Design Opportunities to Reduce Waste in Operating Rooms

Environmental sustainability in intensive care: An international survey of intensive care professionals'views, practices and proposals to the European Society of Intensive Care Medicine

BACKGROUND

The intensive care unit (ICU) is a high-resource area, generating more waste and greenhouse gas (GHG) emissions than standard hospital wards. Environmental sustainability is important for healthcare professionals worldwide, prompting scientific societies to call for urgent action. To respond to this global need, the European Society of Intensive Care Medicine (ESICM) conducted an international survey assessing intensive care professionals' attitudes and practices towards environmental sustainability.

METHODS

Intensive care professionals completed an online survey between 21 October 2023, and 5 January 2024. The survey, featuring 21 questions assessing attitudes and practices towards environmental sustainability and proposals for actions from ESICM, was disseminated during the 36th ESICM Congress via National Intensive Care Societies and ESICM's social media.

RESULTS

We received 635 responses from 48 countries. Four hundred seventy (80 %) respondents acknowledged a responsibility to be aware of the environmental impact of intensive care practice, and 372 (63.5 %) disagreed or were uncertain about their knowledge level to guide practice. Four hundred thirty-seven (84 %) lacked formal training on making sustainable choices. Ninety-five per cent used non-sterile gloves in ICUs, and 63 % were willing to reduce use to support sustainable practices. Two proposed actions for ESICM to improve environmental sustainability were increasing knowledge on ecology (91/187, 49 %) and raising awareness in the field (36/187,20 %).

CONCLUSION

This survey highlighted the need for scientific societies, notably ESICM, to provide robust support and structured education on environmental sustainability. Intensive care professionals acknowledged the environmental impact of intensive care and seemed eager to invest in their education on this topic.

Mitigating the environmental effects of healthcare: the role of the endocrinologist

Human health depends on planetary health, and yet healthcare provision can have unintended consequences for the health of the planet. Emissions from the healthcare sector include greenhouse gases, air pollution and plastic pollution, alongside chemical contamination. Chemical pollution resulting in endocrine disruption has been associated with plastics, which are a source of concerning additives such as phthalates, bisphenols, perfluoroalkyl and polyfluoroalkyl substances, and flame retardants (all routinely found in healthcare products). Many endocrine-disrupting chemicals are persistent and ubiquitous in the environment (including water and food sources), with potential secondary harms for human health, including disrupting reproductive, metabolic and thyroid function. Here we review evidence-based strategies for mitigating environmental effects of healthcare delivery. We focus on what endocrinologists can do, including reducing demand for healthcare services through better preventative health, focusing on high-value care and improving sustainability of medical equipment and pharmaceuticals through adopting circular economy principles (including reduce, reuse and, as a last resort, recycle). The specific issue of endocrine-disrupting chemicals might be mitigated through responsible disposal and processing, alongside advocating for the use of alternative materials and replacing additive chemicals with those that have lower toxicity profiles, as well as tighter regulations. We must work to urgently transition to sustainable models of care provision, minimizing negative effects on human and planetary health.

A cradle-to-grave life cycle assessment of the endoscopic sinus surgery considering materials, energy, and waste

BACKGROUND

Operating rooms generate 1.8 million tons of waste annually, or 20%‒30% of the total healthcare waste in the United States. Our objective was to perform a life cycle assessment (LCA) for endoscopic sinus surgeries (ESSs) in order to analyze its environmental impact.

METHODS

A comprehensive LCA of ESS was performed considering energy, climate, and water use impacts associated with the materials and processes used. It focuses on the ESS performed at a large tertiary academic hospital and then extends the impacts to consider annual US surgeries. The assessment considers end-of-life waste management at both landfills and incinerators.

RESULTS

Single-use instrument production constitutes 89%‒96% of the total impacts throughout the life cycle of an ESS. Waste-to-energy incineration is shown to be a preferred end-of-life destination, as it recovers much of the input production energy of plastic items, ultimately reducing the input to 36%, although this is done at the expense of higher greenhouse gas emissions. For multi-use items, decontamination dominates environmental impact (>99% of totals), but consideration of reusable items reduces overall energy consumption and global warming potential (GWP) by 25%‒33%.

CONCLUSION

Single-use items dominate the total environmental impact of ESS. While multi-use items require additional decontamination over their lifetimes, results show that their incorporation reduces energy consumption and GWP by 25%‒33%, demonstrating the clear environmental benefit.

Investigating the sterile surgical supply waste in laparotomy surgery

BACKGROUND

Operating rooms contribute to over 40% of hospital expenses, with a portion attributed to waste from single-use, sterile surgical supplies (SUSSS). This research aimed to determine the amount of cost wastage due to not using SUSSS during laparotomy procedures.

METHODS

A descriptive-analytical investigation was conducted in two prominent teaching hospitals in Mashhad, Iran 2018. Seventy-seven laparotomy surgeries were scrutinized, documenting both used and unused disposable devices, with their respective costs being assessed. Data analysis was performed using SPSS version 16 software.

