Carbon footprint and cost–effectiveness of cataract surgery:

Intravitreal Injections: Improving Sustainability by Reducing Clinical Waste

BACKGROUND

Intravitreal injections are one of the most commonly performed ophthalmic procedures. It is estimated that over 1 million intravitreal injections are performed in Germany annually. The aim of this study was to quantify the waste and carbon footprint associated with single-use injection sets, and to establish a waste reduction strategy.

MATERIAL AND METHODS

The clinical waste and associated carbon footprint from standard disposable injection sets used by tertiary referral centres in Germany (n = 6) and the United Kingdom (n = 2) were assessed. The safety of performing intravitreal injections with a minimalistic material-sparing approach was evaluated.

RESULTS

The average weight of an injection set (and hence the waste generated from each injection) was 165 g. On average, each injection set comprised 145 g (88%) of plastic, 2.1 g (1.3%) of metal, 4.3 g (2.6%) of paper, and 12.9 g (7.8%) of gauze/swabs. The production of such injection sets was extrapolated to a CO2 equivalent of 752.6 tonnes (t), and the incineration of the resulting waste to a CO2 equivalent of 301.7 t. For 1 million injections, this equates to 145.2 t of plastic, 2.1 t of metal, 4.3 t of paper, and 12.9 t of gauze/swabs. A material-sparing approach can reduce injection set-associated waste by 99% without necessarily compromising patient safety.

CONCLUSION

A resource-saving approach to intravitreal injections can minimise the generation of clinical waste and its associated carbon footprint, thereby supporting sustainability.

Association of day-case rates with post COVID-19 recovery of elective laparoscopic cholecystectomy activity across England

INTRODUCTION

The aim of this study was to investigate the safety of day-case laparoscopic cholecystectomy, and the association between day-case rates and, post the COVID-19 pandemic, recovery of activity to prepandemic levels for integrated care boards (ICBs) in England.

METHODS

This was a retrospective observational study of the Hospital Episodes Statistics (HES) data set. Elective laparoscopic cholecystectomies for the period 1 January 2019 to 31 December 2022 were identified. Activity levels for 2022 were compared with those for the whole of 2019 (baseline). Day-case activity was identified where the length of stay recorded in the HES was zero days.

RESULTS

Data were available for 184,252 patients across the 42 ICBs in England, of which 120,408 (65.3%) were day-case procedures. By December 2022, activity levels for the whole of England had returned to 88.2% of prepandemic levels. The South West region stood out as having recovered activity levels to the greatest extent, with activity at 97.3% of prepandemic levels during 2022. The South West also had the highest postpandemic day-case rate at 74.9% of all patients seen as a day-case during 2022; this compares with an England average of 65.3%. At an ICB level, there was a significant correlation between day-case rates and postpandemic activity levels (r = 0.362, p = 0.019). There was no strong or consistent evidence that day-case surgery had poorer patient outcomes than inpatient surgery.

CONCLUSIONS

Recovery of elective laparoscopic cholecystectomy activity has been better in South West England than in other regions. Increasing day-case rates may be important if ICBs in other regions are to increase activity levels up to and beyond prepandemic levels.

Cataract surgery and environmental sustainability: a comparative analysis of single-use versus reusable cassettes in phacoemulsification

OBJECTIVE

To compare sustainability, financial implications and surgical efficiency of two phacoemulsification cassette systems for cataract surgery: a machine with single-use cassettes and another with daily, reusable ones.

METHODS

Observational study involving retrospective cataract surgery data collection at the Centre Médical de l'Alliance, Braine-l'Alleud, Belgium, a tertiary eye care centre. Information on cassette weight, quantities and transport volume was obtained from routine procedures and purchasing records. The costs for each machine were calculated by reviewing the invoices received from the accounting department.

RESULTS

We found significant differences across comparisons. The reusable cassette machine, when compared with the single-use machine, used 306.7 kg less plastic (75.3% reduction), required 2494 m3 less storage per 1000 surgeries (67.7% decrease) and cost €54.16 less per 10 procedures (16.9% reduction). The machine with daily reusable cassettes also exhibited a 7-minute priming time advantage for 10 procedures, reducing downtime between cases.

CONCLUSIONS

Our findings underscore the benefits of adopting reusable cassette systems: reduced plastic consumption, storage volume and priming time, as well as enhanced efficiency and cost-savings. Healthcare professionals and institutions are encouraged to embrace environmentally conscious initiatives. The use of reusable cassette systems for cataract surgeries offers a pathway to sustainable practices.

