chi square. Qualitative data from the staff surveys were analysed using content analysis.

RESULTS

Knowledge and attitudes to waste management were similar across pre- and post-intervention staff surveys. Knowledge of accurate allocation of specific items to waste streams was variable with errors identified in both the pre- and post-surveys. Waste audit data showed reductions in clinical waste at each measurement, with a 71.2% decrease in clinical waste from baseline to the final audit. Accuracy of waste segregation also improved from the baseline to final audit, resulting in a 48% reduction in waste management costs.

CONCLUSION

The midwife-led initiative improved waste segregation and achieved the associated waste management cost reduction.

IMPACT

A midwifery-led initiative to address waste production and segregation on a maternity ward had a positive impact on waste segregation practices and associated waste management costs. The existence of change champions along with in-service sessions, posters and newsletters to raise awareness of correct waste segregation resulted in a 71% reduction of incorrect items being placed in clinical waste bins. Challenges such as COVID-19 pressures and workload made it difficult for midwives to engage in waste management education and effective waste segregation.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Implementing clinician-led waste management interventions across hospital wards while addressing workload issues are likely to have significant cost benefits for organisations and minimise the environmental impacts of healthcare settings.

Climate Change and Healthcare: Creating a Sustainable and Climate-Resilient Health Delivery System

Climate change poses global challenges as rising temperatures, recurring natural disasters, and the resulting increase in the prevalence of acute and long-term climate-related diseases threaten the health and safety of populations worldwide. The healthcare sector, one of the largest sources of greenhouse gas emissions globally, both exacerbates and suffers from these effects. As leaders in their local communities and the national economy, hospitals and health systems have a responsibility to not only build climate resilience to withstand disaster events but also implement sustainability initiatives that will reduce the healthcare sector's carbon footprint. A wide variety of initiatives that can meet all financial plans and timelines are available. This discussion focuses on three of the most impactful areas for opportunity: building resilience through community, operating room sustainability, and renewable energy sources.

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.

Implementation approaches to improve environmental sustainability in operating theatres: a systematic review

Operating theatres consume large amounts of energy and consumables and produce large amounts of waste. There is an increasing evidence base for reducing the climate impacts of healthcare that could be enacted into routine practice; yet, healthcare-associated emissions increase annually. Implementation science aims to improve the systematic uptake of evidence-based care into practice and could, therefore, assist in addressing the environmental impacts of healthcare. The aim of this systematic search with narrative synthesis was to explore what implementation approaches have been applied to reduce the environmental impact of operating theatre activities, described by implementation phases and methodologies. A search was conducted in EMBASE, PubMed, and CINAHL, limited to English and publication since 2010. In total, 3886 articles were retrieved and 11 were included. All were in the exploratory phase (seven of 11) or initial implementation phase (four of 11), but none were in the installation or full implementation phase. Three studies utilised a recognised implementation theory, model, or framework in the design. Four studies used interprofessional education to influence individuals' behaviour to reduce waste, improve waste segregation, or reduce anaesthetic gases. Of those that utilised behaviour change interventions, all were qualitatively successful in achieving environmental improvement. There was an absence of evidence for sustained effects in the intervention studies and little follow-up from studies that explored barriers to innovation. This review demonstrates a gap between evidence for reducing environmental impacts and uptake of proposed practice changes to deliver low-carbon healthcare. Future research into 'greening' healthcare should use implementation research methods to establish a solid implementation evidence base. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42022342786.

Methods and evaluation metrics for reducing material waste in the operating room: a scoping review

BACKGROUND

Operating rooms contribute up to 70% of total hospital waste. Although multiple studies have demonstrated reduced waste through targeted interventions, few examine processes. This scoping review highlights methods of study design, outcome assessment, and sustainability practices of operating room waste reduction strategies employed by surgeons.

