Review: Environmental Sustainability in the Orthopaedic Operating Room

Close up of surgeon putting on blue gloves in operating room

Only 12 countries’ total greenhouse gas emissions exceed that of the U.S. healthcare sector. Greenhouse gases trap infrared radiation, warming the earth and contributing to climate change now recognized to be a major global health threat.

Operating rooms (ORs), both within the OR and in manufacturing all of the products/devices used in the OR, contribute substantially to greenhouse gas emissions because of the high amount of energy used and waste generated. A recent review in the Journal of the American Academy of Orthopaedic Surgeons explains steps orthopedic surgeons can take to improve environmental sustainability.

The authors are Jeremy T. Smith, MD, Marco L. Ferrone, MD, of the Department of Orthopaedic Surgery at Brigham and Women’s Hospital, Gregg L. Furie, MD, medical director for Climate and Sustainability at the Brigham, and Lorraine A.T. Boakye, MD, of Penn Medicine.

Energy Use

Simple strategies to decrease energy consumption in the OR are to:

  • Use light-emitting diode bulbs in light fixtures
  • Install an “OR setback,” a system in which OR lights and the heat, ventilation, and air conditioning are automatically shut off/adjusted on a timed schedule, yet can be overridden manually or respond to occupancy sensors
  • Have OR staff perform manual setbacks if automatic setbacks are deemed unfeasible

Purchasing and Sterilization

Careful consideration of what is used, disposed of, and sterilized for the OR can reveal opportunities for improvement:

  • Avoid purchasing single-use devices, particularly if they are individually packaged. The energy that goes into producing a single-use device rather than multi-use devices drives increased emissions
  • Reprocess items whenever practical, such as laryngeal mask airways, anesthesia breathing circuits, blood pressure cuffs, pulse oximeter devices, tourniquets, and sequential compression devices
  • Reduce overage, defined as items prepared for a surgery that remain unused by the end of the procedure. It can help to use standardized OR “picklists,” maintained electronically and refined as necessary, to indicate procedure-specific needs
  • Limit the number of trays opened for each case to reduce the number of dirty instruments that must be sterilized

OR Waste

The simplest categorization of surgical waste is:

  • Red bag waste (biohazardous)—Particularly energy-intensive because it’s often sterilized by autoclave, frequently at an off-site facility, before being transported to yet another location for incineration
  • Liquid waste—Often put into a solidifier, then discarded as red bag waste
  • Standard trash

Waste audits can help uncover detrimental waste and consumption patterns. At the Brigham, an audit of a single total hip arthroplasty case (by Elizabeth Yates, MD, of the Department of Surgery at the Brigham) revealed 14.4 kg of waste. 6.7 kg of that was red bag waste, of which 98% was regular trash (mostly hard plastic packaging and lightly soiled drapes and gowns). Moreover, the regular trash contained items that could have been reprocessed or reused, including tourniquets and unopened anesthesia equipment.

To encourage proper sorting of waste, continually educate staff, use smaller red bags, and make standard trash bins readily accessible throughout the OR. Fluid management systems are available that discharge liquid waste directly into the hospital sanitation system to reduce incineration needs.

Anesthetic Gas Emissions

Inhaled anesthetic gases are potent greenhouse gases associated with hundreds to thousands of times more warming potential than carbon dioxide. For example, nitrous oxide is considered one of the top three climatologically significant greenhouse gases.

To mitigate the negative environmental effect of anesthetic gases, avoid them where possible, optimize waste management, and use alternative agents with better environmental profiles, such as substituting halogenated ether for nitrous oxide and isoflurane or sevoflurane for desflurane.

Barriers to Change

Concern about costs is one of the most common objections to environmental initiatives in a hospital. As with many sustainability efforts, critical analyses of energy use in the OR have determined that environmental sustainability initiatives usually align with financial responsibility. An example is a publication from Practice Greenhealth, The Business Case for Greening the OR.

Safety is of course the paramount consideration, and monitoring of patient safety metrics is critical to the long-term success of these efforts.

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