The Environmental Impacts of Electronic Medical Records Versus Paper Records at a Large Eye Hospital in India: Life Cycle Assessment Study

BACKGROUND

Health care providers worldwide are rapidly adopting electronic medical record (EMR) systems, replacing paper record-keeping systems. Despite numerous benefits to EMRs, the environmental emissions associated with medical record-keeping are unknown. Given the need for urgent climate action, understanding the carbon footprint of EMRs will assist in decarbonizing their adoption and use.

OBJECTIVE

We aimed to estimate and compare the environmental emissions associated with paper medical record-keeping and its replacement EMR system at a high-volume eye care facility in southern India.

METHODS

We conducted the life cycle assessment methodology per the ISO (International Organization for Standardization) 14040 standard, with primary data supplied by the eye care facility. Data on the paper record-keeping system include the production, use, and disposal of paper and writing utensils in 2016. The EMR system was adopted at this location in 2018. Data on the EMR system include the allocated production and disposal of capital equipment (such as computers and routers); the production, use, and disposal of consumable goods like paper and writing utensils; and the electricity required to run the EMR system. We excluded built infrastructure and cooling loads (eg. buildings and ventilation) from both systems. We used sensitivity analyses to model the effects of practice variation and data uncertainty and Monte Carlo assessments to statistically compare the 2 systems, with and without renewable electricity sources.

RESULTS

This location's EMR system was found to emit substantially more greenhouse gases (GHGs) than their paper medical record system (195,000 kg carbon dioxide equivalents [CO2e] per year or 0.361 kg CO2e per patient visit compared with 20,800 kg CO2e per year or 0.037 kg CO2e per patient). However, sensitivity analyses show that the effect of electricity sources is a major factor in determining which record-keeping system emits fewer GHGs. If the study hospital sourced all electricity from renewable sources such as solar or wind power rather than the Indian electric grid, their EMR emissions would drop to 24,900 kg CO2e (0.046 kg CO2e per patient), a level comparable to the paper record-keeping system. Energy-efficient EMR equipment (such as computers and monitors) is the next largest factor impacting emissions, followed by equipment life spans. Multimedia Appendix 1 includes other emissions impact categories.

CONCLUSIONS

The climate-changing emissions associated with an EMR system are heavily dependent on the sources of electricity. With a decarbonized electricity source, the EMR system's GHG emissions are on par with paper medical record-keeping, and decarbonized grids would likely have a much broader benefit to society. Though we found that the EMR system produced more emissions than a paper record-keeping system, this study does not account for potential expanded environmental gains from EMRs, including expanding access to care while reducing patient travel and operational efficiencies that can reduce unnecessary or redundant care.

Reuse of Single-Use Devices in Endourology: A Review

Introduction: Single-use medical devices (SUDs) are labeled for single use only, but rising health care costs along with the absence of visible deterioration in the quality of SUDs after one use have led to their reprocessing and reuse. In the past, SUDs mainly consisted of equipment such as guidewires and catheters. However, SUDs have now expanded to flexible endoscopes and energy devices that are much more expensive. Reuse of such devices raises concerns of infection transmission, safety, and lack of effectiveness. We reviewed the disinfection process, cost benefits, potential harms, and legal status of the reuse of SUDs in endourology. Materials and Methods: PUBMED, Embase, and the Cochrane Library databases were searched for articles published between 1970 and March 2023 that reported the reuse of SUDs using the search terms "reuse"; "single-use device"; "disposable medical devices"; "reprocessing of single-use device"; "endourology"; and keywords related to cost, safety, sterilization, and legal status. Online resources were found using Google search engines. Articles on cost savings, device malfunction, disinfection, or legal status in different countries were reviewed. Results and Conclusions: Reusing SUDs has financial, environmental, and practical advantages. The potential savings on medical expenses is the most compelling argument for reprocessing disposable devices. Reusing medical equipment also contributes to the reduction of toxic biodegradable waste. However, there is a scarcity of data on the safety and efficacy of reused SUDs. For patient safety and to avoid complications, the practice must be regulated with established reprocessing standards.

What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve

BACKGROUND

The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste.

METHODS

A single-center prospective study to evaluate the cost of opened but unused single-use operating room supplies was completed by counting the number of wasted disposable products at the end of hand surgery cases. We used χ2 test, t test, Wilcoxon rank-sum test, and simple linear regression to assess the associations between patient and case variables and the total cost of wasted items. Environmentally Extended Input Output Life Cycle Assessment methods were used to convert the dollar spent to kilograms of carbon dioxide equivalent (CO2-e), a measure of greenhouse gas emissions.

RESULTS

Surgical and dressing items that were disposed of and not used during each case were recorded. We included 85 consecutive cases in the analysis from a single surgeon's practice. Higher cost from wasted items was associated with shorter operative time (P = .010). On average, 11.5 items were wasted per case (SD: 3.6 items), with a total of 981 items wasted over the 85 cases in the study period. Surgical sponges and blades were 2 of the most unused items. Wasted items amounted to a total of $2193.5 and 441 kg of CO2-e during the study period.

