Greening the operating room

https://doi.org/10.1016/j.amjsurg.2018.07.021Get rights and content

Highlights

  • Surgical waste is contributing to landfill mass and climate change.

  • Strategies such as repurposing and anesthetic gas reclaiming are potential strategies to address surgical waste.

  • Donation of unused or repurposed surgical supplies may help global surgery efforts while decreasing surgical waste.

Abstract

Background

Climate change will affect most populations in the next decades and put the health of billions of people at risk. Health care facilities represent a significant source of pollution around the world and contribute to environmental changes. To address this topic, we performed a review of the available literature on tactics to reduce operating room (OR) waste and the potential of these strategies to impact the environment.

Data Sources

A literature search was performed querying PubMed, Web of Science, and Science Direct. No comparative data were found; most were opinion papers, white papers, and case studies. For this reason, we proceeded with a narrative review, which provides an overview of the evidence on this topic and identifies areas for future research.

Results

This systematic review summarizes the available literature on the 5 “Rs” of waste management: reduction, reusing, recycling, rethinking, and renewable energies.

Conclusions

Surgery has a unique opportunity to transition to more environmentally-friendly operating room strategies, which may help decrease waste and lessen the impact of climate change.

Introduction

Climate change, i.e. global warming, will affect most populations in the next decades and put the health of billions of people at increased risk.1 Ironically, health care facilities represent a significant source of pollution around the world and, therefore, contribute to environmental changes associated with global warming.2

A study by Chung and Meltzer in 200946 estimated the carbon footprint of the US health care sector, which was shown to contribute with 8% of the nation's greenhouse gas emissions both from health care activities directly as well as from activities associated with the supply chain of health care-related goods and services. Another study on the environmental impact of US health care from Eckelman and Sherman in 201347 indicated that relevant fractions of national air pollution emissions and consequences was attributable to the healthcare sector, including acid rain (12%), greenhouse gas emissions (10%), smog formation (10%) criteria air pollutants (9%), stratospheric ozone depletion (1%), and carcinogenic and non-carcinogenic air toxics (1–2%).

In addition, the sheer amount of, and overall toxicity of, medical waste has increased in recent decades. Certain medical products contribute significantly to pollution and contamination of the food chain from bio-accumulative toxins. As a prime example, medical waste incinerators are among the top 5 sources of mercury and dioxin emissions in the United States.3

Although the topic of the environment may not be a common concern to many surgeons, it is of increasing importance to the communities that they serve and to the medical centers within which they work. Therefore, a movement toward “greening” health care, or improving the environmental footprint of health care, has been building. Individual hospital-based initiatives have been reported over the past decade, with strategies to successfully reduce medical waste while not increasing operating cost.11

During the past 50 years, the healthcare industry has undergone tremendous changes in the types of products it uses and the waste it produces. For example, the industry quickly adopted disposable, typically plastic, products. Historically, there were few regulations for dealing with medical wastes separate from other waste because most hospitals had their own incinerators and incinerated everything. With the increased awareness of infectious diseases, particularly HIV and Hepatitis, more regulations have been initiated regarding safe hospital waste disposal of materials contaminated or potentially contaminated by bodily fluids, such as blood, saliva, or intestinal fluid. Both the introduction of universal precautions standards in 1987 and the adoption of the Medical Waste Tracking Act, signed into law in 1988, set in motion a movement to treat most medical waste, regardless of toxicity or type, as infectious in nature, in an effort to protect the public.

Because of this, there was a dramatic increase in the amount of waste labeled as infectious requiring special ‘red bag’ disposal, most of which underwent incineration. In theory, ‘red bag’ disposal should comprise solid or liquid items contaminated with blood or other potentially infectious material (human bodily fluids including semen, vaginal secretion, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, and saliva). However, this type of disposal tends to get overused when a great amount of waste that does not require special treatment is placed in red bags due to availability (having a red bag in the room) and careless unplanned waste separation.

Recycling became a growing phenomenon in the United States, with 34.7% of all waste successfully recycled in 2011, representing an increase from 16% in 1990 and 28.5% in 2000.4 However, health care centers continue to be the second largest contributors to waste in the United States, with >4 billion tons of waste produced per year.5 Data from single center studies shows that more than 50% of general operating room (OR) waste is uncontaminated and potentially recyclable, but is incorrectly disposed of as contaminated or hazardous waste by OR staff.6 This is often due to lack of staff education on waste segregation and treatment cost of each type of waste, leading to irrational unplanned waste disposal on unintended material for each disposal bag.

Longer surgical cases can generate up to 50 pounds of waste, and orthopedic and cardiac procedures can produce upward of 100–200 pounds of waste per case.7 As ORs and labor-delivery (L&D) suites account for over 50% of all hospital waste, initially targeting ORs to decrease overall waste production through a combination of initiatives such as reprocessing single-use instruments, decreasing the amount of disposables opened within a case, educating staff on classification of waste products, and recycling, can have the largest impact to decrease overall medical waste.

To investigate this topic, we performed a narrative review of the literature around sustainability in the Operating Room to better inform action plans for impactful ‘greening’ the ORs.

Section snippets

Materials and methods

An experienced research librarian performed a search of the relevant literature in September 2017, querying PubMed, Web of Science, and Science Direct using the following search terms combined with “operating rooms” and “surgical theaters”: “green”, “waste reduction”, “reuse”, “recycle”, “solar”, “wind power”, “sustainable”, “hydropower”, “biothermal”, “rethinking”, and “repurposing”. A total of 161 citations were found. The abstracts and titles were screened for relevance and consideration for

Results

Our review summarizes the available literature on reduction, reusing, recycling, rethinking, and renewable energies. This is based on recommendations made by the Association of periOperative Registered Nurses' (AORN). Reduction (i.e. proper waste segregation, reusable sharps container, fluid waste management, energy expenditure, LED surgical lamps, greener equipment packaging), Reuse (i.e. reprocessing of single-use devices, reusable surgical linens), Recycling clean plastic and paper,

Discussion

The present article portrayed the current scenario of sustainability observed in the operating room environment through a wide narrative review. Previously implemented and successful strategies were discussed, as well as failed programs and future perspectives and intentions. We found that one of the most relevant obstacles to executing new plans of action consist in adapting them to the current operating room routine, always being attentive to achieving the best patient healthcare.

Some

Conclusions

This study provides a comprehensive narrative review of current practices and opportunities to improve sustainable operating room practices that could reduce waste, contribute to global surgery initiatives, and contain costs. Given the paucity of data in this area, more research is needed to guide evidence-based practice.

Funding and conflicts of interest

The authors did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors. In addition, none of the authors have any conflicts of interest to declare.

Acknowledgments

The authors would like to acknowledge the substantial contributions of Susan Harnett, PhD, research librarian for the University of Florida College of Medicine Jacksonville, who performed and organized the literature search for this review.

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