METHODS

Embase, PubMed, and Web of Science were screened for operating room-specific waste-reduction interventions. Waste was defined as hazardous and non-hazardous disposable material and energy consumption. Study-specific elements were tabulated by study design, evaluation metrics, strengths, limitations, and barriers to implementation in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 38 articles were analyzed. Among them, 74% of studies had pre- versus postintervention designs, and 21% used quality improvement instruments. No studies used an implementation framework. The vast majority (92%) of studies measured cost as an outcome, whereas others included disposable waste by weight, hospital energy consumption, and stakeholder perspectives. The most common intervention was instrument tray optimization. Common barriers to implementation included lack of stakeholder buy-in, knowledge gaps, data capture, additional staff time, need for hospital or federal policies, and funding. Intervention sustainability was discussed in few studies (23%) and included regular waste audits, hospital policy change, and educational initiatives. Common methodologic limitations included limited outcome evaluation, narrow scope of intervention, and inability to capture indirect costs.

CONCLUSION

Appraisal of quality improvement and implementation methods are critical for developing sustainable interventions for reducing operating room waste. Universal evaluation metrics and methodologies may aid in both quantifying the impact of waste reduction initiatives and understanding their implementation in clinical practice.

How much do we throw away in the intensive care unit? An observational point prevalence study of Australian and New Zealand ICUs

Objective

During the current COVID pandemic, waste generation has been more evident with increased use of single use masks, gowns and other personal protective equipment. We aimed to understand the scale of waste generation, recycling rates and participation in Australian and New Zealand (ANZ) ICUs.

Design

This is a prospective cross-sectional point prevalence study, as part of the 2021 ANZICS Point Prevalence Program. Specific questions related to waste and sustainability practices were asked at the site and patient level.

Setting and participants

ANZ adult ICUs and their patients on the day of the study.

Main outcome measures

Amount of single use items disposed of per shift, as well as the engagement of the site with sustainability and recycling practices.

Results

In total, 712 patients (median number of patients per ICU = 17, IQR 11-30) from 51 ICUs across ANZ were included in our study; 55% of hospitals had a sustainability officer, and recycling paper (86%) and plastics (65%) were frequent, but metal recycling was limited (27%). Per patient bed space per 12-h shift there was recycling of less than 40% paper, glass, intravenous fluid bags, medication cups and metal instruments. A median of 10 gowns (IQR 3-19.5), 10 syringes (4.5-18) and gloves 30 (18-49) were disposed of per bed space, per 12-h shift. These numbers increased significantly when comparing patients with and without infection control precautions in place.

Conclusions

In ANZ ICUs, we found utilisation of common ICU consumables to be high and associated with low recycling rates. Interventions to abate resource utilisation and augment recycling are required to improve environmental sustainability in intensive care units.

The Environmental Impact of Spine Surgery and the Path to Sustainability

STUDY DESIGN

Narrative literature review.

OBJECTIVE

The aim of this study was to review published literature discussing sustainable health care and to identify aspects that pertain to spine surgery.

SUMMARY OF BACKGROUND DATA

In recent years, research has investigated the contribution of surgical specialties to climate change. To our knowledge, no article has yet been published discussing the impact specific to spinal procedures and possible mitigation strategies.

METHODS

A literature search was performed for the present study on relevant terms across four electronic databases. References of included studies were also investigated.

RESULTS

Spine surgery has a growing environmental impact. Investigations of analogous specialties find that procurement is the single largest source of emissions. Carbon-conscious procurement strategies will be needed to mitigate this fully, but clinicians can best reduce their impact by adopting a minimalist approach when using surgical items. Reduced wastage of disposable goods and increased recycling are beneficial. Technology can aid remote access to clinicians, and also enable patient education.

CONCLUSIONS

Spine-surgery-specific research is warranted to evaluate its carbon footprint. A broad range of measures is recommended from preventative medicine to preoperative, intraoperative, and postoperative spine care.

LEVEL OF EVIDENCE

5.

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.

[Prioritized utilisation and reprocessing of reusable equipment in anaesthesiology deparmtents : Recommendations on how to reduce CO2 emissions from anaesthetic equipment]