CONCLUSIONS

This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

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, healthcare 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 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 theatre 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.

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

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

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

[Sustainability in ophthalmology : Adaptation to the climate crisis and mitigation]

Die Klimakrise bedroht die Gesundheit heutiger und künftiger Generationen und stellt das Gesundheitssystem vor besondere Herausforderungen. Zur Anpassung an den anthropogene Klimawandel sind umfängliche Adaptationsstrategien und eine Mitigation des Klimawandels notwendig. In der Medizin sowie in der Augenheilkunde gibt es vielfältige Möglichkeiten zur Reduktion des CO₂(Kohlendioxid)-Fußabdrucks, die es zu ergreifen gilt, die ordnungspolitisch gefördert und eingefordert werden sollten. Das aufkommende Feld der datengesteuerten Nachhaltigkeit kann Werkzeuge liefern, um den ökologischen Fußabdruck der eigenen Tätigkeit zu evaluieren sowie Optimierungen zu initiieren. Lebenszyklusanalysen können Instrumente für systematische Ökobilanzen sein und nachhaltige Produkt- und Praxisentscheidungen ermöglichen. Das deutsche Gesundheitssystem sollte eine quantifizierbare und holistische Strategie zur CO₂-Reduktion entwickeln; Nachhaltigkeit könnte zukünftig ein Leistungsindikator sein. Dieser Artikel diskutiert mit augenärztlicher Perspektive Beispiele zur Adaptation an die Klimakrise und zur Mitigation; dies schließt kleine Maßnahmen, die jeder Einzelne umsetzen kann, als auch größere, strukturelle Ansätze ein.

Correlation Between Degree of Lens Opacity and the Phacoemulsification Energy Parameters Using Different Imaging Methods in Age-Related Cataract

Purpose

To compare the correlation between degree of lens opacity and the phacoemulsification energy parameter in patients with age-related cataract as determined by slit lamp, 25-MHz ultrasound biomicroscopy (UBM), and Scheimpflug imaging (Pentacam) and to evaluate the application of these three methods to measuring lens opacification.

Methods

This observational study was conducted in 319 patients (381 eyes) with different types of age-related cataract. The average age of patients was 67.3 ± 11.4 years. The degree of lens opacity acquired by slit lamp, 25-MHz UBM, and Pentacam was determined by the Lens Opacity Classification System III (LOCSIII), pixel units calculated by ImageJ, and lens density, respectively. We primarily analyzed and compared the correlation between lens opacity and the cumulative dissipated energy (CDE) values of phacoemulsification.

Results

Cortical, nuclear, and posterior subcapsular (PSC) cataracts were evaluated as follows: LOCSIII grades 3.31 ± 1.42, 3.29 ± 1.49, and 0.91 ± 0.83; pixel units 120.91 ± 22.8, 93.2 ± 15.9, and 99.7 ± 13.0; and lens density 51.8 ± 31.2, 21.2 ± 6.10, and 53.3 ± 35.3, respectively. The CDE values were 12.1 ± 12.4, 13.5 ± 9.11, and 3.93 ± 1.96. In cortical cataract, there was a linear correlation among LOCSIII, pixel units, and CDE value (r = 0.560, r = 0.832, and r = 0.582, respectively; both P < 0.05), but lens density had no correlation with other parameters. In nuclear cataract, there was a linear correlation among LOCSIII, lens density, and CDE value (r = 0.747, r = 0.865, and r = 0.906, respectively; both P < 0.05), but pixel units had no correlation with other parameters. In PSC, only pixel units and LOCSIII showed a correlation.

Conclusions

The various imaging methods offered different advantages in terms of determining lens opacity, a feature related to types of age-related cataracts. Choosing the most suitable imaging method to evaluate lens opacification based on the type of age-related cataract is important for accurately predicting the phacoemulsification parameters for cataract surgery.

Translational Relevance

Determining the appropriate phacoemulsification strategy depends on quantitative analysis of the degree of lens opacity to reduce intraoperative and postoperative complications and to obtain the optimal postoperative visual outcome.

Advancing the Sustainable Development Goals through improving eye health: a scoping review

UN member states have committed to achieving the Sustainable Development Goals (SDGs) by 2030. This Review examines the published evidence on how improving eye health can contribute to advancing the SDGs (beyond SDG 3). We identified 29 studies that showed direct benefits from providing eye health services on SDGs related to one or more of poverty (SDGs 1, 2, and 8), education (SDG 4), equality (SDGs 5 and 10), and sustainable cities (SDG 11). The eye health services included cataract surgery, free cataract screening, provision of spectacles, trichiasis surgery, rehabilitation services, and rural community eye health volunteers. These findings provide a comprehensive perspective on the direct links between eye health services and advancing the SDGs. In addition, eye health services likely have indirect effects on multiple SDGs, mediated through one of the direct effects. Finally, there are additional plausible links to other SDGs, for which evidence has not yet been established.

