The global FESSH green survey: sustainability in hand surgery

Virtual clinics in hand surgery

Advances in technology allow some aspects of clinical care to be conducted without the need for traditional face-to-face appointments. This article provides an overview of the advantages and disadvantages of these clinic models, as well as potential future applications.

A systematic review of sustainability practices in plastic surgery

AIM

There is an urgent need to mitigate the environmental impact of surgery, with surgery representing a major contributor to carbon emissions. This study explores literature detailing current sustainability practices and initiatives in plastic surgery and evaluates methods used to facilitate the attainment of net zero targets.

METHODOLOGY

Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a systematic search was performed using MEDLINE, EMBASE and Cochrane Library databases (PROSPERO registration number CRD42023446104). Studies pertaining to sustainability practices in plastic surgery were included.

RESULTS

An initial search yielded 1083 studies, of which 15 met inclusion criteria. The studies were analysed for data on waste, carbon footprint and cost reduction. Hand surgery was the leading subspecialty with initiatives to tackle waste, such as using procedure-specific surgical packs of the Wide-Awake Local Anaesthesia No Tourniquet technique, while also considering surgeons' preferences. Other initiatives were implemented in craniofacial, skin cancer and breast surgery. Successful recycling initiatives were reported with a monthly average of 39.6 tonnes of waste redirected to be recycled per month. Five studies, from skin and hand surgery, demonstrated a simultaneous benefit through reduction in cost by individualising sustainability practices for specific procedures. The average carbon footprint per procedure, of the included studies reporting emissions, was 22.7 kgCO2-eq.

CONCLUSION

This systematic review demonstrated the necessity of an agile approach towards implementing sustainability practices, tailoring sustainability strategies to the requirements of each surgical procedure. The development of standardised outcome sets to evaluate the best practices in sustainability was emphasised.

Sustainable practices in hand therapy: a global perspective

Given its significant environmental footprint, healthcare sustainability is paramount. This study delves into the contributory role of hand therapy, assessing hand therapists' comprehension, implementation and barriers to sustainable practices, focusing on orthotic fabrication. A global survey distributed via social media and professional networks collected data on sustainability awareness, practices and educational needs from 113 respondents, primarily from North America (34%) and Europe (32%). Although 91% recognized climate change, only 34% practised sustainability. Despite 57% attempting eco-friendly actions in orthotic fabrication, such as reusing components (65%), knowledge of reusable materials was low (17%) and recycling thermoplastics was inadequate (74.3%). The main barriers were lack of awareness (59%), material scarcity (56.6%) and time constraints (54%). The findings underscore the urgent need for enhanced education, better resource availability and policy reforms to close the gap between awareness and action, promoting sustainability in hand therapy.

Wide-Awake Hand Trauma Surgery: Designing Strategies to Optimise Patient Experience

INTRODUCTION

The regional hand trauma service in Greater Manchester, United Kingdom, underwent significant reorganisation early in the COVID-19 pandemic, with a shift from predominantly general anaesthesia (GA) procedures to the adoption of a Wide-Awake Local Anaesthetic No Tourniquet (WALANT) technique. We implemented strategies targeted towards optimising patient experience, largely applicable to most healthcare settings.

METHODS

Four domains were explored: (i) compliance in timing to nationally agreed treatment guidelines, (ii) the role of patient information leaflets, (iii) the introduction of a post-operative analgesia protocol, and (iv) broadly evaluating the environmental impact following the implementation of a same-day 'see and treat' service.

RESULTS

Following reorganisation to a predominantly WALANT service, we observed an increase in compliance with nationally agreed standards for the treatment of common hand injuries. Patient education and peri-operative counselling reduced anxiety, whereas post-operative pain was better managed with the introduction of an analgesic protocol. Using a travel carbon calculator, it can be inferred that there are significant reductions in carbon emissions generated when patients are evaluated and treated on the same day as their clinical presentation.

CONCLUSIONS

It is widely acknowledged that WALANT benefits patients and the healthcare system. We contemplated whether further incremental changes in clinical practice could further improve patient experience. Given our findings, we advocate a multi-modal approach with a greater focus on patient outcomes (trials are currently underway, e.g., WAFER) supplemented by universally accepted validated patient-reported outcome measures (PROMs).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis

PURPOSE

Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis.

METHODS

This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis.

RESULTS

2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025).

CONCLUSION

WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures.

REGISTRATION

PROSPERO: CRD42023404018.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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