Currently, few robust data are available to provide estimates of the environmental footprint and in particular the CO₂ emissions of medical devices; however, existing life cycle assessments largely indicate that reusable materials have more favorable emissions and environmental footprints compared to disposable items. Thus, the challenge for every anesthesiology department is to identify items that can be used as reusable products for ecological and other reasons.A prerequisite for the use of reusable items is hygienically correct reprocessing and packaging. Here, a distinction must be made between noncritical, semicritical and critical medical devices, depending on the type of use. In addition, a distinction must be made between categories A-C, depending on the complexity of the reprocessing.In this narrative review article common reusable items used in anesthesiology are categorized and a standardized decision algorithm for reprocessing routes is proposed. Special attention is also given to the packaging of medical devices, which can contribute to the ecological footprint to a relevant extent.This article further explains the framework under which reprocessing can take place and analyzes the current state of knowledge on the life cycle assessment of reprocessing reusable devices.This requires the special commitment of clinically active anesthesiologists to include ecological aspects in the decision to use disposable or reusable items. In the medium term, comprehensible ecological key numbers should be provided on every medical device to make the ecological costs of the articles understandable in addition to the monetary costs.

Operation clean up: A model for eco-leadership and sustainability implementation

Healthcare contributes to environmental harm. Trainee-led Research and Audit in Anaesthesia for Sustainable Healthcare (TRA₂SH) is an Australasian network focused on sustainable anaesthesia practice. TRA₂SH hypothesised that trainee-led audits alongside education presented on a scheduled national day, called Operation Clean Up, can improve engagement with sustainability initiatives. This paper aims to describe the first two years of Operation Clean Up in terms of goals, achievements and data collected so far. Environmental themes for Operation Clean Up were chosen based on available evidence (life cycle analyses and observational studies). The first Operation Clean Up (OCU 2020) focused on reducing the unnecessary use of single-use disposable absorbent pads (known as 'blueys' in Australia, 'greenies' in New Zealand). OCU 2021 included: refuse desflurane, reduce bluey use, reuse drug trays, and recycle paper and cardboard. TRA₂SH provided an information pack to trainees who presented educational material to their department and fed back procurement figures to quantify each item. Descriptive statistics were used to analyse de-identified pooled data submitted to a centralised database.Eight departments submitted data for OCU 2020 and six provided follow-up data. Bluey use was reduced from a median of 37 to 34 blueys per ten surgical encounters. Fifteen departments submitted pre-campaign data for OCU 2021 with follow-up data to be collected during OCU 2022. Baseline data showed a median bluey use of 31 per ten surgical encounters. Volatile-related emissions were calculated; desflurane's proportion was 70% of these emissions yet was 11% of volatile procurement. Two participating departments removed desflurane from their formulary following OCU 2021. Operation Clean Up is a practical model for implementing sustainability initiatives using trainees as eco-leaders.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy

OBJECTIVE

Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role.

DESIGN

In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO_2e) and 1 kg of RMW to 3kgCO_2e was assumed. Paired samples t-tests for comparisons.

RESULTS

From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO_2e by 31.6% (138.8kgCO_2e) was found (mean kgCO_2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO_2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel.

CONCLUSION

In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review

BACKGROUND

Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs.

STUDY DESIGN

A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework.

RESULTS

A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste).

CONCLUSIONS

Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.

Perspectives of vets on plastics in veterinary medicine

INTRODUCTION

The use of disposable plastics and their subsequent environmental impacts are topics of increasing concern in modern society. Medical, including veterinary, sectors are major contributors to plastic waste production. While there is an existing body of literature on the use and reduction of disposable plastics in the human medical sector, few studies, if any, have specifically investigated the use of plastics within the veterinary field. The overall aim of this pilot study was to investigate Australian veterinarians regarding their attitudes toward the ways in which they use disposable plastic in their work and personal lives.

MATERIALS AND METHODS

Seven veterinarians were interviewed, representing a range of demographics and professional backgrounds from multiple states. Thematic qualitative analysis was employed to organise the data into several major themes encompassing many smaller nodes.

RESULTS

The dataset revealed that most, if not all, veterinarians interviewed agree that disposable plastic is used in excess in veterinary medicine, but that veterinarians will never be able to avoid using plastic entirely. Participants supplied differing opinions with respect to the best strategies for reducing plastic waste production within the veterinary field, including recycling, replacing disposable items or improving education.