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

PURPOSE

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

DESIGN

Retrospective, sequential, clinical registry study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Ethical Duty to Reduce the Ecological Footprint of Industrialized Healthcare Services and Facilities

According to the widely accepted principles of beneficence and distributive justice, I argue that healthcare providers and facilities have an ethical duty to reduce the ecological footprint of the services they provide. I also address the question of whether the reductions in footprint need or should be patient-facing. I review Andrew Jameton and Jessica Pierce's claim that achieving ecological sustainability in the healthcare sector requires rationing the treatment options offered to patients. I present a number of reasons to think that we should not ration health care to achieve sufficient reductions in a society's overall consumption of ecological goods. Moreover, given the complexities of ecological rationing, I argue that there are good reasons to think that the ethical duty to reduce the ecological footprint of health care should focus on only nonpatient-facing changes. I review a number of case studies of hospitals who have successfully retrofitted facilities to make them more efficient and reduced their resource and waste streams.

The carbon footprint of cataract surgery in a French University Hospital

PURPOSE

To assess the carbon footprint of cataract surgery in a French university hospital.

SETTING

Operating room of Cochin University Hospital, Paris, France.

DESIGN

Single-center component analysis.

METHODS

One day of surgery was used as a reference. Greenhouse gases (GHG) related to patient and staff transportation were calculated based on the distance travelled and the means of transportation used. The annual consumption of energy (heating and electricity) of our building was converted in kg equivalent of carbon dioxide (CO₂eq), and the principle of proportionality was used to calculate what was used for a single cataract procedure. GHG emissions related to the life cycle assessment (LCA) of the equipment used and the sterilization process were calculated.

RESULTS

The LCA of disposable items accounted for 59.49kg (73.32%) of CO₂eq for each procedure. A single procedure generated 2.83±0.10kg of waste. The average CO₂eq produced by the transportation of the patients to and from our center, adjusted for one procedure, was 7.26±6.90kg (8.95%) of CO₂eq. The CO₂eq produced by the sterilization of the phacoemulsifier handpiece was 2.12kg (2.61%). The energy consumption of the building and staff transportation accounted for the remaining CO₂eq emissions, 0.76kg (0.93%) and 0.08kg (0.10%) respectively. Altogether, the carbon footprint of one cataract procedure in our center was 81.13kg CO₂eq - the equivalent of an average car driving 800km.

CONCLUSION

Our data provide a basis to quantify cataract surgery as a source of GHG and suggests that reductions in emissions can be achieved.

Ophthalmology Going Greener: A Narrative Review

The combined effects of fossil fuel combustion, mass agricultural production and deforestation, industrialisation and the evolution of modern transport systems have resulted in high levels of carbon emissions and accumulation of greenhouse gases, causing profound climate change and ozone layer depletion. The consequential depletion of Earth's natural ecosystems and biodiversity is not only a devastating loss but a threat to human health. Sustainability-the ability to continue activities indefinitely-underpins the principal solutions to these problems. Globally, the healthcare sector is a major contributor to carbon emissions, with waste production and transport systems being amongst the highest contributing factors. The aim of this review is to explore modalities by which the healthcare sector, particularly ophthalmology, can reduce carbon emissions, related costs and overall environmental impact, whilst maintaining a high standard of patient care.

Return of phacoemulsification after emergency status related to COVID-19: experience of a tertiary referral center

PURPOSE

To present a protocol of priority criteria for phacoemulsification after the backlog due to severe acute respiratory syndrome coronavirus (SARS-CoV)-2 pandemic status.

SETTING

Ophthalmology department of Centro Hospitalar e Universitário do Porto (CHUP), Oporto, Portugal.

DESIGN

Cross-sectional, nonrandomized, retrospective study.

METHODOLOGY

Data of all patients waiting for cataract surgery were analyzed at the beginning of May 2020, after 2 months without performing elective surgery. The waiting time since surgical inscription was considered an independent and overriding factor. In addition, higher priority was given to patients with white or brunescent cataracts and patients with low visual acuity: corrected distance visual acuity (CDVA) of 20/200 or less in binocular patients or CDVA of 20/63 or less in monocular patients. Criteria of medium priority included patients who remained with anisometropia and patients with glaucoma or low to moderate risk for chronic angle closure. Data of scheduled surgeries in the following months were then analyzed.

