Hospital chain in India sets a model for low carbon footprint, environment-friendly cataract surgery

Health care procedures are a large contributor to carbon emissions throughout the world. As awareness and concerns about the environmental issues related to global warming increase, the high impact of current surgical procedures and the need for alternative, more sustainable strategies have become a new research focus. In this scenario, the cataract surgery model employed by the hospitals in the Aravind Eye Care System in India is raising great interest internationally.

“In 2015 I was involved by Cassandra L. Thiel, PhD, a postdoctoral researcher at the University of Pittsburgh, in a sustainability research project in ophthalmology. She was interested in the lower environmental impact of our cataract surgery model,” Rengaraj Venkatesh, MD, chief medical officer at Aravind Eye Hospital, Pondicherry, India, said.

“We were not aware at the time that our high-volume, cost-effective cataract surgery protocol was also environment-friendly,” he said.

Reusing, saving energy, reducing waste

Aravind’s reduced carbon footprint is due primarily to the use of reusable materials. The surgical instruments, phaco tips, sleeves and irrigation-aspiration handpieces are flash sterilized in between surgeries, while the tubing and cassettes of phaco machines are disposed only at the end of the day.

Image: Venkatesh R

 

“We also use the same gloves for 10 consecutive cases, disinfecting them with antiseptic solution after each case. Gowns and large drapes are also washed, dried and autoclaved,” Venkatesh said.

Each surgery completed at Aravind results in an average 0.25 kg of waste, of which two-thirds is recycled. In a Western hospital, according to Thiel, 6.5 kg to 8.5 kg of waste is generated by the same procedure, all of which goes to a landfill.

“In the United States and Europe, where flash sterilization is not recommended, the full-cycle sterilization takes 1 to 2 hours. If you do 20 cases, you need to have 20 surgical sets, while we need seven or eight sets and flash sterilize them in between cases, which takes 15 to 20 minutes,” Venkatesh said.

To optimize time and energy consumption, each surgeon operates on two tables, assisted by two scrub nurses and a circulating nurse. By the time one surgery is completed, the second scrub nurse has prepared the next case.

“We save a lot of time and a lot of electricity, and this allows us to deal efficiently with high-volume surgery. With 8 to 10 surgeons working with this two-table system, 10 cases per hour can be comfortably performed by each surgeon,” Venkatesh said.

A low rate of infection

Aravind has rigorous data collection procedures, which have shown that the infection rate is low. The endophthalmitis rate is 0.05%, which compares favorably with the international rate of 0.08%.

“This in spite of reusing, flash sterilizing and not changing the tubing and cassettes for every case, and also taking into account that many of our patients come from outreach eye camps where literacy and hygiene are often below standards. This shows that nothing of what we do puts safety at risk,” Venkatesh said.

Reducing the carbon footprint also comes from cutting down on transport.

“We use city centers and primary eye care centers called the vision centers to do postoperative follow-up for cataract patients,” Venkatesh said. “We are also discussing with Aurolab, our provider of intraocular lenses, to do a special smaller packaging for the IOLs we use internally. In addition, we are bringing solar energy to our hospitals.”

The government of India has brought new guidelines for disposal of biomedical waste that enable recycling of waste generated during surgery, thereby minimizing the waste that goes to the landfill, according to Venkatesh.

The footprint of cataract surgery

In 2013, researchers from the United Kingdom published a benchmark component analysis study on the carbon emissions per cataract surgery. Daniel S. Morris, FRCSEd(Ophth), a consultant ophthalmologist at the University Hospital of Wales, U.K., and lead author of the study, noted one cataract surgery had a carbon footprint of 181.1 kg carbon dioxide equivalent (CO₂ eq).

The study included 2,230 patients treated for cataracts in Cardiff. The procedures had a total carbon footprint of 405.4 tons of CO₂ eq. Putting this into context, the average carbon footprint for one U.K. resident per year is generally estimated at 10 tons of CO₂ eq, which is 5 to 10 times more than the quantity per passenger generated by a flight to New York from London, according to the study.

“There is a lot of waste with every cataract surgery. In our study, we were looking at three different areas for each procedure. One was the energy use in the hospital, the second was the travel made by patients and staff, and the third was the procurement and disposal of equipment for the surgery (instruments, IOL, etc.). We saw, potentially, that there was a lot of energy being used during a surgery and by getting to and from a procedure, but the procurement section came out the highest per procedure,” Morris said, totaling 54% of the total emissions for each surgery.