DISCUSSION

Despite different participants suggesting conflicting ideas, most, if not all, of the ideas presented have support in the scientific literature. This supports a hybrid approach involving refining recycling systems, reducing plastic consumption and improving education on plastic waste production. A hybrid top-down-bottom-up approach must include encouraging cooperation among stakeholders, both within and outside the veterinary sector, as this will be a major contributor to progress. In a broader context, this hybrid approach to inciting change at all levels of the veterinary sector will require engagement from many interdependent entities; as such, this study should act as a starting point for an ongoing process of cooperative change. Recommendations for future research include life cycle analyses of reusable versus disposable veterinary materials; exploring ways to expand sustainability education within and beyond the veterinary sector, and examining methods of improving technology and infrastructure.

Environmental Sustainability in the Cardiac Catheter Laboratory

The health care sector contributes to nearly 5% of global carbon emissions with the exponential growth of medical waste posing a significant challenge to environmental sustainability. As the impact of climate change on individuals and population health becomes increasingly more apparent, the health care system's significant impact on the environment is also raising concerns. Hospitals contribute disproportionately to health care waste with the majority arising from resource intensive areas such as operating theatres and cardiac catheter labs (CCLs). Despite the growing volume of cardiac procedures worldwide, initiatives to reduce waste from CCLs have received limited attention, overlooking opportunities for significant reduction in operational costs and carbon footprint. We aim to raise awareness of the current landscape of waste management in CCLs. We identify areas of resource optimisation and highlight practical strategies and frameworks employed elsewhere in health care to reduce waste. Importantly, we hope to empower health care workers in CCLs to make a meaningful change to their practice and contribute towards a more sustainable future.

Sustainability of dermatological offices and clinics: challenges and potential solutions

Ongoing high consumption of resources results in exceeding the planetary boundaries. Modern healthcare systems contribute to this problem. To address this issue, this article provides an overview of various aspects of sustainable actions in medical offices and clinics that can also be applied to dermatology. Specific fields of action include energy consumption, structural measures, traffic and mobility, organization including digitalization as well as personnel and evaluation. Moreover, we discuss specific topics such as hygiene and cleansing, dermatosurgery and prescription practices. External treatments and cosmetics are discussed separately as dermatological peculiarities. Finally, we provide information on established initiatives for more sustainable health care in Germany. We aim to encourage critical reappraisal of currently established practices and to stimulate the implementation of sustainable measures.

Adopting a portfolio of ultrasonic and advanced bipolar electrosurgery devices from a single manufacturer compared to currently used ultrasonic and advanced bipolar devices: a probabilistic budget impact analysis from a Spanish hospital perspective

AIMS

Advanced energy devices are commonly used in electrosurgery, including ultrasonic and advanced bipolar (ABP) devices. Smoke evacuation and reusable dispersive electrodes are also utilized during electrosurgery to improve staff and patient safety. This study assessed the budget impact of adopting a portfolio of Ethicon energy devices compared to devices from other manufacturers from a Spanish hospital perspective.

METHODS

The main analysis compared the Ethicon advanced energy device portfolio (ultrasonic and ABP devices) to Non-Ethicon advanced energy devices. It was assumed that 4,000 procedures using one advanced energy device each were performed annually, and the cost impact of operating room time, length of stay, and transfusions were considered. A probabilistic budget impact analysis with 10,000 iterations was conducted for generalizability to other hospitals in Spain and Europe. Secondary analysis assessed whether cost savings from the Ethicon advanced energy device portfolio could offset costs of adopting smoke evacuation and reusable dispersive electrodes (Full Ethicon energy portfolio).

RESULTS

In the main analysis, the annual budget impact of introducing the Ethicon advanced energy device portfolio was cost saving in 79.8% of probabilistic iterations (mean: -€945,214; 95% credible interval [CrI]: -€3,242,710; €1,285,942) with a mean budget impact per procedure of -€236 (95% CrI: -€811; €321). In the secondary analysis, adding smoke evacuation and reusable dispersive electrodes was still cost saving in 75.3% of iterations compared to Non-Ethicon advanced energy devices (mean: -€778,208; 95% CrI: -€3,075,086; €1,464,728) with a mean budget impact per procedure of -€97 (95% CrI: -€384; €183). Savings resulted from differences in operating room time, length of hospital stay, and volume of disposable electrodes.

CONCLUSIONS

Adopting Ethicon advanced energy devices demonstrated economic benefits compared to non-Ethicon devices. Introducing the advanced portfolio may improve surgical care quality and the full portfolio was cost saving while improving OR safety for staff and patients.