RESULTS

A total of 717 patients were waiting for phacoemulsification. One hundred ninety-one patients (26.64%) were on the waiting list more than 4.5 months; the medium waiting time was 3.51 ± 1.57 months. According to both priority criteria and waiting time, 348 (48.6%) were categorized as priority cases. A total of 158 patients (22.0%) met the highest priority; 61 patients (8.5%) met the medium priority criteria. In 129 patients (18.0%), priority was considered based solely on higher waiting time. This algorithm allowed surgeons to operate on all priority cases within the first 3 months.

CONCLUSIONS

The presented protocol showed to be effective, providing a timely surgical opportunity for priority cases.

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

Objective

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

Methods and Analysis

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

Results

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

Conclusion

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

Economic and Environmental Impact of Single-use Plastics at a Large Ophthalmology Outpatient Service

PRéCIS:: The use of disposable tonometer prisms and gonioscopy lenses at a large ophthalmology outpatient service incurs significant financial and environmental waste that may not be justified given the limited data surrounding arguments for their use.

PURPOSE

To quantify the economic and environmental burden of single-use plastics from an ophthalmology outpatient service at a large tertiary hospital and describe the relative value and evidence for the safety of disposable versus nondisposable tonometer prisms and gonioscopy lenses.

METHODS

The total number of single-use applanation tonometer prisms and gonioscopy lenses used per year at Boston Medical Center (BMC) was estimated, and the average dollars spent and plastic waste generated in kilograms per year were then determined. These values were compared with the total spending and waste that would be produced if the clinic were to use nondisposable tonometer prisms and gonioscopy lenses exclusively.

RESULTS

Single-use tonometer prisms cost an average of $70,282 per year and produce ~100.8 kg of plastic waste per year at BMC. Single-use gonioscopy lenses cost ~$9,040 per year and produce 8.8 kg of plastic waste per year at BMC. An excess of $65,185 and 109.6 kg of plastic waste could be avoided each year by only using nondisposable tonometer prisms and gonioscopy lenses at the BMC ophthalmology outpatient service.

CONCLUSIONS

Single-use plastics in ophthalmology outpatient services generate significant environmental waste and financial cost compared with nondisposable instruments. This cost may outweigh the benefits of these instruments given the limited data surrounding arguments for their use.

New Zealand ophthalmologists' opinions and behaviours on climate, carbon and sustainability

IMPORTANCE

Ophthalmology faces imperatives to improve sustainability, but there is uncertainty about how to respond.

BACKGROUND

We sought New Zealand ophthalmologists' opinions on climate change, sustainability and the role of ophthalmologists in responding to these issues, as well as information on the extent that ophthalmology practices are acting on sustainability.

DESIGN

Anonymous online survey of New Zealand fellows and trainees (178) of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) was conducted.

PARTICIPANTS

Forty-seven respondents (response rate 26%) were included in the study.

METHODS

Respondents were asked their level of agreement with statements on climate, health and sustainability and invited to comment. Current sustainability activities were collected from clinical leaders and directors of hospital departments and private practices.

MAIN OUTCOME MEASURE

Distribution of agreement scores was the main outcome measure.

RESULTS

Agreement with mainstream positions on climate change was as expected. A minority of up to 19% expressed the opinion that climate change was not due to human activity, and did not require mitigation. Younger ophthalmologists tended to have greater agreement with the need for broad-based political action on climate mitigation than those aged over 50 years. Most practices had room to improve on reducing waste, travel and carbon footprints.

CONCLUSIONS AND RELEVANCE

The majority of New Zealand ophthalmologists are concerned about anthropogenic climate change. Currently, sustainability is not a performance indicator for New Zealand district health boards, so there is limited incentive to drive improvements. These data form a reference point to compare future opinions and ophthalmology carbon footprinting.

Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility

PURPOSE

To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting.

SETTING

Two tertiary care centers of the Aravind Eye Care System in southern India.

DESIGN

Observational case series.

METHODS

Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents).

RESULTS

Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions.

CONCLUSIONS

Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.

Quantification of the Cost and Potential Environmental Effects of Unused Pharmaceutical Products in Cataract Surgery

Importance

Pharmaceutical products, including unused portions, may contribute to financial and environmental costs in the United States. Because cataract surgery is performed millions of times each year in the United States and throughout the rest of the world, understanding these financial and environmental costs associated with cataract surgery is warranted.

Objective

To investigate the financial and environmental costs of unused pharmaceutical products after phacoemulsification surgery.