The Royal College of Ophthalmologists published an Ophthalmic Services Guidance in 2013 that urged the United Kingdom to put more of an emphasis on sustainability in ophthalmology. The guidance said that cataract surgeries are an ideal area in which to “target carbon reduction strategies.”

Is Aravind model exportable?

Many hospitals across India, Nepal, Indonesia, the Philippines, Sri Lanka, Malawi, Nigeria, Kenya, Congo and Ghana have adopted the Aravind model.

“The Lions Aravind Institute of Community Ophthalmology provides consultancy on capacity building, so that these hospitals don’t have to reinvent anything, just adopt the Aravind model and rapidly become self-sufficient,” Venkatesh said.

Interest is growing in the developed world as well. Golden Jubilee Hospital in Glasgow, Scotland, deals with high-volume cataract surgery and recently received a significant investment by the Scottish government to expand services. A Scottish delegation recently visited the Aravind hospital.

“If you implement some of our model, whatever your regulations would allow, I am sure you can make a big impact in saving cost as well as being friendly to the environment,” Venkatesh said.

Marie-José Tassignon, MD, PhD, OSN Europe Edition Associate Editor, visited Aravind and said she was greatly impressed by the efficient system that keeps the cost for private patients affordable, which allows the hospital to use this money to treat patients who cannot pay.

“Also, their attitude toward environmental issues is something we should look at. Most of us have never considered the impact of our profession in terms of pollution. We should definitely be more eco-conscious in our practice, but on the other hand, regulations are forcing us into the opposite direction of producing more and more waste and consuming an increasing amount of energy,” she said.

Regulations should be re-evaluated to cut down on what is harmful for the environment without compromising safety.

“Reducing waste means, for instance, stop accepting the very expensive custom procedure packs that are marketed as mandatory to guarantee safety. And for sure there are alternatives to a lot of things, like the bulky disposable drapes, and less costly,” Tassignon said.

The same surgery completed in the United States results in about 10 times the amount of waste when compared with the Aravind model, Thiel said.

“That is what we are trying to explore in America, how far we can get within existing policies and what can we work toward changing. There is reusable equipment available, but there is a whole other mess of questions that arise when you get into switching to reusable equipment. You have to look at third-party suppliers that can help sterilize these things, what the cost is per system, and if you may need more space to store those systems — space can be limited in a hospital. Those are options and certainly available in our framework,” she said.

“We are often caught in a loop, where whatever we do to consume less ends up into consuming more in terms of time and resources,” Tassignon said. “For instance, multiple-dose vials cost less and reduce waste, but require a lot of surveillance, time-consuming paperwork and verification processes, as well as carrying a higher risk of human mistakes and contamination. At the end of the day, they may cost more because there is more time and more personnel involved and therefore less time for the patients. No wonder single doses are by far preferred nowadays.”

Regulators, health economics experts, hygiene professionals and doctors should work together with industry to develop new strategies, she said.

New health care standards in India

New health care standards introduced in India by the National Accreditation Board for Hospitals and Healthcare Providers (NABH) may impose changes to the Aravind system.

“We may have to comply with new regulations for accreditation and to be recognized by the insurance companies. Most of the NABH standards are for general hospitals, and specific allowances are made for specialty eye hospitals — and we have a lot of them because of the backlog of cataract and need for eye care,” Venkatesh said. “Even though the new standards have addressed several issues relating to keeping the cost low, it may still force us to being less environment-friendly, but we are looking at other ways to keep efficiency high and the carbon footprint low,” he said. “Once a paradigm shift is made, you cannot go back. You want to do more in that direction, make things better and spread the awareness among others.” – by Michela Cimberle and Robert Linnehan

References:

Morris DS, et al. Eye (Lond). 2013;doi:10.1038/eye.2013.9.

Ravindran RD, et al. J Cataract Refract Surg. 2009;doi:10.1016/j.jcrs.2009.01.002.

Somner J, et al. J Cataract Refract Surg. 2009;doi:10.1016/j.jcrs.2008.09.026.

The Royal College of Ophthalmologists, Ophthalmic Services Guidance. Sustainability in Ophthalmology Executive Summary. The Royal College of Ophthalmologists Web site. https://www.rcophth.ac.uk/wp-content/uploads/2014/11/2013_PROF_222_Sustainability-in-Ophthalmology-May-2013.pdf.

Thiel C, et al. Green cataract surgery: Waste generation and carbon footprint of phacoemulsification at Aravind Eye Hospital in Pondicherry, India. Presented at: American Ophthalmological Society meeting; May 19-22, 2016; Colorado Springs, Colo.

Venkatesh R, et al. Curr Opin Ophthalmol. 2016;doi:10.1097/ICU.0000000000000228.