RESULTS

The study revealed that during surgery in the operating rooms, waste of SUSSS averaged 5.9%. Betadine solution and sterile Gauze types were the top two contributors to resource wastage. Sterile Gauze types incurred the highest cost loss. The study found a significant correlation between cost wastage and surgeon experience (r = 0.296, P < 0.001) as well as surgery duration (r = 0.439, P < 0.001).

CONCLUSION

Inadequate management of available and commonly used disposable supplies leads to increased hospital expenses. Enhancing the surgical team's knowledge of sterile surgical supplies usage and making thoughtful selections can play a vital role in curbing health costs by minimizing waste of SUSSS in the operating rooms.

Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change.

The Environmental Impact and Sustainability of Total Hip and Knee Arthroplasty

Background

Operating room waste is disposed of in landfill sites, recycled, or undergoes costly, energy-intensive incineration processes. By assessing the quantity and recyclability of waste in primary hip (THA) and knee arthroplasty (TKA), we aim to identify strategies to improve sustainability.

Methods

A prospective waste audit of 15 primary THA and 16 primary TKA cases was conducted at a tertiary orthopedic hospital between April and July 2022. Waste was categorized into nonhazardous, hazardous, recycling, sharps, and linens. Each category was weighed. Items disposed as nonhazardous waste were cataloged for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined using packaging.

Results

Average total waste generated for THA and TKA was 14.46 kg and 17.16 kg, respectively. TKA generated significantly greater waste (P < .05). Of all waste, 5.4% was recycled in TKA and just 2.9% in THA cases. The mean amount of recycled waste was significantly greater in TKA cases than that in THA cases, 0.93 kg and 0.42 kg, respectively.Hazardous waste made up the largest proportion for both TKA (69.2%) and THA (73.4%). Nonhazardous waste made up 15.1% and 11.3% of total waste for TKA and THA, respectively. In the nonhazardous waste, only 2 items (scrub-brush packaging and towel packaging) were recyclable.

Conclusions

We estimate hip and knee arthroplasty generates over 2.7 million kg of waste in the United Kingdom annually. Currently, only a small percentage of waste is recycled in hip and knee arthroplasty, which could improve through increased use of recyclable plastics and clear labeling of items as recyclable by medical suppliers.

Evaluating the Environmental Impact of Single-Use and Multi-Use Surgical Staplers with Staple Line Buttressing in Laparoscopic Bariatric Surgery

PURPOSE

Operation rooms have a large environmental impact. Single-use staplers (SUS) are widely used surgical instruments that contribute to resource consumption and waste generation, whereas multi-use staplers (MUS) can greatly reduce the environmental impact of surgery. The staple lines are often reinforced with buttressing material to prevent leaks and bleeding. We explore current clinical practice and environmental concerns regarding stapling and buttressing, as well as the environmental impact of staple line buttressing in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, we extend this analysis by taking packaging material and the lithium in power supplies into consideration.

MATERIALS AND METHODS

A survey of bariatric surgeons was conducted to assess stapler and buttressing use in clinical practice. We deconstructed and analyzed the product and packaging composition of a commonly used SUS with separate staple line reinforcement (Echelon Flex™ with Echelon Endopath™, Ethicon) and MUS (Signia™ with Tri-Staple™ reinforced reloads, Medtronic), where the buttressing material was delivered separately or already incorporated in the reload cartridge, respectively. Both systems were compared regarding total waste generation, resource use (determined as total material requirement), and greenhouse gas emission caused by their lithium content.

RESULTS

60 mm cartridges were most frequently used in bariatric surgery, and 67% of surveyed surgeons applied staple line reinforcement. MUS with pre-attached buttressing resulted in a reduction of waste, material consumption, and greenhouse gas emissions compared to SUS with separate buttressing: they reduced product waste by 40% (SG and RYBG), packaging waste by 60% (SG) and 57% (RYGB), resource consumption by more than 90%, and greenhouse gas emissions related to the lithium in the batteries by 99.7%. Preloaded buttressing produced less waste than separate buttressing per stapler firing.

CONCLUSION

The environmental impact of surgery can be greatly reduced by using MUS with pre-attached buttressing rather than SUS with separate buttressing.

[Recycling of Disposable Surgical Instruments - Is It Worth It?]

The German healthcare sector is responsible for 5.2% of the country's greenhouse gas emissions. One contributing factor is the enormous amount of waste generated daily in German hospitals, making them the fifth largest waste producer in Germany. Despite the potential for recycling, a significant portion of hospital waste is incinerated, as mandated by current regulations. This results in high levels of noxious CO2 emissions and the loss of valuable resources. The goal of this project was to demonstrate the feasibility of recycling complex, contaminated disposable surgical instruments.The study included frequently used disposable surgical instruments that could potentially be recycled as electronic waste. The instruments were wipe-disinfected and sterilised internally within the hospital. After sterilisation, the devices could be classified as electronic waste in consultation with the environmental authorities and then machine-recycled externally by a waste disposal company. Sorting machines shredded and separated the instruments into individual fractions of cables, plastics, different metals, and circuit boards, which were further processed into secondary raw materials.In the first six months (09/2022-03/2023), 239 kg of material were recycled instead of being incinerated. This resulted in a reduction of 545 kg CO2e. The metal content was estimated as 50% of the total weight; 30% were recyclable plastics, resulting in an 80% recycling rate. The ongoing recycling costs were 1.90 €/kg after deducting revenues. Thus, recycling in this model was approximately 3.9 times as expensive as incineration. A survey of the operating theatre personnel found high satisfaction with the recycling project and a minimal additional workload of less than five minutes.We demonstrated that recycling of contaminated disposable surgical instruments is possible in coordination with government authorities. This approach avoids waste incineration and leads to a reduction in CO2-equivalent emissions. However, the higher costs of recycling and the requirement for in-house decontamination pose limitations on the implementation of such projects. To address this, it is necessary for lawmakers to reconsider current regulations and involve manufacturers in recycling costs to fully exploit the enormous recycling potential.