Design, Setting, and Participants

This descriptive qualitative study included 4 surgical sites in the northeastern United States (a private ambulatory care center, private tertiary care center, private outpatient center, and federally run medical center for veterans). Prices and data for use of services and pharmaceuticals were obtained for the tertiary care and outpatient centers from January 1 through April 30, 2016; for the ambulatory care center from June 1, 2017, through March 31, 2018; and the federal medical center from November 1, 2017, through February 28, 2018. Data were collected from routine phacoemulsification surgical procedures without vitreous loss or other complications. Volume or weight of medications remaining after surgery was measured. Total and mean costs of medications per case and month were calculated. Environmental effects were estimated using economic input-output life cycle assessment methods. Data were analyzed from December 1, 2017, through June 30, 2018.

Main Outcomes and Measures

Cost of unused pharmaceutical products (in US dollars) and kilogram equivalents of carbon emissions (carbon dioxide [CO2-e]), air pollution (fine particulate matter emissions of ≤10 μm in diameter [PM10-e]), and eutrophication potential (nitrogen [N-e]).

Results

A total of 116 unique drugs were surveyed among the 4 centers. Assuming unmeasured medications had no materials left unused, a cumulative mean 83 070 of 183 304 mL per month (45.3%) of pharmaceuticals were unused by weight or volume across all sites. Annual unused product cost estimates reached approximately $195 200 per site. A larger percentage of eyedrops (65.7% by volume) were unused compared with injections (24.8%) or systemic medications (59.9%). Monthly unused quantities at the ambulatory care center (65.9% by volume [54 971 of 83 440 mL]), tertiary care center (21.3% [17 143 of 80 344 mL]), federal medical center (38.5% [265 of 689 mL]), and outpatient center (56.8% [10 691 of 18 832 mL]) resulted in unnecessary potential emissions at each center of 2135, 2498, 418, and 711 kg CO2-e/mo, respectively. Unnecessary potential air pollution between sites varied from 0.8 to 4.5 kg PM10-e/mo, and unnecessary eutrophication potential between sites varied from 0.07 to 0.42 kg N-e/mo.

Conclusions and Relevance

This study suggests that unused pharmaceutical products during phacoemulsification result in relatively high financial and environmental costs. If these findings can be substantiated and shown to be generalizable in the United States or elsewhere, reducing these costs may be of value.

Strategies to Reduce Greenhouse Gas Emissions from Laparoscopic Surgery

OBJECTIVES

To determine the carbon footprint of various sustainability interventions used for laparoscopic hysterectomy.

METHODS

We designed interventions for laparoscopic hysterectomy from approaches that sustainable health care organizations advocate. We used a hybrid environmental life cycle assessment framework to estimate greenhouse gas emissions from the proposed interventions. We conducted the study from September 2015 to December 2016 at the University of Pittsburgh (Pittsburgh, Pennsylvania).

RESULTS

The largest carbon footprint savings came from selecting specific anesthetic gases and minimizing the materials used in surgery. Energy-related interventions resulted in a 10% reduction in carbon footprint per case but would result in larger savings for the whole facility. Commonly implemented approaches, such as recycling surgical waste, resulted in less than a 5% reduction in greenhouse gases.

CONCLUSIONS

To reduce the environmental emissions of surgeries, health care providers need to implement a combination of approaches, including minimizing materials, moving away from certain heat-trapping anesthetic gases, maximizing instrument reuse or single-use device reprocessing, and reducing off-hour energy use in the operating room. These strategies can reduce the carbon footprint of an average laparoscopic hysterectomy by up to 80%. Recycling alone does very little to reduce environmental footprint. Public Health Implications. Health care services are a major source of environmental emissions and reducing their carbon footprint would improve environmental and human health. Facilities seeking to reduce environmental footprint should take a comprehensive systems approach to find safe and effective interventions and should identify and address policy barriers to implementing more sustainable practices.

Trash to treasure Retcam

Digital fundus imaging is being used in diagnosis, documentation, and sharing of many retinal diseases and hence forms an essential part of ophthalmology. The use of smartphones for the same has been ever increasing. There is a need for simpler devices to couple the 20D lens and smartphone so as to take fundus photographs which can help in fundus documentation. This article describes a simple inexpensive technique of preparing a smartphone fundus photography device (Trash To Treasure (T3) Retcam) from the used materials in the clinics within minutes. This article will also review the optical principles of the T3 Retcam and describe the step–by–step method to record good-quality retinal image/videos. This inexpensive device is made by recycling and modifying the plastic hand sanitizer bottle in the clinics/hospitals which can be used for documenting, diagnosing, screening, and academic purposes.

Minimal Custom Pack Design and Wide-Awake Hand Surgery: Reducing Waste and Spending in the Orthopedic Operating Room

BACKGROUND

The US health care sector has substantial financial and environmental footprints. As literature continues to study the differences between wide-awake hand surgery (WAHS) and the more traditional hand surgery with sedation & local anesthesia, we sought to explore the opportunities to enhance the sustainability of WAHS through analysis of the respective costs and waste generation of the 2 techniques.