For more information:

Daniel S. Morris, FRCSEd(Ophth), can be reached at University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, United Kingdom; email: dsm@doctors.org.uk.

Marie-José Tassignon, MD, PhD, can be reached at Department of Ophthalmology, Antwerp University Hospital, Wilrijkstrtaat 10, 2650 Edegen, Belgium; email: marie-jose.tassignon@uza.be.

Cassandra L. Thiel, PhD, can be reached at University of Pittsburgh, 4200 Fifth Ave., Pittsburgh, PA 15260, USA; email: clthiel@gmail.com.

Rengaraj Venkatesh, MD, can be reached at Aravind Eye Hospital, Cuddalore Main Road, Thavalakuppam, 605 007, Pondicherry, India; email: venkatesh@pondy.aravind.org.

Disclosures: Morris, Tassignon, Thiel and Venkatesh report no relevant financial disclosures.

 

At a time of increasing concern about global warming, how does the environmental impact of reusable and disposable instruments compare?

Think about reusing more, managing waste better

We, as ophthalmic surgeons, are polluting quite a lot. Taking into consideration how small the eye is, it is unbelievable the amount of waste we produce for a single surgical procedure. Our peers 30 years ago would not believe where we are today. I am not too old but old enough to remember the times when we had literally, with the exception of syringes, no disposable tools at all for cataract surgery, including the drapes and scrubs. All that was revolutionized in favor of disposable. It is on one side very good because it enhances safety, but on the other side we are polluting a lot and should think about that.

If I were granted a wish, I would want an environment-friendly machine to convert disposables into heat and electricity for the clinic. First, I would not have to pay for the waste to be disposed somewhere else; second, I would save on energy bills; and third, I would avoid some of the pollution produced by trucks coming in and out for the waste. I do not know what the regulations are in other countries, but in the Czech Republic all the disposable waste generated by cataract surgery — which is bloodless surgery with a low risk of infection — is considered to be an infectious hazard, and we have to put it into red boxes, label it and send it to be destroyed as a highly infectious material. This prevents us from separating materials, and yet the small plastic IOL containers are not infectious and could be piled one into the other to save space and be disposed of with the recyclable plastics. The same applies to syringes that contain only saline solution. But current rules prevent us from doing so.

One small thing I do and teach co-workers is to put the surgical gloves into the sleeve of the gown and then fold the gown tightly into its sleeve to save space in the garbage. In my clinic, we reuse the phaco handpiece and instruments such as the chopper and spatula. We use disposable syringes and cartridges, while phaco tips and cannulas are sometimes disposable and sometimes reusable. We tend to reuse some instruments because it is cost-effective, easier and more environment-friendly. At the clinic, including the OR, we run paper-free electronic medical records and have online access to diagnostic devices so there are no printouts needed for our surgical patients. We only print a final report for them as a handout.

Pavel Stodulka, MD, PhD, is an OSN Europe Edition Board Member and CEO of Gemini Eye Clinic, Zlin and Prague, Czech Republic. Disclosure: Stodulka reports he is a consultant for Bausch + Lomb.

Reusable instruments are not worth the additional risk

No one would argue that disposables are advantageous over reusable instruments from the point of view of carbon emission and global warming. However, we need to consider the trade-off between the benefits for global warming and the risks for patients and surgeons associated with reusable devices. The biggest fear for surgeons is probably the risk of toxic anterior segment syndrome associated with traces of OVDs or tissue on the surface of surgical instruments. Biofilm accumulation is also a source of infection and was found to be the cause of iatrogenic transmission of Creutzfeldt-Jakob disease in elderly patients and children.

To minimize contamination hazards with reusable instruments in a busy OR, a strict and complex sterilization protocol needs to be implemented. This requires reliable professionals, time and energy, which eventually result in increased costs for operating and maintaining the system.

One may say that the quality of reusable instruments is much better. This is true in general, but reusable instruments deteriorate with time and use, and evaluating time-correlated degradation is difficult and often merely subjective.

Therefore, similar to the needles, blades, knives, syringes, tubes, drapes and gowns, I think that reusable instruments should be kept to a minimum when the quality and cost of the alternative disposables are acceptable. If many surgeons start replacing reusable with disposable instruments, the price of disposables will eventually be cut down by effect of mass production. Also, simplifying the procedures will be helpful to reduce the need for reusable instruments.

Naoyuki Maeda, MD, PhD, is a professor at the Department of Ophthalmology, Osaka University, Japan. Disclosure: Maeda reports he has received a research grant from Topcon.