‘Greening the OR’ initiatives help orthopedic, oncology, pediatric surgery sustainability
Click Here to Manage Email Alerts
Cost savings and a smaller environmental footprint may be achieved by hospitals and health care systems that implement key OR quality improvement strategies, according to a review of quality improvement initiatives and interventions.
Results of a scoping review study by Gwyneth A. Sullivan, MD, MS, and colleagues showed that across 23 published studies about quality improvement (QI) initiatives, 28 QI interventions related to the OR and surgical procedures were described.
Application of these interventions at various centers by clinicians in the specialty areas of anesthesiology, as well as orthopedic, hand, oncologic, pediatric, gynecologic and other types of surgery, through the studies the researchers examined, highlighted the importance of following the sustainability principles of refuse, reduce, reuse, repurpose and recycle, which are known as the five R's of sustainability.
Sullivan told Healio she and her colleagues want their study to become a reference for surgical teams and others, including device manufacturers, who want to adopt initiatives for a greener OR.
“What we wanted to do was put together this information in a way that it would be practical and useful for those who are interested in implementing greening the OR initiatives at their own institutions, so they can see who’s done this before and what have they done. Was it, in a sense, cost saving, did they have a positive environmental impact? And then, almost use this as a reference to be able to identify those studies and be able to go take a look at them, as well,” Sullivan, a general surgery resident at Rush University Medical Center, said.
Initiatives categorized into 5 R’s
The study compared differing published studies and results of the QI initiatives at various institutions and discussed the impact these had using a triple bottom-line framework, which was a challenge, according to Sullivan, who is currently conducting research in the division of pediatric surgery at Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine.
However, the researchers wrote in their abstract that they found, “[QI] improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally.”
These initiatives were categorized in the study according to four of the 5 R’s — refuse, reduce, reuse and recycle.
Drilling down on the studies, the researchers reviewed showed wide variability in the methods of measuring cost savings and environmental impact used in each study, Sullivan said.
“I don’t think there is an answer that one strategy is necessarily going to be, overall, the most impactful. A lot of it, too, depends on local factors,” she said.
Using the example of waste disposal, “we know that the cost for waste disposal for recyclables vs. solid waste is going to vary from region to region and even within the same city, [it] could vary based on different haulers, based on different prices and such, so it makes it challenging to compare a lot of these interventions to one another,” Sullivan said.
Examples of interventions
Overall, there were 11 refuse interventions (39.3%), eight reduce interventions (28.6%), three reuse interventions (10.7%) and six recycle interventions (21.4%) addressed in the reviewed literature. Results showed these ranged in annual cost savings from $837 for education on diverting recyclable materials from sharps containers to $694,141 for education that helped reduce regulated medical waste.
The sharps container intervention diverted 11.4 kg of sharps waste per month, and the reduction of regulated medical waste intervention impacted the environment through a 30% reduction in medical waste, according to the abstract.
Sullivan discussed using a life cycle analysis — the gold standard and “the best way to look at this” — which is used to measure environmental impact throughout the lifespan of a product and estimates greenhouse gas emissions (GGE) from the life cycle of a product.
“For example, within surgery, this has been used for things like devices, but also for procedures. One group looked at this in the sense of calculating the environmental impact of a hysterectomy through a life cycle analysis.
“In our review, we identified few studies that applied these more robust analytical approaches to calculating GGE and typically estimated that environmental impact was in things like the pounds of waste diverted from landfills, for example. The best way to look at this is through these life cycle analyses type of approaches. There have been certain hotspots that have been identified using life cycle analyses,” Sullivan said noting the 2021 peer-reviewed study by Jonathan Drew and colleagues that identified specific “hot spots” within surgical and anesthetic care, which included single-use devices, anesthetic gases and HVAC systems.
Optimize HVAC systems in ORs
Commenting on optimizing use of HVAC systems, Sullivan said, “You can reduce the number of times that they cycle in the OR, for example. Most of the time they cycle somewhere between 20 and 30 times an hour while maintaining positive pressure, but when the room isn’t in use, you can cycle it less without having any effect on infection control and prevention.”
This is one example of possible interventions the researchers did not see being readily implemented , Sullivan said. “That doesn’t mean that it’s not happening and not out there in more reports and white papers, but those are the gaps that we had identified through the study that I would encourage people who are serious about kind of taking on this issue and trying to tackle emissions at their own center through interventions focused on reducing impact in the OR — those are the big areas to focus on: single-use devices, anesthetic gases and HVAC systems,” she said.
Sullivan said, “There’s a lot of potential going forward and the more we talk about these things, the more we bring it to people’s attention, hopefully the more focus will be directed toward it. I’m optimistic for the future of it and definitely happy to see so much enthusiasm around these topics.”
Reference:
Drew J, et al. Environ Health Perspect. 2021;doi:10.1289/EHP8666.
Perspective
Back to Top
Robert E. Van Demark Jr., MD, FAAOS, FAOA
Sullivan and co-authors have once again reminded us of the large carbon footprint generated by health care. They performed a review of 23 quality improvement initiatives intended to “reduce the environmental impact of the operating room while decreasing costs.”
With recent discussions on environmental sustainability, this is a timely article. Health care in the United States accounts for 8% to 10% of national GGE. The environmental impact of surgery is huge: ORs and labor and delivery rooms account for 50% to 70% of total hospital waste.
The 23 quality improvement initiatives described 28 different interventions. The interventions were classified into four groups of refuse, reduce, reuse and recycle. All of these strategies have resulted in cost savings and reduced surgical waste.
I became interested in the “Lean and Green” surgery program in 2016. Inspired by the work of Donald H. Lalonde, MD, FRCSC, and Mark E. Baratz, MD, our group started a program for reducing the size and cost of our outpatient surgical packs. Since 2017, using “Lean and Green” surgical packs, our practice has saved our system $81,000 and cut surgical waste by 19 tons.
The authors have challenged us to make a difference. As stated in their conclusion, “Surgeons, health care practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.”
References:
Yu J, et al. Plast Reconstr Surg Open. 2019;doi:GOX.0000000000002481.
Thiel CL, et al. Hand (N Y). 2019;doi:10.1177/1558944717743595.
Collapse
Click Here to Manage Email Alerts