METHODS

We created a "minimal" custom pack of disposable surgical supplies expressly for small hand surgery procedures and then measured the waste from 178 small hand surgeries performed using either the "minimal pack" or the "standard pack," depending on physician pack choice. Patients were also asked to complete a postoperative survey on their experience. Data were analyzed using 1- and 2-way ANOVAs, 2-sample t tests, and Fisher exact tests.

RESULTS

As expected, WAHS with the minimal pack produced 0.3 kg (13%) less waste and cost $125 (55%) less in supplies per case than sedation & local with the standard pack. Pack size was found to be the driving factor in waste generation. Patients who underwent WAHS reported slightly greater pain and anxiety levels during their surgery, but also reported greater satisfaction with their anesthetic choice, which could be tied to the enthusiasm of the physician performing WAHS.

CONCLUSIONS

Surgical waste and spending can be reduced by minimizing the materials brought into the operating room in disposable packs. WAHS, as a nascent technique, may provide an opportunity to drive sustainability by paring back what is considered necessary in these packs. Moreover, despite some initial anxiety, many patients report greater satisfaction with WAHS. All told, our study suggests a potentially broader role for WAHS, with its concomitant emphases on patient satisfaction and the efficient use of time and resources.

Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis

BACKGROUND

Human health is dependent upon environmental health. Air pollution is a leading cause of morbidity and mortality globally, and climate change has been identified as the single greatest public health threat of the 21st century. As a large, resource-intensive sector of the Canadian economy, healthcare itself contributes to pollutant emissions, both directly from facility and vehicle emissions and indirectly through the purchase of emissions-intensive goods and services. Together these are termed life cycle emissions. Here, we estimate the extent of healthcare-associated life cycle emissions as well as the public health damages they cause.

METHODS AND FINDINGS

We use a linked economic-environmental-epidemiological modeling framework to quantify pollutant emissions and their implications for public health, based on Canadian national healthcare expenditures over the period 2009-2015. Expenditures gathered by the Canadian Institute for Health Information (CIHI) are matched to sectors in a national environmentally extended input-output (EEIO) model to estimate emissions of greenhouse gases (GHGs) and >300 other pollutants. Damages to human health are then calculated using the IMPACT2002+ life cycle impact assessment model, considering uncertainty in the damage factors used. On a life cycle basis, Canada's healthcare system was responsible for 33 million tonnes of carbon dioxide equivalents (CO2e), or 4.6% of the national total, as well as >200,000 tonnes of other pollutants. We link these emissions to a median estimate of 23,000 disability-adjusted life years (DALYs) lost annually from direct exposures to hazardous pollutants and from environmental changes caused by pollution, with an uncertainty range of 4,500-610,000 DALYs lost annually. A limitation of this national-level study is the use of aggregated data and multiple modeling steps to link healthcare expenditures to emissions to health damages. While informative on a national level, the applicability of these findings to guide decision-making at individual institutions is limited. Uncertainties related to national economic and environmental accounts, model representativeness, and classification of healthcare expenditures are discussed.

CONCLUSIONS

Our results for GHG emissions corroborate similar estimates for the United Kingdom, Australia, and the United States, with emissions from hospitals and pharmaceuticals being the most significant expenditure categories. Non-GHG emissions are responsible for the majority of health damages, predominantly related to particulate matter (PM). This work can guide efforts by Canadian healthcare professionals toward more sustainable practices.

Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery

INTRODUCTION

Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it".

METHODS

We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil.

RESULTS

The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario.

CONCLUSIONS

Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".

Carbon Footprint in Flexible Ureteroscopy: A Comparative Study on the Environmental Impact of Reusable and Single-Use Ureteroscopes

PURPOSE

There are no comparative assessments on the environmental impact of endourologic instruments. We evaluated and compared the environmental impact of single-use flexible ureteroscopes with reusable flexible ureteroscopes.

PATIENTS AND METHODS

An analysis of the typical life cycle of the LithoVue™ (Boston Scientific) single-use digital flexible ureteroscope and Olympus Flexible Video Ureteroscope (URV-F) was performed. To measure the carbon footprint, data were obtained on manufacturing of single-use and reusable flexible ureteroscopes and from typical uses obtained with a reusable scope, including repairs, replacement instruments, and ultimate disposal of both ureteroscopes. The solid waste generated (kg) and energy consumed (kWh) during each case were quantified and converted into their equivalent mass of carbon dioxide (kg of CO₂) released.

