Going green in operating rooms reduces cost and improves environmental impact

CHICAGO (November 30, 2022): Operating room (OR) personnel who rethink how they deliver surgical care to focus more on sustainability interventions could substantially reduce hospital costs and decrease their ever-growing carbon footprint, according to a new study published as an “article in press” in the Journal of the American College of Surgeons (JACS).

The healthcare industry accounts for about 10% of all greenhouse gas emissions in the United States, with operating rooms considered to be the main energy consumers and waste producers. ORs can use up to six times more energy than the rest of the hospital and put out more than half of the waste across the hospital.^1,2,3,4 Recognizing the impact the climate crisis has on public health, the Agency for Healthcare Research and Quality, part of the United States Department of Health and Human Services, released a primer earlier this year to help healthcare organizations reduce greenhouse gas emissions and protect communities from climate threats.

“Surgeons have an opportunity to really be leaders in this space. Mainly because the single biggest producer of waste is indeed the operating room,” said Mehul V. Raval, MD, MS, FACS, study coauthor and pediatric surgeon at the Ann & Robert H. Lurie Children's Hospital, Chicago. “The opportunity to reduce our carbon footprint falls squarely on us, and I see surgeons taking a prominent role in leading efforts, not just locally with their green implementation teams, but in setting national standards and policies that will move this effort forward for an overall sustainable way of approaching healthcare delivery.”

He explains that the aim of this analysis was to answer the question: which interventions have been most effective at both reducing costs and having a positive environmental impact?

“There's a lot of enthusiasm around this topic, and people are excited to start some of these initiatives at their institution. From making sure that waste is deposited into the proper bins to wider adoption of recycling programs at hospitals, surgeons can start small. If we can come together just to think about what we are using, we can lower the amount of waste that we are producing overall, and reduce our emissions,” said Gwyneth A. Sullivan, MD, MS, lead study author and surgical resident at Rush University and a research fellow at Northwestern University Surgical Outcomes & Quality Improvement Center, both in Chicago.

The study design was a retrospective review of 23 studies involving 28 quality improvement initiatives that incorporate what is known as the “triple bottom line” framework into operating room management. This framework considers the combined impact of environmental, financial, and social interventions.

Because sustainability goes beyond just reducing trash and recycling, studies were then categorized by five approaches of sustainability: refuse, reduce, reuse, repurpose, and recycle. The researchers identified peer-reviewed, quality improvement initiatives that both reduced environmental impact of the operating room and cut costs.

 Key findings

• The 28 interventions identified involved 11 “refuse” initiatives, eight “reduce” initiatives, three “reuse” initiatives, and six “recycle” initiatives. No interventions were identified in the repurpose category. All quality improvement initiatives reviewed were implemented.
• All interventions demonstrated cost savings. For example, one quality improvement initiative at a hospital saved $2,233 per year by implementing an intervention that transitioned an operating room from a traditional to a waterless surgical scrub (a sterile technique in which clinicians use a waterless surgical scrub formulation to provide a comparable antiseptic effect). The environmental impact of this effort saved the hospital 2.7 million liters of water annually.
• The intervention that showed the greatest cost savings was a simple education initiative: $694,141 was saved annually by educating staff on how to properly consolidate and throw away medical waste, which is more expensive to dispose of than regular trash. The environmental impact amounted to a 30% reduction in medical waste in the hospital.

Other shifts to become greener and trim costs included powering down lights and equipment overnight and decreasing the frequency of washing non-contaminated anesthetic equipment. Over one-third of the studies were identified in the “refuse” category. With this approach, surgical teams use fewer supplies or alternative supplies of a specific item. Today, surgeons use premade packs of gowns, gloves, and surgical equipment for cases. Interventions in this category included altering practices and removing unnecessary disposable items from premade packs.

“At the end of every day and every case, it’s disturbing how many bags of trash we are throwing away, especially with the use of disposables and plastics that we see growing in use as time goes on,” Dr. Raval said.

Where to go from here

Researchers also identified specific gaps in the literature that they believe might inspire researchers to conduct future studies. For example, anesthetic gases make up about half of greenhouse gas emissions of operating rooms; studies evaluating interventions that reduce these and other sources of emissions could make a substantial impact. This current outline can be used as a roadmap for surgeons to start implementing some of these interventions and investigating the impact of their greener efforts.

“There is increasing national awareness of the role of the healthcare system in its contribution to emissions. We need experts in this area to help formulate strategies to reduce emissions from hospitals and the healthcare system overall,” Dr. Sullivan said. “In the future, we hope to see all operating rooms having a green OR team with a sustainability focused group of surgeons, nurses, and anesthesiologists, working alongside the supply chain team, environmental services, and  hospital management to make decisions using this multi-faceted approach.”

Study coauthors are Hayley J. Petit, BS; Audra J. Reiter, MD, MPH; Jennifer C. Westrick, MSLIS; Andrew Hu, MBCh.B; Jennifer B. Dunn; Brian C. Gulack, MD, MHS; Ami N. Shah, MD, FACS; and Richard Dsida, MD.

The authors report no disclosures related to the scope of this work.

Citation: Sullivan GA, Petit HJ, Reiter AJ, et al. Operating Room Quality Improvement Initiatives and Environmental Impact: A Scoping Review. Journal of American College of Surgeons. DOI: 10.1097/XCS.0000000000000478

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¹ Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS One. 2016;11(6):e0157014.

² MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health. 2017;1(9):e381-e388.

³ Guetter CR, Williams BJ, Slama E, et al. Greening the operating room. Am J Surg. Oct 2018;216(4):683-688.

 ⁴ Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. Feb 2011;146(2):131-6.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an influential advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

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