Sustainable Healthcare to Provide Quality Care in the Surgical Industry in the United Kingdom

The surgical industry makes a major contribution to sustainable healthcare. This article aims to critically evaluate sustainable healthcare to provide quality surgical care in the United Kingdom. For this study, a systematic review was conducted using peer-reviewed studies and articles from the United Kingdom related to surgical and anesthetic fields that were published within the last five years. The journal articles were selected based on their relevance to the sustainability and performance of the healthcare system, including risks, and subsequently screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 model screening approach. The findings of the relevant journal articles were then critically evaluated for each theme. A total of 79 studies were retrieved, and 15 of the retrieved studies met the inclusion criteria. Of those, 10 articles evaluated existing sustainability practices, only seven articles discussed significant determinants of quality healthcare, and only 86.67% of the articles highlighted the implications of sustainability. The key predictors of high-quality medical care are effective resource management, the acquisition of a moral surgical team, the provision of professional services, integration, short hospital stays, and low mortality and morbidity rates. Conserving water, optimizing treatment routes and transportation, and creating cultural change were found to be the pillars of high-quality, sustainable healthcare. The concept of sustainability varied between these studies, and limitations on sustainability as a result of reduced mortality, morbidity, and business services were observed. Anesthetic gas emissions from operating rooms continue to have the most detrimental effect on the sustainability of the surgical industry. A significant gap was noted between the available data and their implications.

Microplastics in the surgical environment

Atmospheric microplastics (MPs) have been consistently detected within indoor and outdoor air samples. Locations with high human activity are reported to have high MP levels. The aim was to quantify and characterise the MPs present within the surgical environment over a one-week sampling period. MPs were collected in samplers placed around an operating theatre and adjoining anaesthetic room at 12 h intervals. Particles were filtered onto 0.02 µm membranes and analysed using micro-Fourier-transform infrared spectroscopy. The number of MPs identified during the working day sampling period varied, with a mean of 1,924 ± 3,105 MP m^-2 day^-1 and a range of 0 - 9,258 MP m^-2 day^-1 observed in the theatre, compared with a mean of 541 ± 969 MP m^-2 day^-1 and a range of 0 - 3,368 MP m^-2 day^-1 for the anaesthetic room. Across both rooms and at all sampling points, an increase in levels with a decrease in MP size was observed. Identified particles consisted of mainly fragment shaped MPs (78 %) with polyethylene terephthalate (37 %), polypropylene (25 %), polyethylene (7 %) and nylon (13 %) representing the most abundant polymer types. MPs were not detected in the theatre during non-working hours. The results provide novel information on defining polymer levels and types, in a room environment where the use of single plastics has been regarded as beneficial to practice. These results can inform cellular toxicity studies, investigating the consequences of human MP exposure as well as represent a potentially novel route of exposure for humans for this emerging contaminant of concern, via surgery.

Environmental sustainability in orthopaedic surgery : a scoping review

AIMS

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation's total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

METHODS

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: "orthopaedic surgery" and "environmental sustainability".

RESULTS

A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.

CONCLUSION

Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary.Cite this article: Bone Jt Open 2022;3(8):628-640.

A Systematic Literature Review for the Recycling and Reuse of Wasted Clothing

With the growing frequency and quantity of clothing purchases, the elimination rate of waste clothing is increasing. Many researchers have contributed to the topic of the recycling and reuse of waste clothing, and therefore many related literature reviews are emerging. The current reviews only focus on waste textile recycling and waste-clothing life-cycle evaluation. The topic of waste-clothing recycling itself is ignored. In this article, we propose a systematic review of the recycling and reuse of wasted clothes. Firstly, we summarize the existing methods of waste-clothing collection and recycling and the related recycling technology, and discuss their advantages and disadvantages. The involved literatures are journal articles, book chapters, and conference papers selected from Google Scholar and Web of Science. Citespace software, as a literature visualization tool is used for the analysis. Based on this review, the low efficiency of waste-clothes recycling can be attributed to poor organization from a management aspect. From a consumer perspective, because of the differences in understanding among consumers about waste-clothing recycling, the existing clothing-recycling system cannot be fully utilized. The results of this review provide reference for further research on waste-clothing recycling, and make suggestions for the relevant governmental/industrial development strategies.