RESULTS

Flexible ureteroscopic raw materials composed of plastic (90%), steel (4%), electronics (4%), and rubber (2%). The manufacturing cost of a flexible ureteroscope was 11.49 kg of CO₂ per 1 kg of ureteroscope. The weight of the single-use LithoVue and URV-F flexible ureteroscope was 0.3 and 1 kg, respectively. The total carbon footprint of the lifecycle assessment of the LithoVue was 4.43 kg of CO₂ per endourologic case. The total carbon footprint of the lifecycle of the reusable ureteroscope was 4.47 kg of CO₂ per case.

CONCLUSION

The environmental impacts of the reusable flexible ureteroscope and the single-use flexible ureteroscope are comparable. Urologists should be aware that the typical life cycle of urologic instruments is a concerning source of environmental emissions.

Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes

BACKGROUND

Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health.

METHODS

We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions.

RESULTS

The SUD plastic handle generates an estimated 16-18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5-6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4-5 uses, and reusable blades 5-7 uses, before loss.

CONCLUSIONS

LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.

Femtosecond laser-assisted versus phacoemulsification for cataract extraction and intraocular lens implantation: clinical outcomes review

PURPOSE OF REVIEW

Femtosecond laser-assisted cataract surgery (FLACS) has gained popularity in recent years with the new technology suggesting potential improvements in clinical and safety outcomes over conventional phacoemulsification cataract surgery (PCS). A decade since the advent of FLACS has given time and experience for laser technology to develop in maturity, and better quality evidence to become available. This review evaluates current evidence on the clinical and safety outcomes for FLACS in comparison to PCS.

RECENT FINDINGS

FLACS technology continues to improve and with it our confidence in tackling more complex patient indications. Concurrently other new technologies such as precision pulse capsulotomy also look to deliver the biomechanically ideal 5.2 mm capsulotomy, particularly as there remain suggestions from large studies and meta-analyses of raised capsular complications with FLACS compared with PCS and IOL technology responding to advantages of a consistent capsulotomy. Visual benefits of FLACS over and above PCS also remain to be conclusively demonstrated, with equivalence but not superiority. Economic modelling continues to indicate that FLACS remains 'not' cost-effective.

SUMMARY

FLACS can be considered non-inferior to conventional PCS in term of safety and clinical outcomes. However, FLACS has yet to demonstrate an overall cost-benefit to the patient.

Attitude of US obstetricians and gynaecologists to global warming and medical waste

OBJECTIVES

Global warming (or climate change) is a major public health issue, and health services are one of the largest contributors to greenhouse gas emissions in high-income countries. Despite the scale of the health care sector's resource consumption, little is known about the attitude of physicians and their willingness to participate in efforts to reduce the environmental impact of health services.

METHODS

A survey of 236 obstetricians and gynaecologists at the University of Pittsburgh Medical Center in Western Pennsylvania, USA. Survey responses were compared to Gallup poll data from the general population using a one-sample test of proportions, Fisher's exact tests, Chi-square test, and logistic regression.

RESULTS

Physicians in obstetrics and gynaecology were more likely than the public (84% vs. 54%; p<0.001) to believe that global warming is occurring, that media portrayal of its seriousness is accurate, and that it is caused by human activities. Two-thirds of physicians felt the amount of surgical waste generated is excessive and increasing. The majority (95%) would support efforts to reduce waste, with 66% favouring the use of reusable surgical tools over disposable where clinically equivalent. Despite their preference for reusable surgical instruments, only 20% preferred the reusable devices available to them.

CONCLUSIONS

Health care providers engaging in sustainability efforts may encounter significant support from physicians and may benefit from including physician leaders in their efforts.

The carbon footprints of home and in-center peritoneal dialysis in China

OBJECTIVE

The provision of healthcare itself is associated with abundant greenhouse gas (GHG) emissions. This study aims to determine the carbon footprints of peritoneal dialysis (PD) with the different modalities and treatment regimes.

METHODS

A total of 68 subjects performed with PD treatment were enrolled in this study. Emissions factors were applied to data that were collected for energy consumption, travel, and procurement.

RESULTS

The carbon footprints generated by the provision of PD treatment for the individual patient were calculated and normalized to a 2-l PD dialysate volume. The fixed emissions were higher in patients who received PD therapy in center than at home, mostly attributing to the consumption of electricity. Conversely, PD treatment performed in center yielded less variable emissions than that of at home, which resulted from reduced constituent percentage of waste disposal and transportation. Collectively, packaging consumption mostly contributed to the total carbon footprints of PD.

CONCLUSION

This study for the first time demonstrates the delivery of PD is associated with considerable GHG emissions, which is mainly attributed to packaging materials, transportation, electricity, and waste disposal. These results suggest that carbon reduction strategies focusing on packaging consumption in PD treatment are likely to yield the greatest benefits.